What is the problem the NHS bill is meant to solve?

I think it’s important to ask what problem or problems the current NHS bill is/are meant to be addressing. Before we can talk about evidence, and whether or not the reforms are backed by them, we first have to know what it is they are meant to achieve.

I confess I still don’t really know.

Thinking about the last year or so there has been a range of problems put forward by the government, but none have been made consistently by them, and all have struggled to find much in the way of evidence or support. It’s almost as if the government believe that, if they present enough problems, one will eventually find support and stick. So far, it hasn’t worked.

Way back in 2010 the original White Paper (remember that far back?), perhaps oddly, didn’t really make much of case. When compared with Labour’s 1997 and 2000 documents, it’s pretty hard to find exactly what the reforms were for. You might have thought a White Paper on NHS reform would start with a diagnosis, and then give you the treatment. What happened here, however, is something rather odd – except for fleeting glances we are given the treatment without the diagnosis. I’m no medical doctor (as we academics like to joke, I have a proper PhD), but that does seem to be going about it wrong to me.

The lack of diagnosis did not seem to deter the government from cracking on. I was surprised that the responses to the White Paper didn’t seem particularly vexed about the lack of diagnosis, but perhaps we can put that down to wanting to appear co-operative with the new government.

After the Bill arrived, however, things started to get less cosy.

One of the first stabs at making a case for the reforms was based around healthcare in England was  falling behind other systems, and that if the NHS was world class, extra lives would be saved from those who have died from heart disease, respiratory disease and cancer. You can find Chris Mason taking the arguments for these claims to pieces here (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html)

So if the reforms aren’t about standards of clinical care. The government seems to have got this wrong. How about another claim – that in order to meet the expectations of patients, the NHS needs to be improved?

The problem with this claim as it seems that NHS satisfaction from patients keeps hitting record highs. During the listening exercise it was at the highest level since the patient satisfaction survey began in 1983, and at nearly twice the level it was at in 2001 (http://www.bbc.co.uk/news/health-12805586). By December 2011 it had risen even higher (http://www.patrickkeady.org/well-done-nhs-70-up-from-34/).

Now again, there is room for improvement. But given the NHS keeps scoring higher and higher for satisfaction, it hardly seems that this is something that justifies a major structural reform.

Okay, so if it’s not clinical problems or patient satisfaction, what else might it be? Well how about productivity? The NHS got big rises in funding during the 2000s, so now its productivity has fallen, and in an era of austerity that surely needs addressing, right?

Well, again no. Nick Black from the London School of Hygiene has claimed that declining productivity in the 2000s is a myth in his recent work and that ‘a fuller account of the evidence reveals like substantial gains in productivity-gains in evidence-based practice, patient outcomes and patient experiences’ (I’m delighted to cite the Telegraph on this just to show non-partisanship (http://www.telegraph.co.uk/health/healthnews/9074733/Falling-productivity-in-the-NHS-is-a-myth.html).

Black goes on to say that ‘If the main reason for the Health and Social Care Bill is a lie, the upheavals it will produce are entirely unnecessary. This is further evidence to kill this damaging and dangerous bill’. Hardly high praise for the reforms.

Okay, so what else could it be?

How about that the big rises in funding in the 2000s mean that the NHS is now really, really expensive, and so we must find ways of reforming it to reduce the burden on the taxpayer?

Er, no. Sorry. The UK’s spend per head is only just above the average for the OECD nations, and remember, this is after years and years of much less spending on healthcare in the 60s, 70s, 80s, and 90s. We spend less than Germany, France, Sweden, Ireland(!), as well as a range of other nations including the US (as you might expect), Canada (that you might not), the Netherlands, Switzerland, Denmark, Austria, Belgium, and Iceland. So if we are expensive, they are more so. (http://www.oecd-ilibrary.org/sites/health_glance-2011-en/07/01/g7-01-01.html?contentType=&itemId=/content/chapter/health_glance-2011-60-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011-en&mimeType=text/html).

So how about the reforms needing to happened because the NHS needs the extra capacity from the private sector in order to meet increased demand?

Well, here’s the thing. The NHS has been using the private sector since the 1980s on ‘waiting list initiatives’. We are now at the point where it derives 25% of its total revenues from the NHS (http://www.hsj.co.uk/comment/leader/a-weak-private-sector-is-bad-news-for-the-nhs/5040671.article). So the private sector in the UK is now financially dependent on public funding. Remind me again which sector is meant to need the other one again? The NHS has been using private facilities for thirty years – we don’t need reforms to use the private sector as extra capacity.  Although it is a pretty good indicator that we ought to be spending more in public healthcare rather than less that this has been allowed to persist.

So. If the NHS reforms aren’t about clinical standards, or patient expectations, or productivity, or unsustainable levels of funding, or meeting extra capacity through private sector, what else are they for?

Well, how about this? We need the NHS reforms because it will make health services more locally responsive by delegating control to local doctors. That story’s certainly been tried a few times.

Well, again now. Have a look at the ‘organograms’ at http://abetternhs.wordpress.com/2012/01/31/scrutin/, and claim again there will be less bureaucracy after the reforms. So again, they aren’t about this.

Finally, we saw an intervention from the Secretary of State himself http://www.hsj.co.uk/comment/opinion/andrew-lansley-competition-is-critical-for-nhs-reform/5041288.article.

Here Lansley argues that competition is necessary for NHS to reform to make it more innovative, and he gives the example of the development of the music industry from records to CDs to mp3 players as an example of what he has in mind.

Are you kidding me? The NHS is not like the music industry – unless you are of the same mindset as the Institute of Economic Affairs (http://www.iea.org.uk/blog/how-to-abolish-the-nhs) and want to abolish the NHS, you can’t be allowing freedom of entry and exit into healthcare – with anyone licensing themselves to be a doctor and any organizing setting itself up as an NHS provider (even in the reforms they have to be both ‘willing’ and accredited). You can’t just set yourself up in healthcare. Equally, the NHS itself does not really produce medical technologies, it provides healthcare. It buys medical technology from the private sector when it has been proven both to work and be cost-effective. We don’t need the NHS reforms to do this – we’ve always done it. So I confess I don’t understand Lansley’s argument – it seems to more or less say ‘trust the market, it’ll be great’. I seem to recall the Labour government  saying a similar thing to the City of London in 2007 (if you feel like inflicting pain on yourself, read this, given just before the financial crisis hit (http://ukingermany.fco.gov.uk/en/news/?view=Speech&id=4616377).

So, there we are. I’m still none the wiser as to what the NHS reforms are for.

These reforms are a bill in search of a problem to attach themselves to. In the academic literature this is call a ‘garbage can’ approach to policymaking – a solution in search of a problem. Not evidence-based policy, but ideologically-driven policy. This may not even be conscious – let’s be honest, there’s little above that Labour weren’t advocating before the 2010 general election, and Alan Milburn has censored the government for betraying his NHS reforms (http://www.telegraph.co.uk/news/politics/8578022/David-Camerons-NHS-reforms-are-now-a-car-crash-says-Alan-Milburn.html ). As such, it’s hard to argue it would have been better under Labour.

The lack of a clear reason for the NHS reforms leaves it easy for people to find links between Conservative electoral donors and the reforms and accuse them of being ‘in the pocket’ of the private sector who might gain from the reforms (let’s go to the Mirror for a change http://www.mirror.co.uk/news/uk-news/nhs-reform-leaves-tory-backers-105302). This is what happens if you can’t explain why you are doing something, and leave yourselves vulneralble to personal attack.

Time for a complete change of direction for NHS reform? You bet.

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3 Responses to “What is the problem the NHS bill is meant to solve?”

  1. Patrick Keady Says:

    My view is that while the NHS is doing fine, that it could do so much better. In other words, the clinical outcomes are fine but there is room for improvement. This is where I agree with the – concept – of reform. For example, we know that about 10% of hospital discharges are delayed because of mistakes made by NHS professionals – what a waste of patients’ time and NHS resources.

    I would like to see a Bill with a vision of reducing mistakes made by NHS professionals from 10% to 1%.

    Rather than whole scale organisational change – this is where I disagree with the the concept of reform, which we have seen after all of the recent general elections.

    Some PCTs were performing well before the White Paper was published in 2010 and this was due in part, to the excellent engagement that they had with some very challenging GPs. However, the fitness-for-purpose of other PCTs was at best, questionable. The same goes for the 10 SHAs.

    It would have been more productive for all the ‘good’ PCTs/SHAs to continue, while ‘contracting-out’ the failing PCTs/SHAs – either to other PCTs/SHAs or the private sector. In this way we would reward the better organisations and penalise their ineffective counterparts.

    We have a history of getting it wrong with reward – the NHS generally rewards the underachieving organisations with more resources (financial, people etc) and the overachievers get nothing.

    The focus needs to shift to rewarding the high-performers and not accepting poor performance. Currently for example, 1.5% of a Trust’s NHS income is contingent on Trusts meeting CQUIN Quality indicators. This will expand to 2.5% in 2012/13. In effect, the system seems to be saying to Trusts that Quality doesn’t matter that much really! Even though high quality results in better services to patients and less wastage of NHS resources.

    Recently I met with a Finance Director of a high performing Trust. Her view is that 30% of a Trust’s NHS income should depend on Quality and that sounds good to me.

    While I fully hear and agree with most of the messages coming from the Royal Colleges, now is the time to move forward. From what I’m hearing outside the NHS, members of the public are losing patience with the ‘kill the bill’ stance from some of the Royal Colleges . Now is the time to relay alternatives to the Coalition – its in the reputational interests of the Royal Colleges, the Coalition and ultimately it is in the interests of Patients too.

  2. Nick Nakorn Says:

    A very helpful summary. The point of the reforms is, I think, purely ideological; the intention is to completely privatise the system over time so that the stripped-down state can be said to be idealistically minimal. No one would mind if that lead to better universal healthcare free at the point of need/use at a reasonable cost. But, as is clear from pretty much every privatised system in the world, that what you actually get is patchy coverage, a disenfranchised underclass with no healthcare and a national bill for twice the amount. I’m ideologically not in favour of privatisation but would accept it if it was better able to meet the needs of the poor at a similar cost to the NHS. Indeed, those of us not opposed to a ‘big’ state might even be content to see the state shrink if the private sector can do a better and more equitable job for the poor; but the evidence tells us that in competitve situations the winners are always the ones with the power and resources and it’s the poor – whether they are uninsured ‘customers’ or contracted-out ancilliary workers – who always are neglected.

  3. Do the justifications for NHS reform stand up to scrutiny? | Abetternhs's Blog Says:

    […] What is the problem the NHS bill is supposed to solve? Ian Greener […]

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