Evidence, fact and opinion in the NHS bill debate

On 23rd February on the Daily Politics, Clare Gerada (CG) appeared with Anna Soubry  (AS) to debate the NHS bill. I’ve included a rough transcript at the bottom of this piece to try and show what happened, along with a link to a recording of the debate on the BBC website. I think, for me, it exemplifies what has gone on during the NHS bill debate.

The debate begins with CG explaining how she has consulted with her GP colleagues, and how her views can be claimed to be representative of them. She says some parts of the bill are good, but the results of the RCGP consultation suggest that her members don’t want it.

Andrew Neill (AN) then tells AS that CG represents 90% of GPs, AS replies ‘I think she’s wrong’. AS explains that CG is wrong because she has spoken to ‘Real GPs, on the ground’ in her constituency, that consortia were formed there before the government were even elected, and that she was approached by a GP from her constituency (who doesn’t practice there) who told her that she had to get the bill through so he could, in his words, ‘deliver the treatment to my patients that I want do do’.

AN then challenges what AS is saying, saying it is ‘anecdotal evidence’,.

AS replies ‘It may well be’.

AN challenges AS to explain why her evidence is more important than CGs. AS replies she didn’t say it was.

After a period when everyone tries to pick the discussion again, CG explains that her own practice was one of the commissioning pathfinders, and suggests perhaps the GP AS spoke to was one of the 56 out of 2,500 who voted….but is cut off by AS who asks ‘What about the doctors in my constituency….what about the 95% of other areas of the country?’

CG suggests that AS’s views are not reflected in what she is hearing from 18 months of consultations.

AS replies ‘We’ve consulted as well’.

AN then suggests that CG has a ‘strong ideological opposition to competition or further choice’. CG asserts that the bill is ‘an attempt to privatise the NHS’ (AS then engages in much shaking of her head), and that there is nothing in the bill to prevent a mixed-funding system (as per the US) appearing.

AS then asserts that is ‘an opinion. That is not a substantial fact…’

CG then replies that the RCGPs are not against competition, but against ‘the full, fettered, any qualified provider where you have everybody competing for the same hip, the same knee’.

The debate then ends.

What his shows for me is the two very different styles of argumentation and evidence presentation that we have seen during the bill.

CG is attempting to use first, the argument that the RCGPs have consulted widely during the bill, and so she knows the opinions of the 90% of GPs she represents. This argument is based on legitimacy through repeated consultations. Legitimacy through democracy.

AS attempts to refute this by claiming that the GPs she speaks to in her constituency say differently, and one GP in particular has urged her to press ahead with the reforms. She admits this may well be anecdotal.  She then gets herself into a tangle when AN asks her why we should view this anecdote as being more important than CGs consultations, to which AS replies ‘I didn’t say it was’. This leaves us wondering why she mentioned it in the first place.

The argument for the NHS bill has often been outright anecdote, or anecdote dressed as science. Outright anecdote is the position adopted by AS here, as well as by David Cameron in PMQs where he has repeatedly claimed the medical profession back his reforms because he has spoken to a particular doctor or small doctor group that supports him.

The strategy of using anecdotes as evidence is one increasingly used in British politics. Remember the last election, during the debates, when all the leaders had spoken to someone in their constituency who had told them (something that supported their view)? It is almost as if politicians only believe there is a problem if they’ve heard it themselves from one real-life person (not sure there is another kind), but also that this is the only kind of evidence that actually counts.

In the second burst of exchanges we see another NHS bill argumentative strategy – claiming something is, or isn’t fact. AS claims that CG’s view that there is nothing in the bill that prevents a US-style mixed-funding system is ‘your opinion. That is not a substantial fact….’

Now from someone who has just presented anecdote as evidence, this is an odd strategy to take. Having confused anecdote with evidence, AS is now saying that CGs view of the bill is just an opinion (or perhaps, an anecdote?). 

What is odd is the mixing up of anecdote and fact from AS, but also the way the government more generally have presented anecdote dressed as science on repeated occasions. During the debate, the government has repeatedly attempted to present claims about the need for reform as being based on scientific fact, but which appear to disintegrate upon any scrutiny. Chris Mason’s blog on government leaflets explaining issued after the listening exercise show this clearly (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html).

This approach – anecdote pretending to be evidence – is perhaps even more bizarre than presenting anecdotes and expecting to be believed.

What this highlights above all perhaps, is that the government don’t appear to be interested in any kind of informed discussion about the bill. This isn’t about making the NHS better, or about what doctors think, but about putting in place change no matter what. That is deeply depressing – we deserve higher standards of political debate than they have given us, and a great deal more honesty too.

 

Gerada and Soubry transcription from Daily Politics, 23rd February 2012

http://www.bbc.co.uk/news/uk-politics-17144005

AN: Anna Soubry’s boss, Simon Burns, he claims that you don’t represent the views of GPs up and down the country in these health reforms, what do you say to that?

CG:  I think I do. I represent 44,000 general practitioners, of which over 90% when we’ve surveyed them very recently wanted me to ask for withdrawal of the bill and that’s against a background of one and half years of consultation. Three surveys, five counsels, five executive councils, a national conference. Endless consultations. I can categorically tell you my members, the members of the Royal Colleges of GPs, do not want this bill. Some of the parts of the bill are good. I mean putting GPs on control of money, putting patients first, addressing health inequalities. But in its totality, the bill is a mess, the bill is flawed, and the bill will not achieve what you and Andrew Lansley and the Prime Minister are setting it out to achieve, and the more Colleges…

AN: We haven’t got too much time. She represents 90% of GPs .

AS: I think she’s wrong.

AN: (Interjection)

AS: No hang on, let me finish. 

AN and AS talk over one other

AN: You said your views represent…

AS: I didn’t say that. Andrew you asked me a question. I didn’t say that. But let me tell you what I think.

AS: I go into my constituency. I talk to GPs. Real GPs, on the ground. In my area, the consortia was formed before we got elected into government they were in existence. They are putting into operation already what we are seeking to achieve

CG: Why..

AS: Let me finish, I don’t wish to be rude. But let me finish and explain. That is my experience in my constituency with my GPs, and let me tell you this. I was approached by a doctor who lives in my constituency but practices in Nottingham. And he took hold of me and he said ‘For God sakes get this bill through, so I can deliver the treatment to my patients that I want to do’

AN: But that’s anecdotal evidence

AS: it may well be

AN: Her evidence is surveys and conferences and..

AS: yeah, but I’m talking about

AN: Why would your anecdotal evidence be more important than hers?

AS: I didn’t say it was

CG: I would as a general practice, we were one of the first waves of

AS: Part time

CG: We were one of the first pathfinders. We have lots of practices across London. I speak to general practitioners. The doctor you spoke to might be one of the 56 that voted, the 56 out of two and a half thousand

AS: What about the doctors in my constituency, that have formed a consortia, that are doing it. What about the 95% of other areas of the country

CG: But that’s not being reflected in what we are hearing in the Royal College of GPs. I’m not a politician, I’m head of GPs. All I’m doing is reflecting the views, and we have consulted over the last 18 months. GPs write to me every day

AS: We’ve consulted as well

AN: Let’s bring..back in. You say your are not a politician. Reading your case against the bill and so on  you do have a strong ideological opposition to competition or further choice

AS nodding

AN: You’ve even said that this is an attempt to privatise and turn it into an American-style system

CG: It is an attempt to privatise the NHS

AS Shaking her head with eyes shut

CG: We are not against competition

AN; Turn it into an American-style system

CG: Turn it into a mixed funding system with a state funding so core services with individuals

AS: Interjection

CG: There is nothing in the bill that prevents that from happening

AS: But that’s your opinion. That is not a substantial fact where you can say

CG: that is the opinion…

AN: The American system involves private insurance, that’s at the core, is that what they’re going to do?

CG: I would like to ask what there is in the bill that prevents that from happening and what you’ll find is that

AS: Interjection

CG: Is that there is nothing in the bill that prevents that from happening. You ask about competition. We are not against competition, we have never been against competition where it adds value to patients. What we are against is the full, fettered, any qualified provider where you have everybody competing for the same hip, the same knee.

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9 Responses to “Evidence, fact and opinion in the NHS bill debate”

  1. Dave Neary (@DaveNeary1) Says:

    I watched this exchange on the Daily Politics and couldn’t agree more about Anna Soubry’s use of anecdote as evidence in policy making. It is the equivalent of making policy on the back of an envelope…in the dark.

    The whole process of the Health and Social Care Bill has been a wretched example of how not to do health policy from the Coalition Agreement on ‘no top-down re-organisation’ but this one will cost around £2billion at a time when the NHS faces a huge challenge (I almost pity David Nicholson having his name put to it) on the efficiency savings front. Lansley’s solutions may have been tolerable in a period of plenty – he’s been doing health for a long time and must have really wanted to be in DH when the money was really flowing in over recent years – but they’re pretty hopeless now.

    I fear that you’re right that the Government will get the Bill on the statute book whatever the cost because backing down now will be too embarrassing. Maybe Shirley Williams will get the competition section watered down or removed but the commissioning structure – CCGs with private commissioning support organisations and the National Commissioning Board with its four sub-national (was going type regional but they’re not and we can’t use the R-word anymore)…oh and toothless health and wellbeing boards, Public Health England, clinical senates…

    The NHS is resilient but a wiser Secretary of State than Lansley would have done very little to the structure and concentrated on public health prevention and self-management but there are too many vested producer interests in the former and the latter is not exciting enough…

  2. Colin Forster Says:

    Clare Gerada is wrong and disingenuous to say that 90% of her members asked in the survey to withdraw the bill.

    Out of 44,000 only 3,100 responded (about 7%).

    Of these 3,100, only 1,800 selected “agree” or “strongly agree” to the question to withdraw the bill. This is 59% of the respondents and about 4% of the total membership.

    It is also a lower percentage of respondents than answered positively to a similar question in a similar survey in Oct 2011.

    • Ian Greener Says:

      Colin – the key point is that Clare Gerada was elected to represent the RCGP, and has, with all the flaws you point out, has the majority support of the members who voted in consultations. She can claim her support derives from consultation and democracy.

      This is, of course, flawed. But it is rather less flawed than members of Parliament talking about meeting nameless GPs who support the bill. It is also worth pointing out that the vast majority of medical bodies that have consulted with their members have not come out in favour of the bill.

      The line of argument point out is a more valid one than the government have used – it is a shame that they haven’t engaged in this way. Perhaps they don’t use it because they, equally, don’t have a mandate for these reforms with them not being present in their manifestos, and regular polls of the public show they do not support these changes. As such, democracy is not their friend in relation to these changes.

      • Colin Forster Says:

        Ian, a self-selecting tiny minority of the membership voted with only 59% agreeing to ask to withdraw the bill. If the survey response had been representative, I would bet money that it would have been much less than 59%. The RCGP constructed the survey to get the result it wanted. It was not a genuine appraisal of it’s members views.

        The result was less positive than the survey in October and yet they used it to change their stance on the bill.

        Has Ms Gerada otherwise consulted all of her 44,000 members? I doubt it. If she has other evidence that the majority of her members are of this view then she should present it rather that quoting this dishonest survey.

        As I’ve said elsewhere, yes of course the Govt make stuff up too, but we are supposed to be better than them.

        p.s. can you clarify your point about the other colleges. I think there is a typo in there.

      • Ian Greener Says:

        All of the points you raise are sensible Colin – I don’t know how representative the polls and surveys were. I would imagine they were sent to a representative sample, but I don’t know this.

        The key point though is that the government have gone down a different route the – ‘I spoke to someone in my constituency’ approach, and tried to suggest this indicates the medical profession support them. That is plainly nonsense.

  3. Colin Forster Says:

    Ian, the anti-Bill campaigners are also adept at quoting letters from 1 or 2 dissenting CCGs or holding up one dodgy Cumbrian Professor as the tip of a persecution iceberg.

    My key point is that it seems that a supposedly non-political Royal College may have rigged a survey of it’s own members. Not very honourable.

    • Ian Greener Says:

      If it is that any of the Royal Colleges have rigged a survey, I’d encourage you to make that very public. I’m not aware that is the case though.

      • Colin Forster Says:

        Ian,

        Here are the results of the poll: http://www.rcgp.org.uk/pdf/Health%20and%20Social%20Care%20Bill%20-%20RCGP%20survey%20results.pdf

        There were 3119 responses. These could actually have been multiple responses from the same person.

        To Q4 “Do you think it is appropriate to seek the withdrawal of the HSCB”, 1905 either supported or strongly supported this.

        Q5 and Q6 were answered in total by 1896. Quite clearly, only those who felt it was appropriate to seek the withdrawal of the bill went on from Q4 to answer these questions. Equally clearly, anybody who thought inappropriate to seek the withdrawal was highly unlikely to vote in support of so doing.

        For Q5 (call for withdrawal jointly with other colleges) 98.4% supported.

        For Q6 (call for withdrawal regardless of other colleges) 92.7% supported.

        The use of Q4 (which was not in the October survey) had the very obvious and very deliberate effect of removing from the final questions most of those who would have voted “no”. This question rigged the poll.

        Clare Gerada and many others then went on to quote these 98% and 92% numbers as if they actually represented the views of the membership.

        Doing so is clearly dishonest and, in my view, is much worse than quoting anecdotal evidence which people can see for what it is.

  4. Susanna Rees Says:

    On the Chester Conservatives website, there is an article purportedly authored by Baroness Warsi.

    http://www.chesterconservatives.com/
    News story
    Health Bill passes Power back to Patients
    Friday, February 10 2012

    It is very poor use of English and very poor grammatical construction and has the effect of confusing. However, I worked out what Baroness Warsi was trying to say.

    “The first argument against the Bill is that we don’t need legislation. Those who articulate this argument all of a sudden should be asked why, then, do they oppose it?

    “It” would normally refer back to the previous noun – “argument” but there is an unannounced shift of context and the speaker is now referring to the noun mentioned before “argument” and no longer to “argument” as we would have expected so it is confusing and misleading.

    The last phrase is “they oppose it” but we have not been informed by the speaker that he is jumping back to the previous noun, “legislation”.

    She means: “Firstly some people say there is no need for new laws. Ask them “Why if you believe that do you not believe that?”

    ?

    Then she says:

    “The second argument against the Bill is that it introduces a free market free for all. This is inconsistent with the first argument, and indeed with the Bill. It is a myth that the Bill introduces a free market – rather it ensure the NHS is a properly regulated sector, which gives patients power while protecting patients’ interests.”

    In other words: “The second argument … is inconsistent with the first argument”

    She says the two “contradictory” arguments are
    (1)There is no need for new NHS laws.
    (2) The Bill does introduce a health market’.”

    She appears to imply that people are saying that any NHS regulation means a health market is being created.

    This is a misunderstanding on her part. She has misunderstood.

    She is blind to the fact that the Bill is a specifically competition and market-shaping Bill. The opponents are not against “new laws” but they are against “new laws” that turn the NHS into a market.

    Her main argument is only: “no it doesn’t” or “no it isn’t”. Not much more than that.

    “The final argument is the most threadbare. People claim that the NHS needs to deliver £20 billion of efficiencies over the next few years, and that this Bill is a distraction. That is a cruel deceit. The Bill is needed to ensure that the NHS is more efficient. It is needed precisely to avoid a situation happening in the future where a Labour Government allows a £20 billion productivity black hole in the NHS from opening up.”

    This means: “the NHS will not be able to concentrate on making £20bn cuts if at the same time it has to re-structure itself”.

    She uses a perjorative term “threadbare” to try to demean this. She implies that this is an unkind lie. She explains very clearly that competition and market-creating laws will make the NHS spend a lot less than they do now on patient care and will stop Labour spending too much on the NHS. Presumably she means they will spend it on profits and shareholders and lawyers and accountants instead.

    The last sentence does not even parse correctly: “It is needed …to avoid a situation … where …Labour …allows a £20 billion productivity black hole in the NHS from opening up.”

    She did not even care enough to check her English.
    “Not bovered”.

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