Evidence in health policy? Don’t make me laugh…

This week the government told us that they weren’t going to introduce minimum alcohol pricing or plain, unbranded packets for cigarettes because there wasn’t enough ‘concrete evidence’ in the case of alcohol (http://www.bbc.co.uk/news/uk-politics-23346532) or, in the case of cigarettes, that it wanted to wait and see how things went in Australia (who are already doing this), first (http://www.bbc.co.uk/news/health-23288993). Now, if we put aside claims in the media that all of this is really about Conservative links to particular lobbyists it is using as strategists, or that is simply caving in to industry (http://www.guardian.co.uk/society/2013/jul/17/minimum-unit-price-alcohol-shelved?INTCMP=SRCH), then there is the beginning of sensible claim here – that we should be basing our health policy on evidence. Surely that would be a good thing, wouldn’t it?

Well, yes it would be a good thing if we based our health policy on evidence, but there are two problems here. First, if we wait for evidence, especially on public health issues, then we won’t ever do anything new. What we need to do is experiment to find out what interventions have the best chance of working, being aware of how different contexts affect results. If we are actually serious about trying to improve public health, how about we try things, carefully evaluate them, and then introduce them more widely if they work? There will be problems around borders and boundaries (if alcohol is cheaper in one area than another we might expect this), but the extent of this can be over-stated (Scotland is more than capable of doing things differently to England it would seem), and most people, most of the time, won’t be sufficiently motivated to make enough different to jeopardise an experiment. So let’s have a go – if we are serious about improving public health, let’s try out some new thinking and see what happens.

The second problem with the claim that the government are engaged in evidence-based policymaking in health is, of course, that they’ve spent billions of pounds reorganising the NHS at a time of austerity, but based on the very flimsiest of evidence that their plans have any chance of actually making things working. Even the research the government cited in their White Paper as supporting their research (the competition-based work from the LSE) seems to have been misunderstood by them. What we have an expensive, distracting reorganization at a time when the NHS needs to save money, and also at a time when what seems to be becoming clear from the devolution of health policy across the home nations is that what health systems need to improve is stability and continuity – not continual disruption and change. The WHO report on Scotland is particularly interesting in relation to this point (http://www.euro.who.int/en/who-we-are/partners/observatory/health-systems-in-transition-hit-series/countries-and-subregions/scotland-hit-2012).

So, if we are serious about making health policy evidence-based, that doesn’t mean we should sit on our hands and wait to see what happens when other countries experiment with public health measures (where things may be very different culturally and contextually anyway), and it certainly doesn’t mean we should be reorganizing the NHS. As those things are what the government are doing, it is easy to be cynical and suggest instead, that things are being driven instead by the alcohol and tobacco industry, and by simple ideology.

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Submission to Labour’s inquiry into the Effectiveness of Health Systems

Here is the submission I made to Labour’s inquiry into the effectiveness of health systems. I’ve also published it on the Socialist Health Association’s website at

Xenophobia and health policy

Today the government have announced that they are thinking of charging non-EU visitors to the UK £200 a year to access the NHS, or tell them to take out private health insurance. We are told that this is to address ‘health tourism’ and Jeremy Hunt says he is ‘determined to wipe out abuse in the system’. The Department of Health doesn’t really know how much of a cost issue this is, but seem to be giving what is a guestimate at about £30M a year.

So, let’s ask two questions. First, why is this a problem now? Second, what is the government planning to do about it and does it make any sense?

Why is health tourism a problem now? Let’s be honest, it isn’t really. £30M is a lot of money, but is less than 0.3% of the NHS budget, and actually, we have no idea whether the problem is this big because we really don’t know. So if you are going to change government policy, wouldn’t you want to know how big the problem is first? It’s a pretty difficult research issue (I’m supposed to be good at designing research and doing any kind of good research in this area seems pretty fraught to me), but surely some attempt needs to be made to whether this is actually a problem before you spend time and money trying to fix it.

And so this isn’t really about health tourism (or whatever we want to call it) being a problem now, it’s about the government playing to supporters who are keen to show that it is being tougher on foreigners, or perhaps, if we are being cynical, about them trying to distract from the latest NHS reorganization fiasco (take your pick, but the news that there continue to be major problems with the ‘111’ telephone service is the most recent).

Given this isn’t really the most pressing problem (or perhaps even a problem at all – we don’t know), asking what the government plans to do about it, I’m afraid, makes things even sillier. Now in immigration I can see how we can charge people who plan to stay longer than six months, and don’t come from the EU. It won’t be terribly popular, and we already have a pretty awful reputation with many overseas visitors (many of whom, like students, bring in lots of money), but this is just about viable provided that immigration services ever get the resources they need and raise their competence levels (too big ‘ifs’ there).

But then, how are we going to check whether people should be receiving NHS services or not, and then, how are we going to charge people who aren’t. Checking people will fall to health professionals, and frankly they don’t have the time. GP consultations (where most health appointments occur) are already short, and most surgeries don’t have the facilities to be checking people for their immigration status on the way in or out. So we are going to have to invest in new systems and possibly new staff – and they won’t come cheap. And are we really going to refuse people who don’t have the right coverage or can’t pay?

Then we will have to charge people. That’s going to involve investment in new systems, and possibly credit control and debt collection. Again, that’s going to cost money.

Now really, are all these new systems we are going to need to check people and charge them, when applied across the whole country, going to cost less than the guestimate abuse of £30M? Doesn’t seem likely to be me. I used to work in credit control (no, really), and it takes a great deal of time and effort. Don’t the government realise this?

So in all, we have the government making a lot of noise about a problem we don’t know is a problem (on cost grounds), and which will probably cost more to implement than the funds it can raise. This isn’t about saving money – it’s about playing to xenophobia.