What do we do now the NHS bill looks like becoming law?

Given the lack of Liberal Democrat support for voting even for amendments from members of their own party on March 13th, it looks as if the NHS bill is likely to become law. I hope I’m wrong on this, as I’ve provided lots of reasons here why I think that’s a bad idea, but it looks like the fat lady may be singing on this one.

So what do we do now?

One thing that seems to be clear is that the the coalition government are confusing law with implementation. Just because something is law, it doesn’t mean it will be implemented. Remember internal market one from the 1990s? What happened there was that Ken Clarke got the medical profession so angry that even Thatcher moved him on, and put in place more conciliatory figures to actually implement the legislation. As a result, remarkably little happened.

I don’t believe that Cameron is a fool. I think what he’ll do now is get the Health and Social Care bill on the statute book, slap Lansley on the back, and move him on. He’ll put someone else in charge who will say things like ‘start with a clean slate’ and try and defuse things.

But to make sure this happens, the clinicians have to keep making it clear that they do not support the NHS bill – but that if the government will give ground, so will they. But the government must make the first move, and I think it will do so after the bill becomes law, and Lansley is moved on.

So action point 1 – it is crucial that the health organisation bodies keep up the pressure and make clear that the government needs to listen to them if they want this bill implemented.

A second point is that the implementation of the bill is in the hands of health workers up and down the country. You have the power now to decide how to deal with this mess, but deal with it you must. As my colleague Bob Hudson pointed out on March 7th (http://www.guardian.co.uk/healthcare-network/2012/mar/07/nhs-reforms-what-happens-bill-passed?INTCMP=SRCH), it is perfectly possible to take the government as part of their word and organise locally to foster co-operation, increase patient involvement and commission in a collective way to prevent any private cream-skimming. I’m afraid though, this will be in the hands of CCGs – it is therefore crucial that GPs and other health professionals get involved here to make sure that the worse elements of the bill can be mitigated.

Action point 2 – health professionals have to get involved in CCGs in order to mitigate against the worst effects of the bill

Third, we need to acknowledge that it will be necessary to behave in anti-competitive ways to sort out a range of long-standing problems in the NHS in England. We already have a fragmented system, notably between health and social care, and between acute and community health services. If we take the government at their word and try to drive genuine bottom-up change we will far greater collaboration across both of these boundaries. We can’t possibly meet adult social care outcomes frameworks without greater collaboration and more clearly defined care pathways that work directly against the grain of competition. Equally we have to go back to planning community services in such a way as to minimise unnecessary acute admissions. We will need CCGs to take a lead in driving service improvements across these boundaries to prevent even greater fragmentation.

Action point 3 – health professionals in CCGs need to take a wider view and look across their local health areas to work across the boundaries that have dogged us in the 2000s.

What we face potentially now is a tragedy of the commons. If all health organisations go into their bunkers and try and compete, we will see national framework goals missed, and an extension of the beggar-my-neighbour approach we’ve already seen far too much of between community and acute health services.

We need our GPs and other health professionals, through their roles in CCGs, to show us some serious leadership. It will take them away from their role with patients, and I still believe this a really bad idea. Our health professionals will have to work against the grain of a bad bill to make it work for their patients. They will need all our support in doing so.

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6 reasons why the NHS bill should be dropped

Here is my attempt to explain what is at stake in Parliamentary debates around the NHS bill. I think, for me, there are six points I’d like to raise against which I have seen no sensible government response.

1. There is no democratic mandate for a significant reform of the NHS. In the 2010 election, no political party proposed the present reforms, or anything like them. There was next to no debate on the NHS before the election. We were assured by David Cameron there would be no ‘top-down’ reform of the NHS.

As there is no democratic mandate for the NHS bill, it should be withdrawn.

2. At best, the evidence supporting increased competition in healthcare is deeply contested. The government have made a big play on research from Zack Cooper and his collaborators showing that ‘competition saves lives’. Now I think there are substantial problems with this work as I’ve written on this blog, on the LSE blog, in the Lancet, and in future publications. But even if you do believe this research, it doesn’t relate to the new NHS form – it relates to the NHS between 2006 and 2010. The same researchers have found little gain from public/private competition (between 2006 and 2010 it was primarily public/public competition).

There is next to no research showing the NHS bill is supported by research. It should therefore be withdrawn.

3. The government have made no clear case for their NHS reforms. In the last two years we’ve had a variety of claims about getting GPs involved in commissioning (they will struggle to take on this role, and end up outsourcing it to others), about reducing bureaucracy (but the reorganisation will probably increase the number of tiers of organisations rather than reducing it), about improving clinical quality (when many of the statistics they have shown are out of date or just plain wrong).

The government doesn’t seem to know what the their own NHS bill is for. As such, it should be withdrawn.

4. The NHS bill has been so amended it is now completely different, and should be scrapped and started again. The lack of clarity from the government as to what their NHS bill is about has meant that they have made over a thousand amendments to it. The NHS bill that went through the Commons has now been substantially amended. It is almost impossible to predict what the effects of such amended legislation will be. This bill is incoherent – what on earth are we doing allowing something to become law that has been found to be so faulty it has been amended out of recognition.

The NHS bill has been amended so often it is incoherent and its effects cannot be predicted. It should therefore be withdrawn.

5. The NHS bill is not supported by those who will need to implement it. There are now very few clinical bodies that even remotely support the NHS bill. Most actively oppose it. The government began this process claiming they had the support of clinicians. This is simply no longer the case. They have not listened to the concerns of doctors or nurses or other health workers.

To be a success, an NHS reorganisation requires the support of those who will implement it. This bill is not supported by the vast majority of health workers. It should therefore be withdrawn.

6. The NHS bill is not supported by the general public. Opinion polls suggest that the majority if people in England would like the NHS bill to be withdrawn. Despite the government’s repeated reassurances and amendments, it seems they have no faith in this bill.

The NHS bill not only lacks an electoral mandate, or support from the clinicians who will have to implement it, it is not supported by the public either. It should therefore be withdrawn.

To be clear, the NHS needs to get better. It is already doing pretty well in terms of equity and efficiency, but does need to improve its clinical outcomes. However, it almost impossible to see how the present reorganisation will make things better. The reorganisation is costing billions, and causing disruption to no clear end. We need to start this process again and ask what we want our NHS to look like in the future. We can then start to work out how to make the NHS better. This reorganisation, however, is a waste of time and money. The NHS bill should be withdrawn.

The NHS bill as a failure of democracy

My overwhelming feeling about the NHS bill now is how it represents a comprehensive failure of democracy.

We didn’t vote for either the Conservatives or the Lib Dems to reorganise the NHS in this way. It wasn’t in their manifestos, and this wasn’t a part of the 2010 election debate or even the coalition agreement. There is no democratic mandate for this reorganisation.

The government have still failed to tell us what the reorganisation is for. They present claims about making the NHS less bureaucratic, but this simply isn’t the case – the bureaucracy that has built up around commissioning is now far greater than that of the PCTs. Equally, GPs won’t be in charge of commissioning as they will be heavily controlled because of the bureaucracy I’ve just mentioned, but also because they will be increasingly outsourcing their commissioning to private companies – why ask a highly-paid and highly-trained GP to make these decisions? Their skills and expertise lie elsewhere. Finally, there are arguments about making the NHS sustainable into the future. I have no idea how this bill does that. I would argue that the NHS has for the vast majority of its history, been relative to any comparative country’s healthcare, been starved of resources. We have only just now got up to about the OECD average spend on healthcare. If there is a healthcare spending crisis, then other countries have a much bigger problem, and that actually we have some years of under-investment to catch up on first. In sum, there has been no sensible reason given for this reorganisation – the government are not being open and clear about their motives.

Third, the bill has now been amended so many times that confusion reigns about what is in it, and what not. In the last couple of days there have been angry exchanges in the media between Polly Toynbee and Shirley Williams about private patient caps. The question this raises for me is that, when you get to a point where serious figures actually disagree what is even in the bill because it has been so amended (well over 1,000 changes and counting), then you have failed to go through a democratic system of making a bill law. The bill is a mess, an undemocratic mess. The bill as it is now is very different from the bill that the commons originally voted on. I don’t doubt it would get through a commons vote again as the Lib Dems don’t seem to have grasped how the bill, in my view (and other’s) has the potential to transform English healthcare, but it should be voted on again as it is now so different. And if legislation can be changed this much through amendment, it no longer carries any legitimacy.

Then we had the nonsense this weekend at the Liberal Democrat conference, where one of the political parties in the coalition government voted against offering its delegates the right to vote against the bill in favour of a motion supporting it, and then voted against the motion asking Liberal Democrats in the Lords to vote in favour of the bill. Is this really the best they can do? It seems to me that the Liberal Democrats have lost any right to be taken seriously on this issue – it is too important to be this obfuscatory and weak, hiding behind your own nebulous bureaucracy rather than allowing an open discussion and free vote on something that clearly matters a great deal to your party.

The next point is the farce of the risk register. The last time we got into such a mess over releasing information was over Iraq under the Blair government. There seem to me to be few grounds for not making the register public, but the government have repeatedly refused, even in the face of the information commissioner demanding it be published. Now I don’t know what’s in the risk register, but had it just been made a public document last year we’d all be better informed. Surely that’s what democracy is meant to be about?

Next there are confusions over the research evidence base of the bill. John Rentoul, for example, in the Independent, keeps presenting the LSE research on competition which supports competition as straight fact when it is rather contested. This isn’t just my view (or Allyson Pollock’s). Bevan and Skellern reviewed this work in the BMJ last year and found significant gaps in it. To present this work as ‘proving’ competition works is premature, and even if you do still believe the work shows competition works, rather ironically, it actually shows Labour’s policies of the 2000s work, not that the NHS bill will work.

Then there are confusions over the implications of the bill. Allyson Pollock and her co-authors have argued it provides a basis for charging (or at least doesn’t preclude it). Others are more skeptical about this. But again, the problem here is that these matters haven’t been openly and democratically discussed – we are stuck with a heavily amended bill that makes little sense and which is no longer coherent. It is hard to debate a 450 page bill amended over 1,000 times which simply has not been adequately scrutinised in its current form.

We also have a distinctive democratic gap in terms of support for the bill. Opinion polls suggest the public don’t support it, and we know that just about every clinical representative group (with the exception of the Royal College of Surgeons and a couple of very small bodies) have now called for its withdrawal. This despite both Cameron and Lansley claiming until relatively recently that the bill had the support of those working in the NHS.

The NHS bill does not represent informed, evidence-based policymaking. The bill is now so amended it is a mess, and it puts in place a range of competitive dynamics and private commissioning support which may be irreversible, and over which we may have little democratic control in the future – I see huge problems over claims of commercial confidentiality, as we have had with PFIs.

The NHS bill represents a failure of democracy.

NHS competition and bad science – a reply

Henry Overman (http://spatial-economics.blogspot.com/2012/03/nhs-competition-bad-science-or-bad.html) makes a number of points about our blog on the LSE site (http://blogs.lse.ac.uk/politicsandpolicy/2012/03/05/bad-science-nhs-competition/) which I think are worth replying to.

His first general point is that our criticisms don’t reflect the various Cooper papers, and he cites our blog versus the Cooper papers.

This seems an odd strategy. Cooper has, in addition to his academic papers, published a range of pieces in the Guardian and FT (and in many other places), as well as in press releases and on Radio 4. He seems to have no problem with his main finding being represented as being ‘competition saves lives’. He therefore doesn’t claim, as in the first example on Overman’s blog entry that the ‘major improvements in primary prevention in general practice’ could be due to ‘primary prevention and hospital care’. Cooper is being very clear – he believes competition saves lives. To present the work in any other way is to misrepresent what Cooper has claimed from it.

Overman’s second point is that Cooper is clear on the mechanism for improving care – ‘Competition on elective care improves management which also happens to benefit AMI’. This appears to contradict his first point (that the major improvement might have come through primary prevention in general practice), and further muddy the waters by claiming that competition ‘also happens to benefit AMI’. What does that mean? Is that causal or not? Overman suggests AMI was chosen because patients have no choice in relation to it. This amounts to a causal chain whereby even the clinical areas which are not responsive to competition themselves, were affected by competition. Does this sound remotely credible to you?

Overman’s third and fourth points are that it isn’t necessary for patients to remember or make informed choices to provide ‘incentives for hospitals’. However, he doesn’t really explain what the incentive for hospitals actually were. Perhaps these incentives comprise of the additional payments that might accrue from more patients choosing a hospital. But, at a time when waiting lists were in place, there seems to be little incentive for clinicians to want to be chosen – in fact we might argue the opposite, that being chosen less would help clinicians get through their waiting lists. Because the paper does not actually work through any causal chain (despite Cooper calling himself an ’empiricist’ in his FT piece), there is no actual data on how the incentives were actually received by any real clinicians or managers. That these incentives existed is simply inferred, not shown.

Overman’s fifth point is that the EJ is more than capable of reviewing work like this. I think my response would be that the paper has internal validity (which might have been what the reviewers were looking for), but simply does not capture the complexity of the phenomena it is meant to be investigating. If you are going to make claims that ‘competition saves lives’ – which is itself ridiculous – health workers save lives, not governance structures – then you’d better have some pretty strong evidence. In my view, Cooper and his co-authors don’t. They have massively over-generalised from narrow data, and timed press events publicising their more sensational findings to be taken up by politicians and journalists who haven’t even read their work. This isn’t good science.

What difference will the NHS bill make for patients?

The NHS bill, in a nutshell, passes budgets down to GP commissioning groups (which will be heavily supervised), and increases the scope of private provision in the NHS. What difference will that make for patients?

The government’s argument is that patients will be able to choose which provider they want, and hospitals and other providers of care will be forced to compete for their choices. They argue this will drive up standards of care.

I have profound worries about GP commissioning. I like GPs, but I’d rather them be thinking about my care than buying care for me. The skills of buying care are very different from looking after their patients. When GPs took control of budgets in the 1990s it actually led to a fall in patient satisfaction – we don’t know exactly why, but I’d guess it was something to do with GPs becoming focussed on costs and patients not getting the referrals or prescriptions they expected to (the first year of GP fundholding saw a fall in both). That might be a good thing – perhaps those referrals and prescriptions weren’t necessary? However, I’d really my doctor be focussed on providing care for me rather than having to worry about what it’s costing. At present, we can pool costs by having large commissioning organizations (the much-maligned PCTs), so if my care ends up being expensive, that can be balanced out by lots of other people not needing any care at all. In the smaller care commissioning groups I worry that expensive patients will come to be regarded as a significant cost to their particular GP practices – and that seems to be a bad starting point for thinking about their care.

The first benefit the government are claiming for their bill is that it will increase choice. Choice can be a good thing. For patients with long-term conditions who are able to become experts in their own healthcare, this seems sensible. Should ‘expert’ patients want to choose, having acquired the knowledge to do so, we should support them. But this is already largely the case – the expert patients programme has been in place for ten years now. What about the rest of us?

Let’s take a standard sort of treatment which both public and private sector can provide – a hip replacement. There’s like to be several potential providers here. So you need a hip replacement. Which provider do you go to? Well you might have a choice between waiting times, between recorded success rates (however they are defined) and perhaps might also base your choice on how far you are prepared to travel, or even if you are prepared to conduct your research, the type of hip replacements offered by each provider (ones made of metal seem like a bad idea given recent coverage  – and don’t get my engineer father started on how insane it was to use metal at all for this).

So there we go – a whole bunch of relevant factors. What next? Well you need to work out which are more important for you, somehow weight them, and make a choice.

Now you may find all of that an empowering process. I don’t think I would – I’d want my GP to tell me who would do my particular hip replacement best locally, and to go to them. That’s asking quite a lot of a GP, who is effectively taking the risk for me, as well as having to act as my researcher, but hey – she’s got seven years of medical training and years more post-qualification experience. I’ve got an ‘A’ level in biology. She’s probably better at this than me.

So there’s benefit one – you get more choice. You probably won’t get much of a choice over exactly when you’ll be treated by any particular provider (you’ll probably have to have private insurance for that, and even then the choices you are offered will be pretty constrained), but you can have a choice of which provider you get – provided of course all the information is available – and it probably isn’t. Which makes me wonder how you’d make a choice (and please don’t point me to the NHS Choices website which has very little of the information I’d suggest you’d need above).

Now let’s say you choose a private provider, and things don’t go entirely to plan. What then? This is where uncertainty raises its head. In your basic-NHS model, you go back to the same clinic that did the operation and they be expected to remedy things. If you’ve gone to one of those fancy private providers you may have a problem.

First, the private provider will still have to be there. They do go bust you know. If you are a few years in, there’s no guarantee they will still be around. If they are there, you might have an argument about whether they are responsible for fixing you up. Private medicine is based on profit – I’m sure the doctors working within it have good intentions (except those providing breast implants, given the PIP nonsense) but they do have a strong incentive to pass any problems away from them. So if you need additional care, they will either want to get paid for it, or want to pass you to another provider. This is pretty much what my mother-in-law experienced in the Australian system when her hip replacement was rather bodged. No-one was interested in taking responsibility and helping her – everyone wanted to avoid the cost she might incur for them.

So if something goes wrong, there’s quite a chance you’ll end up at another provider. The local comprehensive NHS hospital won’t be allowed to go bust, but will be under considerable financial pressure. Even so, it is likely to be your best option. You’ll probably have to go back to your GP and make another choice to get a referral, but it should still be possible. Then you can hopefully get some help.

However, the story doesn’t end there. To help recover, you might need rehabilitation. That will need you either to go to a hospital for another service, or more likely, receive a service in your home through a community-based service. The provider you meet with (you may need to make another choice here) for your service will need to know what your needs are, and will need to link up with your NHS hospital to look at your medical records. They may need to refer you on to other services – you may need to access specialist therapy of one kind or another. That’ll need a new contract with another service provider.

The whole point of all this is that, if you think that it can be difficult getting NHS services to join-up now, you ain’t seen nothing yet. Can you imagine what it will take to join up services across multiple providers from different organizations and all the contracts that will entail? And all the ways things will be able to go wrong? I’m not saying the NHS gets this right – but I can at least see how it’s meant to work in theory. I can’t even do that for the new arrangements, unless the mighty IT gods descend and create some kind of super-integrated system. That didn’t work out so well under Labour – over £6bn was spent to little effect.

So, from the patient’s perspective the big gain is meant to be more choice. I personally don’t want it – I want my local NHS to be good enough for me not to have to worry about choice. I’d rather save my choices for when I buy shiny IT equipment. The price of this choice is fragmentation. The more providers we introduce, the more difficult it is to see how the system can be joined up for any kind of care which isn’t really simple. And care, by definition, is seldom straightforward.

Patient choice, outcomes data and care quality improvement

Should we release clinical outcomes data to the public to inform patient choice decisions? The argument in favour of publishing outcome data is that it will allow patients will be able to make more informed choices. At a simple level, wouldn’t we all like to know that we were choosing the best possible treatment available to us, and to be able to act on that information?

I think that clinical outcome data should be released, but using it as the basis for patient choice is a mistake. We can do better than that.

My first objection is that not all groups will use outcome information in the same way. Not everyone has the capacity to understand outcomes data – it’s complex stuff, and often involves making trade-offs between waiting and quality, and quality itself can have measures that directly contradict one another. There’s a reason why it takes all those years to qualify as a clinician – our bodies are complicated. That means that measuring the performance of those who try and cure our illnesses and ailments is tricky. A few years ago I showed some surgery data to patients asking them which surgeon they would choose. They struggled to come up with any kind of meaningful answers – they found patterns in the data that weren’t there, and often came to the ‘wrong’ conclusions – they chose the surgeon with the worst outcomes. Coming up with a good format to publish information in, is a big barrier. We need something that will communicate clearly, but also not over-simplify. That’s a tough call, and it may not even be possible.

Equally, not every patient wants to exercise choice – indeed a number of surveys suggest that patients want reassurances their local healthcare provision is good, not choice. If it is the case that only particular categories of patient choose, then that creates a significant problem of equity.

This leads to my second objection. If we start trying to use outcome data for patient choice, where does the choice process end? How many providers to I look at? Do I compare everywhere? If I don’t mind travelling I might look at data for the whole country. The trouble here is that healthcare choices aren’t like choosing a microwave. If I get a bad microwave I might be cross, and it may take time to save up for another one. If things don’t go well after I’ve made a healthcare choice (especially on behalf of someone I love, like a child), then I’m stuck with cognitive dissonance. Should I have chosen something else? Did I do wrong? Sheena Iyengar’s book ‘The Art of Choosing’ gives a range of areas (including healthcare) where making choices can lead to long-term problems for people, even if they did everything in their power to make the ‘right’ choice.

We also have to place choice in the specific context of healthcare. We can’t let comprehensive providers of care fail – we don’t have the capacity or the political will to allow this happen. As such, we are stuck with our large hospitals, and the trick now is making the best of them. If people stop choosing the local hospital because of poor outcomes data, then that hospital will have its cost base undermined, but it won’t be allowed to close. Patient choice isn’t really a driver of improvement, it’s a kind of sop to make us think we are driving up care standards when we are really just trying to look after ourselves – and, as I suggested above, even that comes with potentially adverse consequences.

The problem is that the purchaser-provider split is an expensive nonsense. Choice doesn’t drive improvements. Commissioning doesn’t drive improvements. We have unused facilities in providers because purchasers can’t afford their use, and when those providers are NHS facilities with large fixed costs that simply sit around when not used, this is a dreadful waste of resource. We have hospitals dealing with emergency admissions because of gaps in community health services, but with no-one addressing the problem everyone knows exists as responsibilities are split between purchasing and commissioning. Choice feeds into the purchaser/provider logic, fragmenting service provision even further. This isn’t the way forward.

Improvements come from clinicians and managers working together to drive up standards. Outcomes data are a part of that – we need to hold clinicians and managers to be held to account for the service that they provide, and outcomes data are clearly one part of that.

But even more importantly, we need to be democratically holding our local health services to account. We need more than the old ‘health scrutiny’ role of local authorities – we need, in my view, for health services to be a part of local government so we can directly elect people to hold them to account.

Outcomes data can be a part of the democratic process to demand improvements. What defines us collectively isn’t our individual choices, but our collective decisions. We live in a democracy – and we need health services to be far more democratically accountable. Offering individual choices rather than facing up to the hard business of improving health services is bad for us all.

The research on NHS competition – evidence, rhetoric and empiricism

In a piece published here in the FT on February 21^st and available at http://www.ft.com/cms/s/0/5a996db2-5c93-11e1-8f1f-00144feabdc0.html#axzz1nCFZ4BWd, but behind a paywall you have to at least register to access) Le Grand and Cooper suggests that the argument over the future of competition is a case of, following Ayers, ‘empiricists’ versus ‘intuitivists’ with the latter becoming ‘crowded out’ and their evidence of competition improving the NHS being ignored.

They go on to say that patient choice was introduced in 2006, and four studies based on hundreds of thousands of patient observations have clearly and consistently shown that ‘public hospitals facing more competition from other public hospitals improved their outcomes and became better managed’ and that ‘the introduction of competition in the NHS could be credited with saving hundreds of lives’.

They write that many of the principles in the NHS bill were sound, but the debate around the bill has empowered provider interests and the intuitivists who have made unsupported claims that have led to dead-end debates, and the ‘robust evidence base’ for competition being likely left on the cutting room floor.

There are a large number of problems with their argument.

First, there is more than one way to do empirical social research. Le Grand and Cooper seem to be saying that the methods they like, predominantly large-scale regression-based models, are the right way. The imply that theirs are only methods which are robust and so the only ones upon which evidence should be based. They seem to be suggesting that they have announced their findings on competition in the NHS, and that they are definitive.

The empirical parts of the findings from the research by Cooper, Propper and others are important – they suggest the NHS has seen changing referral patterns and increases in quality in particular locations. But they do not make any empirical link between these findings and competition, rather they assert rather than demonstrate that NHS hospitals faced competition after 2006, and so their results must be due to that change.

But their work takes no account of empirical research from other disciplines that finds those working in hospitals being largely disinterested in patient choice or competition because they already have waiting lists and see little benefit in competing for more patients. Equally, it makes no attempt to explain exactly how their empirical findings came about.

A more open-minded approach to considering the health reorganisations of the 2000s tends to regard the introduction patient choice and payment by results as one of many changes, so it is near-impossible to attribute the outcomes found in their research to a single factor. It is not enough to simply assert that competition appeared in 2006. Surely an empirically-driven research project would seek to explain not only what happened after that date, but how. We do not dispute the empirical parts of their work, but we do think that the claim that those changes occurred due to competition are at least contentious, and probably mistaken.

For competition to have caused the changes found in the research Le Grand and Cooper favour, even in the most stripped down and unrealistic form, two things must have happened. First, that that the introduction of patient choice plus payment by results led to competition, and second that competition is able to drive up clinical quality. They don’t show either, but rather assume both.

It is hard to see how choice plus payment by results equals competition. A general point is that economic theory itself tell us that market structures with only a providers, as is the case in the NHS, are more likely to be collusive than competitive with little incentive to improve quality. Empirically, it is hard to say how the introduction of patient choice led to hospitals competing. Only around half of the patients surveyed after the introduction of choice even remember being offered it to them and only a tiny proportion made use of the NHS Choices website specifically launched to help them make them in an informed manner. Even where patient choice was both in place and informed – so that patients chose shorter waiting time and better performing hospitals – the hospitals they did not choose faced little in the way of penalty provided they were able to keep their demand levels stable from other patients waiting for treatment.   A shortage of demand does not seem to be a problem in the NHS (or why do we spend so much time worrying about waiting lists?), and unless patient choices lead to real financial problems for hospitals not chosen, the causal link is broken.

Can competition drive up clinical quality? To assert this assumes that those working in hospitals have both the motivation and the means to respond to falls in demand especially by improving care. Provided local areas have sufficient demand for a hospital’s services, there seems to be little motivation to react to patients choosing to go elsewhere. Even if hospitals do face financial pressures, it doesn’t seem to be the case there is a threat of closure – a mere two weeks ago the government gave a £1.5bn bailout to 7 hospitals in financial trouble over their PFI contracts.

Different groups of workers in hospitals also respond differently to the threat of losing patients through competition, even where we assume it to be present. Managers, who may be on performance-related contracts, will regard them as a more serious threat, and yet raising clinical standards requires manager to get clinicians to improve their practices. Empirical research over decades suggests that it is pretty difficult for managers to get clinicians to do things differently in the best of times. Simply assuming away this problem as an inevitable consequence of competition seems rather extraordinary – and completely ignores detailed work carried out by researchers who believe there are considerable problems with the underlying research upon which these claims were based, and which we published in the Lancet.

What this leaves us with is the view that Le Grand and Cooper are dismissing those that don’t use their methods, or believe in their particular kind of economics, as ‘intuitivists’. This is rather closed-minded, and a little odd as the data they use wasn’t collected through their own personal observations, and seems to be have been interpreted according to their own theories rather than the more inductive approach which is at the heart of Ian Ayers’ book (which I included myself in my recent book on research methods (http://www.amazon.co.uk/Designing-Social-Research-Guide-Bewildered/dp/1849201900/ref=sr_1_1?ie=UTF8&qid=1330159375&sr=8-1) as making a range of interesting contributions

There is more than one way to do empirical social science. There is more than one way to explain research findings. I’d like to invite Le Grand and Cooper to be rather more open about their assumptions and to regard their findings as the beginning of a discussion about evidence for NHS reorganisation, rather than, as they seem to be believe, the final word.

Social enterprises and community care

There is a thoughtful piece in the Guardian healthcare network by Allison Ogden Newton about social enterprises and community care (at http://www.guardian.co.uk/healthcare-network/2012/feb/23/nhs-reform-capital-overshadows-debate).

I think it is clear that there is a consensus that we need more community-based services to prevent un-necessary hospital admissions, to treat patients more appropriately.

I will also agree that in order to foster innovation, we need new community-based organisations to work with the NHS as it requires fresh perspectives and new ways of doing things to find new answers.

However, I disagree that competition is necessary to achieve this. I also have concerns about the NHS relying on non-public provision for the long-term delivery of services.

It isn’t necessary for new organisations providing care for the NHS to be competing with other providers of care. We can do this just as we co-operatively. The NHS can buy care from social enterprises and other non-public bodies without the need for them to be competing with one another. I have no problems with the idea of such services being commissioned, and their impact and effects evaluated through careful research.

Equally it seems to me to be unwise, either for social enterprises or the NHS, for non-public providers to become dependent on public funding. It’s a bad idea for the NHS in case those providers run into financial difficulties, and which will result either in them having to be bailed out by the government, or patients face the disruption of having to be reallocated to other providers, possibly in systems which don’t have the spare capacity to support them.

It also seems like a bad idea for social enterprises to become dependent on public funding – their vibrancy is surely based on being able to be sustainable without becoming dependent on the state. If social enterprises are dependent on the state for financing, they might as well be public bodies. The private health sector is, I read, already getting 25% of its revenues from the public purse, so effectively sustained by it. That doesn’t strike me as being healthy for either public funders or private companies, and repeating the error with social enterprises would be short-sighted.

My suggestion then would be a more research-driven approach – asking social enterprises to provide services to the NHS which would be evaluated, and if successful, rolled out across the system, but funded publicly. There is no intrinsic reason why public funding should prevent innovation – that’s about good management, and there’s no intrinsic reason why good management only exits outside the public sector.

Why no top-down NHS reorganisation will work – the hubris of policymaking

“We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality — judiciously, as you will — we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors . . . and you, all of you, will be left to just study what we do.” – Senior Aide to George Bush, at http://www.nytimes.com/2004/10/17/magazine/17BUSH.html

The government promised us in the last election that there would be no top-down reorganisation of the NHS. I think in their own world that Lansley, Cameron and Clegg may have started out believing that the present reforms weren’t ‘top-down’ – that they were about passing responsibility (and control) over funding down to GPs, so creating a kind of bottom-up change (albeit one implemented in a top-down way)

But I’d like to refer to a phrase other than ‘top-down’ in that last sentence – the ‘in their own world’ bit.

I’d like to start from the assumption, which I actually believe, that politicians genuinely want to do good (no sniggering at the back there). They then construct plans to try and make the world better, but of course start off with their own prejudices and beliefs, and work out from there.

More than that, politicians tend to hang about with, and listen to people, who support their prejudices and beliefs. This is perhaps why it’s so dramatic when blogs like Conservativehome come out against the NHS reforms (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html) – we expect political parties to be homogenous places (but don’t worry – here’s Baroness Warsi to make it all better (http://conservativehome.blogs.com/platform/2012/02/sayeed-warsi-torychairman-as-conservatives-it-is-our-duty-to-support-the-nhs-bill.html).

The internet makes this tendency worse. A range of commentators have pointed out that we now have unparalleled ability to only see the news we want to see, with our prejudices built in. Jaron Larnier (http://www.amazon.co.uk/You-Are-Not-Gadget-Manifesto/dp/0141049111/ref=sr_1_1?ie=UTF8&qid=1329475840&sr=8-1) shows how this can stifle inventiveness and deaden our social interactions with others – because we don’t have to engage with those we disagree with, or work out how to argue with them.

Now – the quote with which this piece began. Imagine you’d been in a political party for years, never really had to engage with others outside of your own views (except for those tedious electoral campaigns, but even then, if you have safe seat you don’t see too many of them), you had the Institute of Economic Affairs talking such extreme nonsense (http://www.iea.org.uk/blog/how-to-abolish-the-nhs) that they make you feel moderate, and you find yourself to be Secretary of State for Health. Not only have you not really been much exposed to detailed debate about a topic, but you also now have power. In these circumstances you might believe that you genuinely can ‘create your own reality’. You’ve studied the NHS. You know what’s wrong. And you’re going to fix it.

So you prepare your plans, you publish them. The first battle is getting them into law. That means that other people pay attention to your proposals for the first time, and they start objecting. You make assertions which are taken as common-sense in your own community, but you find out that others don’t share them.

That gives you a choice. You can either begin to seriously question the common-sense you and your communities hold, or you can try and get the plans through by giving away a few concessions, or even try and just bluster through. More often than not, your plans eventually get to become law, even though you might be dead wrong, because you can rely upon the whips in Parliament, and because you are the majority government. Second chambers can be a pain to get your legislation through, but in the end, you can over-rule them.

Then comes the really tricky bit. You then have get people who have been campaigning against you to implement your reforms. The best you can do is to include the legislation game-changing alterations that mean that the whole structure of your reforms force people to do things differently. The disastrous rail reforms of the mid-1990s are a good example of this – they tried to create competition when there really could be none, and did nothing to address under-investment in rail infrastructure – something that was only really faced up to after some appalling rail disasters.

The NHS Bill goes some way to forcing people to do things differently. PCTs are abolished and CCGs will be given their responsibilities. The boundaries between public and private providers will get blurrier (at least, until, the latter either go bankrupt or leave the NHS again). However, having created so much anti-feeling amongst NHS workers, an awful lot of people now have a stake in undermining the reforms. They won’t (I hope and believe) undermine patient care, but there is certainly scope for undermining the introduction of market forces through local collaborative agreements, and of using commissioning to similar ends.

But what this shows above all is the hubris of policymaking. It is hubris to imagine you can, as a new government, change public organisations from top to bottom and expect everyone within them to go along with your plans, and for them to work. To assume you know better than those working in public services how they should be organised and delivered.

That’s one reason why top-down NHS reorganisations don’t work, but I’d go further and say they can’t work. Policymakers are too closed off from viewpoints other than their own to have to talk through their ideas properly. But more importantly, there is no right answer to NHS reform that can be imposed from the centre. We need greater plurality and local adaptation for health services, and much stronger local democratic links. We can have national standards but allow local areas to work out or adapt how to achieve them best for them. Top-down plans won’t work – they are hubris.

A brief FAQ on the NHS bill

A brief FAQ on the proposed changes to the NHS in England. I’ve done my best to strike a balanced voice, but apologise if cynicism takes over at various points. Equally, I’ve tried to cover lots of ground in as short a space as possible, but this necessarily means missing some things out.

1. How exactly is the bill going to change the NHS?

Well it’s complicated (!). In principle, the bill will abolish Primary Care Trusts (which purchase care as well as providing some of it at present in community health services), and replace them with GP commissioning groups instead. It will also shrink the number of Strategic Health Authorities and increase the potential involvement of the private health sector in the NHS both in terms of provision, but also in terms of offering advice to the new GP commisioners. However, the bill’s amendments have resulted in commissioning organisations having several tiers of management – possibly meaning the whole thing will be more bureaucratic than before. Equally, the benefits of extending private provision are contested (see below). Finally, the argument is that commissioning groups will mean a smaller role for the Secretary of State. Many of those against the Bill have argued that this means the Secretary of State will no longer responsible for the NHS, which could create something of a democratic gap, and have sought assurances that this will not be the case.

2. Why ask GPs to purchase care for their patients?

Advocates of this system say that GPs are closest to patients and so know what they want. Those against wonder why we are asking people whose primary job is to care for people to do something related, by very different (like asking a pilot to design and purchase an aeroplane). Equally, the bill’s opponents are often concerned that by making commissioning bodies smaller, they will not be able to pool risks. What this means is that those who need the most expensive treatments will take up a bigger proportion of a small commissioning body than they would if there was a big one, with a bigger budget. Small commissioning bodies should be more responsive to their particular community’s needs, but have a smaller total budget, and so a reduced ability to pool risks. This at least theoretically, has a problem that where a community has a disproportionate amount of expensive illness, their commissioning body might run out of money. A bigger commissioning body is better able to pool risks, and so is less likely to be affected by a disproportionate amount of expensive illness, but is less able to be sensitive to particular communities.

3.Why make greater use of competition?

Advocates of competition claim that there is evidence that it has saved lives since patient choice was introduced by Labour in 2006 (as in http://blogs.independent.co.uk/2011/04/10/competition-in-health-care-saves-lives/). This research was picked up by the government, and appears to have been used by them to legitimise and justify the reforms. Andrew Lansley has suggested that competition will act as a spur to medical innovation as well (HSJ piece).

Those who disagree have written pieces showing this research is, in their view, flawed (http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext (where there is are responses from the authors and the critics as well). The responses to Lansley’s piece above suggest his view is not without dissenters.

4. Will making greater use of the private sector improve the NHS?

Those in favour say it asks as a spur to driving up standards and reduce waiting lists (http://m.hsj.co.uk/5040671.article). Those against argue that they’ve already seen private sector disasters like Southern Cross, PIP and that there are other big problems as well (https://t1ber1us.wordpress.com/2012/02/10/the-problem-of-the-private-sector-in-nhs-reform/).

5. What about if hospitals or other providers fail (go bankrupt) in the new competitive marketplace?

The government have put together a ‘failure regime’ in the NHS bill to try and deal with this. Critics argue that it is unlikely that large healthcare providers will be allowed to ‘fail’ (closing NHS facilities has always been politically contentious, and finding sufficient capacity to take all the patients from a large provider is unlikely), and that non-public providers will simply form sub-companies, limiting their explosure and commitment to providing NHS care (as happened, for example, in the failed East coast mainline franchise). It is possible private organisations could be asked to take over failing NHS organisations (as has happened at Hinchingbrooke hospital), but then that would potentially leave taxpayers ‘on the hook’ should they run into trouble, and it proved impossible for them to be closed.

In sum, unless healthcare providers are allowed to fail, it is hard to see how market-based incentives can work, and it is hard to see how big providers can be allowed to fail.

6. What evidence is there in favour of the reforms?

The government have repeatedly claimed that their reforms are evidence-based, based mostly on the competition-based research discussed above. There are pretty strong refutations of the evidence underpinning the reforms from Ben Goldacare at http://www.guardian.co.uk/commentisfree/2011/feb/05/lansley-use-word-evidence and from Chris Mason at (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html).

7. How much will the reforms cost?

The government originally claimed that the reforms would cost about £1.5bn. However, claims from others vary widely up to about £4.5bn at the top. In either case, the NHS needs to find savings of around £20bn in the coming years, and the costs of the reform add further to the savings needed. The government argue that the reforms will make the savings more attainable. Opponents wonder at the sense of undergoing significant structural reform at a time when the NHS is trying to find savings.

8. If the reforms don’t work out, can we just get rid of them?

Competition law means that, once areas of public service have been opened to non-public competitors, it is very difficult to remove competition subsequently. This may mean that the changes may be irreversible.

9. Why are we reforming the NHS now?

The government argues that the NHS needs to make £20bn of savings, and so major reforms are needed to achieve that goal. Those against the reforms wonder how you can change an organisation so much and still expect it to save money, and ask why the NHS reforms weren’t publicised and debated in the 2010 General Election if the Conservatives knew they were going to do this (the White Paper was published just six weeks after the government was formed).

10. Who supports the bill, and who is against it?

The BBC have a good list of clinical organisations at

http://www.bbc.co.uk/news/uk-16954223

Newspapers of the left (for example, the Guardian), have argued against the reforms for some time. In recent weeks, more right-of-centre publications such as the Spectator (http://www.spectator.co.uk/coffeehouse/7642848/lansleys-battle-shouldve-never-been-fought.thtml) have argued that the bill is becoming a liability, and the ConservativeHome website also published editorials against the reforms last week (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html).

There are media voices in favour of the Bill (John Rentoul of the Independent seems to support at least some aspects of it (see http://www.independent.co.uk/opinion/commentators/john-rentoul/john-rentoul-lansleys-bill-is-safe-but-he-is-not-6785686.html?origin=internalSearch).

11. Is it too late to not go ahead with the bill now?

The NHS is already some way through implementing the changes contained in the bill, and it will be difficult to go back to how things were in 2010 – staff have been made redundant, building leases sold off. However, commentators and academics have proposed a ‘Plan B’ including this one from Kieran Walshe http://www.guardian.co.uk/commentisfree/2012/feb/01/nhs-reform-plan-b