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

July 20, 2013

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.


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

July 5, 2013

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

July 3, 2013

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.

Culture and healthcare – what are we on about?

June 26, 2013

Have you noticed that whenever anything goes wrong in an organization at the moment, it is described as being due to ‘a culture of…(something bad)’? What on earth are people talking about?

The Chairman’s statement of the Francis report, for example, says ‘There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service. It was a culture which too often did not consider properly the impact on patients of actions being taken, and the implications for patients of concerns that were raised. It was a culture which trumpeted successes and said little about failings.’ (p. 3).

Now I have the greatest respect for the process which Robert Francis went through in his inquiries into Mid-Staffordshire, but this seems to me to be woolly thinking. Have you ever worked in an organization (especially a big one, like a hospital) which had only one ‘culture’. All the ‘culture’s in the quote above are in the singular, and this also goes for the other present examples of the term being used as a cause of poor institutional performance. What do we mean by culture? What do we mean by there being only one of them?

‘Culture’ is a messy word, and there are whole books just trying to work out what it means (even when applied to organizations – my favourite is Alveson’s). The most simple definition tends towards something like ‘the way we do things around here’, so let’s go with that. Now, for there to be just one culture, the ‘we’ would have to be everyone, and the ‘things’ and the ‘around here’ would have to be what they do and where they do them. So when we talk about ‘a culture of…(something bad)’ we are saying ‘everyone around here does (something bad) this way’. And we might add – and there is no other way of doing things, and there are no exceptions, and the people who work here have no choice in that. Really? Have you ever worked anywhere like this?

Culture in the singular suggests that everyone does the same thing. That would actually be quite an achievement in itself (have you tried getting everyone to do exactly the same thing?). Now think of this in the context of healthcare, where we have multiprofessional teams who we know tend to regard the world in different ways (we know that different professionals view health reform in different ways, and different professionals prioritise different care treatments as two obvious example). So we have different professionals groupings who ‘culture’ somehow has got everyone to all behave in the same way.

I’m not suggesting that nothing cultural goes on in the case of poor performance. The problem is that describing culture as singular over-simplifies complicated situations and stops us from trying to find what was really going on. If we are to understand how carers can reach a situation, as at Mid-Staffordshire, where they were falling so short of the standards they knew to be acceptable, then we need careful research and not to impose over-simplified ideas on them. Equally, suggesting that we can make things better by creating ‘a culture of (something good)’ is equally sloppy. Well-run organizations are not the result of some magic bullet, but the hard work of those who keep working at making them well-run. This stuff doesn’t happen by itself.

Organizations have many cultures. I’d go further and suggest that particular meetings can have cultures, and that those cultures can vary depending on who is chairing them and who turns up for them. Wards can have cultures, but they too will vary depending on who is on duty (think of night shifts especially, which can be wholly different depending on the particular mix of staff working at a particular time). Understanding how cultures change and when they seem to support good work is the key – not suggesting that there is somehow just one culture and that the people within that organization apparently have no choices in deciding to go with or against it.

So please, next time someone says ‘a culture of (something)’ to you, say ‘really, just one? And the people in that culture had no alternative?’. Only by getting to grips with the detail of how organizations fail (or succeed) can we hope to try and make things better.

Health inequalities and Grimmer Up North

May 24, 2013

Next week I’m participating in a panel at Durham, and organised by Durham’s Wolfson Research Institute and Demos, on the them of ‘Grimmer Up North’, and discussing health inequalities.. Here’s some thoughts.

A good starting point is to ask why health inequalities exist. Is it because some people can’t physically access safe and hygienic food, housing, leisure and work? Well, yes, that is still a problem. Some social housing is terrible, and people are facing some difficult choices as a result of the changes to the benefit system the government introduced (not least the ‘bedroom tax’, which is really a reduction in benefits where people have more space in their houses than the government believes they need). So we still don’t have good housing for everyone, and some people are undoubtedly under considerable financial pressure – turn on daytime television and watch the ‘payday’ loan companies advertise to you at rates which, frankly, I can’t believe are legal. So poor housing and financial pressures – not a good place to start from if you want to live a long, healthy life.

But surely all of this is a matter of choice? If people worked harder (or got a job) and ate decent food, smoked less, drank less booze, wouldn’t the health of the nation improve immediately. Well, yes and no.

The liberal view of us is that we are all (unless the state or something else coerces us) free individuals who make our own choices. Economics takes this one step further in saying we are rational too. Our laws suggest we are responsible for our actions, taking a not dissimilar view – we are responsible for our choices. Now, as a myth to live by, this isn’t a bad one. I can’t imagine a world where I am allowed to do whatever I like to whomever I like – that would be pretty awful for everyone else (and for me!). However, it’s probably not quite right.

Our sense of self, the thing that is meant to be the rational chooser, is probably a myth (that word again). Both recent neuroscience and philosophy suggest we are fragmented and split as either our brain simply doesn’t function this way, or our mind is subject to a range of irrational tendencies that don’t really fit with the individual, rational model. We are hugely influenced by those around us, we massively discount the future in favour of the present, kid ourselves that we are better than we (by most external measures) are (do you know people who think they are below-average drivers or have a poor sense of humour?). In short, we don’t really correspond to the model of individual behaviour that we tend to assume applies to us (which is, of course, another example of how big the problem is!).

At the same time as this, we aren’t the cultural dupes that some sociologists make us out to be. People, even when doing things that appear pretty destructive, aren’t fools. We are, however, habitual creatures. Can you imagine how awful it would be if we had to think about everything we did? No wonder we go onto cruise control when we drive our cars, or eat, or drink, or when we are with friends…..and often, as a result, do things that aren’t terribly healthy as a result.

So where does this leave us? Well, we know that significant health inequalities exist (I gather life expectancies have the largest range by district in both London and Glasgow), that there are good grounds for suggesting a North-South divide exists (Danny Dorling’s work suggests it begins North of Lincoln, South of Grimsby) and that assuming people make rational, individual choices is not going to lead to good policy.

My own view is that we need to try and remember a little compassion, and to stop thinking of people who engage in a range of practices that are harming their health (be they obesity, or drinking, or smoking or whatever else) not as idiots, or as fools, but as a sign that we (as a society) are going wrong.

How is it that there are, literally walls of cheap booze available in our supermarkets, and that every time I go to the counter in some shops I’m offered massive slabs of chocolate at discount prices? Why do we celebrate drunkenness and regard it as normal in our city centres on a weekend? Why are our emergency health services over-run with people who have drunk to excess on Friday and Saturday nights? What are we doing that makes this everyday, not the exception? Why do we castigate the poor as irresponsible spongers when our society grows ever less socially mobile? Why do we tolerate social mobility declining at the same time as the rich grow richer?

We need to think again about health inequalities, and about the way we talk about them. We need, in the language of Annemarie Mol, a logic of care. This isn’t just about sympathy and empathy, although those are clearly important. It’s about saying (and meaning it) that we are ‘in this together’, and agreeing what we need to change things better for all of us. And then doing something about it.

Liberal ideas about choices and people are all about ‘me’. But we’ll never deal with health inequalities that way – we need ‘me’ to make society work, even if it doesn’t really reflect what we know about the way our brains and minds work. To deal with health inequalities we need to deal with ‘we’, not ‘me’. We need to start caring about them, and about each other. We need to challenge lazy assumptions by policymakers, and start engaging with one another about some of the behaviours that harm us and individuals, and harm others along with way. That is really caring.

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

March 13, 2012

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.

6 reasons why the NHS bill should be dropped

March 12, 2012

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

March 10, 2012

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.

Competition and the NHS – reponse to Le Grand

March 9, 2012

Today on the LSE policy and politics blog, Julian Le Grand has posted a piece that is critical of our earlier blog casting doubt on the LSE team’s work claiming ‘competition saves lives’. You can read it here (http://blogs.lse.ac.uk/politicsandpolicy/2012/03/09/hospital-competition-le-grand/).

I’ve posted my reply on the LSE website, but here it is again for completeness’ sake.

I have liked and admired Julian Le Grand’s work for years, and he is on many my teaching reading lists. But I do have to wonder what is going on here.

There is a basic category error in the piece above – competition doesn’t save lives. It never can. Clinical workers save lives, hopefully with the support of managers. To simply assert (as economists are inclined to do) that competition changes incentives is to not engage with the difficult, messy, empirical work of exploring exactly what has changed and how (if anything, and the moral of reorganisation in the NHS is how little changes). So the key question here is what exactly changed after 2006, and how did it change both managerial and clinical behaviour. The answer, I’m afraid, is that we really don’t know.

Even reviews of research that consider the econometric work that Cooper and Propper favour on their own terms find there are big gaps (for example, Bevan and Skellern in the BMJ (http://www.bmj.com/content/343/bmj.d6470). Most particularly, their research is based on a ‘black box’ where incentives and changes are assumed rather than being empirically demonstrated.

It is also interesting that Le Grand cites the King Fund’s work as supporting his claims. Again, that is very contestable, as David Hunter’s review of the book, again from the BMJ (http://www.bmj.com/content/343/bmj.d7786) suggests. My reading of the book was that Labour’s market-based improvements were extremely modest when compared to what was achieved elsewhere. It therefore seems odd that Le Grand presents this work as supporting him, when I’m really not sure that’s what the book is saying.

Above all, it seems to me that it’s time we started being a bit more humble about our work. Le Grand and Cooper, in their FT piece, seemed to be suggesting that there is only one way to do research, and people who do other kinds of work are mere ‘intuitionists’. This reads to many of us as an intolerant and rather blinkered view of social research. In order to understand what is going on in the NHS we need a range of different methods and different types of work. To imagine we can provide some kind of definitive answer, as they appear to be suggesting, from work that doesn’t empirically examine whether the changes they believe are going on are actually happening, without actually asking anyone involved in their implementation, seems a little odd.

Conflicts of interest and the NHS bill

March 9, 2012

Let’s assume for a moment that the NHS bill passes, and that it leads, as the government want it to, to a competitive environment for care. Every thought how much conflict of interest this would lead to?

Let me say, first of all, that I like doctors, and what follows isn’t meant to be hostile, even if it reads a such.

GPs are the cornerstone of the reforms. They are meant to be getting involved in commissioning as well as acting to make sure patients make the best choices (at least they will be advising patients on choice, at most making the choices for patients if, like me, they don’t think they are qualified to be making choices).

Thing is,  most GPs have been asked to consider themselves as independent contractors in the NHS. They get paid on a really complex mix of different kinds of fees, and have increasingly invested in provision in areas of primary care outside of their own surgeries (which they may also part-own as well). If you are regarding yourself as an independent contractor in a non-competitive environment all this is at least moderately sensible (I’d prefer GPs to be salaried myself, buy hey ho).

None of these arrangements, however, are sensible in a market-based environment. Somehow we are going to have to make sure GP commissioners don’t face the situation where they have to choose between providers, some of which they have a financial interest in. That will mean potentially excluding the very large numbers of GPs who have done largely what the government asked them to, and got involved in local healthcare provision, and even then GP commissioners don’t have interests themselves, they will be in a difficult position because of their partners’ and colleagues’ financial interests. Even in advising patients about choices, GPs will have to disclose their financial interests – and what on earth are patients meant to do with this information? If you are in a collaborative environment, not driven by profit, there is greater scope for allowing GPs to refer to organizations in which they have an interest, as this is surely covered by professional ethics. If, however, we are moving to a competitive, for-profit basis, things are getting a lot more fraught. I’m not convinced the government has worked this through.

If the situation for GPs is going to get a lot more complex for hospital consultants. Consultants may work for both the NHS and private sector. In that case, they will be effectively working for organizations that are now expected to compete with one another. Surely that can’t be right? It would be like someone working for both Apple and Microsoft – far too much potential for conflict of interest through seeing information that is commercially confidential. In a competitive environment, I’m afraid, you have to choose whose side you are on, and stick to it. Professional ethics, again, don’t cover this.

Professionalism, as US sociologist Elliot Friedson suggested is a third logic – neither market, nor bureaucracy, but something else. If healthcare is going to be delivered competitively, you can’t depend on professionalism alone to prevent conflict of interest. And if you are depending on professionalism to prevent a creep of non-professional, market-based ethics into relationships, why introduce markets?

There is one more conflict of interest that has sadly become very apparent in recent weeks. Every time the NHS bill has been debated in the Lords, a running commentary on twitter has appeared explaining the financial interest many of those speaking have in relation to private medicine. That hasn’t stopped them, however, from making points entirely in favour of that interest. That is breath-taking – and to think that politicians wonder why we no longer trust them. If we can’t depend on politicians to deal with pretty obvious conflicts of interest, I wonder what the future holds for those that are tasked with implementing their reforms.