A better NHS

The government’s intention to privatise the NHS continues unabated after a ‘so called pause’ and a ‘so called listening exercise’ in which the rarely spotted ‘future forum’ gathered opinions from carefully selected stakeholders and reported back to No.10. Of greatest significance is that the duty of the secretary of state for health, enshrined in the NHS act since 1948, ‘to provide and secure the effective provision of services’ has been delegated to an unaccountable quango called the NHS commissioning board. Withdrawing the duty leads to the abolition of structures and functions that follow from that duty meaning that eligibility and entitlement to a comprehensive range of NHS services will no longer be assured.

The other significant non-change after the pause is the role of competition which was widely reported to have been watered down, but emerges intact and probably more central than before the pause, with the Competition and Cooperation Panel (CCP) taking on the role of preventing anti-competitive behaviour. They have made it clear that they regard existing NHS hospitals as ‘vested interests’ and that competition is an unmitigated good.[1]

Hostility to the bill is widespread in the medical and nursing professions, with the British Medical Association voting for the bill to be withdrawn at their ARM this month, and protests taking place outside hospitals throughout the country.

The question that remains more than a year after the publication of the health bill is what problems the bill is supposed to resolve. It has never been the opinion of significant numbers of either patients or professionals that the NHS was in need of more choice or competition.[2]

From my perspective as a GP the main problems that need reform are listed below. It is important to note that the health bill fails to address any of them, and in almost every case will make the problems worse.

1.Collaboration. Both hospital specialists and GPs are aware of huge variations in clinical practice, but without good communication and collaboration, little or nothing is done. Evidence from the US Mayo clinic and others shows that when clinicians collaborate rather than compete, costs and clinical errors are reduced and quality increases. In the last few years we have set up historically unprecedented close working relationships between GPs and our local hospital. We have improved the quality of GP management, reduced unnecessary referrals and made sure patients are seen by the appropriate specialist without the need for repeating investigations. By introducing a range of providers to compete with NHS hospitals with the Cooperation and Competition Panel enforcing competition, the health bill will allow private providers to challenge us for colluding unfairly with each other and will fragment and disintegrate patient care. GPs should be federated so that they have to take responsibility for their peers to ensure uniform quality of care in a geographical area. The health bill encourages GPs to collaborate by setting up commissioning consortia but allows them to exclude underperforming practices and challenging patient populations allowing the creation of ‘sink consortia’ and very small consortia with an unsafe risk pool.

2. Management. There is a long history of animosity between clinicians and managers and between NHS managers and the public. This pariah status of managers is unwelcome and unjustified. The promise in the health bill to increase clinician involvement in the planning of services was initially welcome, but any good has been blown apart by the unjustified demonization of NHS bureaucrats, the arbitrary 45% cuts to management and the loss of many of the most experienced managers, the destruction of existing NHS structures at huge cost, and the replacement of 163 statutory bodies with 521 new ones. There is no justification for claims that the NHS is over managed, but it is important to note that since the introduction of the internal market in 1991, administration and transaction costs have increased by about £10bn.

3. The purchaser-provider split. The purchaser-provider split rewards hospitals for doing more and GPs for referring less. Consequently it damages relationships between GPs and specialists and hinders rather than facilitates joint responsibility for patient care because GPs suspect hospitals of over investigating and over treating patients for profit, whilst hospitals suspect GPs of holding onto patients who need specialist attention to save money. The purchaser-provider split needs to be abolished, but it is central to the market-driven health bill. As I explain in another post the costs of managing the purchaser-provider split are enormous. The Nuffield Trust examined commissioning organisations in California and found that the number 1 reason for them going bust was failure to manage the administration costs.

4. Guidelines. The National Institute for Clinical Excellence assesses the cost-effectiveness of treatments. The potential benefits are enormous. Clinical guidelines are all too often not followed because of lack of familiarity rather than clinical reasoning and there are unwarranted variations in both the quality and quantity of care. IT needs to be improved to aid clinical decision making. Guidelines need to be available instantly so as not to interrupt workflow or consultation time. The health bill has lurched back and forth over its position on NICE.[3] Social policies such as a minimum price on alcohol and banning smoking have much bigger health impacts than medical interventions, but worryingly what remains cut is NICE funding for a number of important public health projects including studies into reducing harm from alcohol. Instead the government have entered into public health partnerships with the food and drink industries which have clear conflicts of interest.

5. Inflation. Health care costs are rising because of a number of factors including the costs of new treatments and widening diagnostic and treatment thresholds. Ageing, surprisingly makes little difference, no more than 1% per year. The health bill has no analysis of why costs are rising or what to do about it. By introducing competition and converting health care to a commodity the evidence is that costs will increase much faster than before.

6. Data. The outcome of health care is health gain. It is very difficult to measure health gain because of the huge numbers of variables, the social determinants of health, the subjective nature of health, the variable time-lags between interventions and outcomes and more. If we are to become more efficient, then we need also to agree on how to measure efficiency. For all the emphasis on outcomes and efficiency in the health bill there is nothing in it about how to improve the measurement of outcomes or efficiency.

7. Inequalities. Having worked in deprived and affluent areas I know that general practice in deprived areas is far more clinically challenging and less financially rewarding. There are serious inequalities in the resources available, the quality of care and the incentives for GPs. There is nothing in the health bill to reduce inequalities, indeed funding is already being shifted from poor to wealthy areas and the evidence is that competition in healthcare creates, ‘islands of excellence in a sea of misery’

8. Accountability. There is and always has been a democratic deficit in the NHS. From the secretary of state to the GP commissioner, at every level there will be less accountability as a result of the health bill.

9. The specious separation between health and social care. For general practitioners and patients it is obvious that there is a continuum. When the social care of a vulnerable patient fails too often they end up in hospital where they remain at great cost until appropriate care in the community is found. There are enormous cuts to social care and the NHS will remain the refuge of those with nowhere else to go.

The opportunity to address the problems the NHS faces has been wasted by this coalition government on a neoliberal project to hand a cherished public service over to commercial interests. If the government were seriously interested in preserving a comprehensive NHS, making it more fair and ensuring it is affordable and sustainable for future generations they would be listening to people who spend every day working in it and being treated by it instead of those who see it as a business opportunity.

See also

Allyson Pollock’s suggested amendments to the bill

Kieran Walshe: NHS reform has become a quagmire. Here’s a plan B. Guardian/BMJ

---

[1] Policy Projects. Delivering Choice and Competition –Operating a Market in Healthcare http://policyprojects.com/reports/21jundeliveringchoice.pdf

[2] Playing with Department of Health statistics, How much choice do patients want? http://markhawker.tumblr.com/post/4421202662/playing-with-department-of-health-statistics

[3] The Changing Fortunes of NICE and Health Secretaries http://www.inpharm.com/news/162430/changing-fortunes-nice-and-health-secretaries

Inspired by Iona Heath, The Mystery of General Practice

To help keep an NHS that puts patients before profits, please join Keep Our NHS Public today!