Editorial Monday 13 February 2012: Aha! It's about competition again: Andrew Lansley's latest defence of the reforms
The first time I started skimming the HSJ / Reform piece by Health Secretary Andrew Lansley (saviour, liberator), I got as far as the line "without health, we have nothing", and stopped.
Scanning very quickly for 'God is love', 'it's nice to be nice' and 'please adjust your dress before leaving' (because cliches should always travel in groups of four), I treated myself to a pause. It seemed topical.
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Okay. What fresh hell is this?
Financial challenge blah blah ... rising demand and expectations blah blah (see the Guillebaud Commission) ... new treatments and technologies blah blah ... long-term conditions blah blah.
Jesus. The target demographic must have done something really bad in a previous life, to deserve this.
Aha! (as #SimonBurns4SOS would say if we were in the House.) We reach something that looks almost like a point: "in understanding the nature of this change and how to cope with it, there is little that we can learn from examining the past. The NHS ... has for the greatest part of its history existed almost solely to respond to an acute need for treatment. It is only in the last 20 years that medical advances have truly begun to shift the focus of healthcare systems towards the management of long and healthy lives".
Where to start? Well, it's certainly true that the past twenty years are more relevant, and the past ten more relevant still. But if we are to address the real issues facing the NHS, which are efficiency, productivity and clinical variation in activity and outcomes, then the 1976 Priorities For Health And Personal Social Services document said that we should do more surgery as day cases and pay greater attention to clinical variation, especially where it is unwarranted.
That is 36 years old, and as relevant today as it was then. (You can some read more about the 1976-is-the-new-2012 parallels here.)
More to the point, I think that general practice would argue that its focus has always been "the management of long and healthy lives", since the start of the NHS and indeed before it.
Mr Lansley goes on to write, "once the job of healthcare systems was to manage the decline and death of patients suffering short-term illness from which there could be no recovery". Well, for many clinical conditions, that's 30 years ago. Transplantation, artery grafting, stenting, joint replacement, dialysis, reproductive medicine - none of these are bleeding-edge. Statins are now off-patent.
What's next? "In economics terminology, extra investment in healthcare confers supply-side benefits". Well, yes, that's true, although it's basically an externality if we're speaking healthecon101. What's Mr Lansley's corrolary point?
"It is partly because of this that we witness around the world countries gravitating towards a model of healthcare provision we are fortunate to possess already in this country". Um. So you've been selling these reforms for the past eighteen months as necessary because the NHS is poor by international standards, and yet now you're telling us the world is coming towards doing things our way?
Curiouser and curiouser.
More to the point, countries are moving towards universal provision because they recognise the benefits of global risk-pooling, herd immunity through vaccination and potential leverage for commissioners through significant scale. They have also noticed that governments tend to get involved in the healthcare of the poorest and sickest regardless of system.
Here's a longish chunk: "the key task of any healthcare system in the future is to ensure that those innovative new treatments and technologies get to the right patients, in the most efficient way. In achieving this aim, the challenges which are putting pressure on public sector services over the world – meeting the rising expectations of a public which is becoming better informed – can be turned to our advantage. Because if we allow more informed and more demanding patients and health professionals to agitate for these new treatments and technologies to be made available – rather than accepting the misplaced belief that a centrally-planned system based on past patterns of delivery can do it better – then the NHS will find itself facilitating rather than frustrating innovative care".
The first sentence is spot-on. The second is OK. The third is 100% assertion and opinion, and shows why the Bill is essentially wrong on the issue of planning.
The Healthcare For London stroke reconfiguration is known to have improved health outcomes. It is worth remembering that on taking office, Mr Lansley stopped it, for a pointless 'bottom-up' consultation, to chime with his presentational 'this is not a top-down reorganisation because it's bottom-up' politics.
There is also the massive issue of hospital reconfiguration. Many urban areas (London being the classic example) have too much acute capacity, some of which is of the wrong kind and in the wrong places. Dealing with this requires planning - not based on Mr Lansley's straw-man suggestions of "past patterns of delivery", but as the stroke review did, based on clinical evidence.
Planning, communicating and implementing this kind of change requires strategic management capacity. The Bill does not provide for that (indeed, abolishes it); nor does Mr Lansley's favoured placebo of competition. There are significant lessons on this in new NED of Monitor Keith Palmer's excellent suth-east London review for the Kings Fund, which concluded that "market forces alone are unlikely to result in improvements in quality of care for patients in many hospitals, and could result in deterioration in some cases. The transfer of commissioning from primary care trusts and strategic health authorities to GP consortia increases the risks of deterioration in quality of care for some patients and a widening of the quality gap between best and worst performers".
Competition can certainly achieve some things. It can't do everything.
Mr Lansley goes on "in any other sector, it is the thousands of individual decisions to adopt a new technology – from, say, cassettes to compact discs to mp3 players – which combine to sweep away less effective services. And this individual creativity and innovation is best supported by competition".
Oh dear: no less confused. Healthcare is not any other sector, and is more frequently a 'distress purchase' than a consumer choice . It is also specialist labour-intensive. There are also issues of information asymmetry - producers know much more than consumers, and their products can be hard to compare - and of natural geographical monopolies. Making better or cheaper widgets is lovely, until somebody uses industrial grade silicone in your breast implants. PIP were sure using creativity and innovation to win in competition based on price.
Mr Lansley believes that competition "means simply that those who strive to innovate to provide the best possible care should find their efforts supported rather than stymied". Godfather of economics Adam Smith didn't: in Wealth Of Nations, he wrote, "people of the same trade seldom meet together ... but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices".
Mr Lansley also says that competition "means giving patients more control over the care they receive, sharing in the decisions made about their treatment", which is a lovely definition of co-production, but an utterly ridiculous definition of competition.