Editorial Tuesday 31 January 2012: No monopoly on political syllogism? Questions for the troika editorial

Today saw the publication of ’The NHS deserves a better, more open debate over health reform’, a joint editorial by the editors of the British Medical Journal, Nursing Times and Health Service Journal.

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Click here for details of 'Taking the pith out of the Health & Social Care Bill - “Integrate my chutzpah”, says Andrew ‘Not Looking For  A Fight’ Lansley', the new issue of subscription-based Health Policy Intelligence.

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It is fortunate that healthcare publishing does not have its own Co-Operation And Competition Panel, otherwise I shold be referring the trio of Godlee, McLellan and Middleton for such blatantly anti-competitive behaviour.

Editorial preferred providers? The mind boggles.

Their intervention is not quite calculated to improve the mood of Health Secretary Andrew Lansley (saviour, liberator).

Its timing is interesting after last week’s furore, with the ‘hokey-cokey’ protest statement that wasn’t from the Academy Of Royal Medical Colleges (“in out, in out, shake it all about”) following the decisions of the RCN and RCM to oppose the Bill outright.

Why now?
The timeliness is also debatable. The Health Bill is no worse an “unholy mess” today than it has been since its publication. The first Future Forum was a poor attempt to vajazzle the Health Bill while making scant meaningful change, with Monitor’s change from promoting competition to preventing anti-competitive behaviour delighting lovers of sematics, but meaning nothing practical.

The Future Forum injected a profound split into Monitor, by ensuring that it would retain a role as a sector regulator for providers while also becoming the economic regulator – and fatally, having no proper role separation defined with the NHS Co-Operation And Competition Panel, while giving Monitor key roles in the failure regime as we pointed out in September and again last week with the inspiring notion of credit ratings agencies getting involved.

No, Monitor doesn’t seem to know whether it’s coming or going (here’s a clue: if it’s white, you’re coming and if it’s yellow, you’re going).

Meanwhile, the Nicholson Health Service has been tightening its grip over a further-centralised system, making the prospect of abandoning the Bill possibly just as dangerous as going ahead with it.

There is much to enjoy in the editorial: it is correct that we still have scant clue how the new system will work, and that the reforms have “destabilised and damaged one of this country’s greatest achievements: a system that embodies social justice and has delivered widespread patient satisfaction, public support, and value for money”.

It also makes points which require questioning.

The first is in its suggestion that the Future Forum changes made the Bill less stable. There is little evidence available for this, particularly politically: the Bill had to be paused because had it not been, the Liberal Democrat party would have been split, and probably taken out the Coalition Government’s majority.

It also asserts that there is “a broad consensus among policymakers from all major parties for over 30 years about what is required to deliver an effective and efficient health service. Cornerstones of this worldview include a division between commissioners and health providers and the use of choice and competition to drive improvement”.

Scottish and Welsh policymakers might have a wry smile at that one.

So might other policymakers in the NHS in England – if perhaps not in London. It is not very long ago that the Health Select Committee in March 2010 concluded that ”If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished”.

Avoiding the politician’s syllogism
There is little serious debate that as a politician, Andrew Lansley would make a fantastic civil servant (which he once was to his political hero Lord Tebbit, who pointed out last April that thinks his reforms are a dire idea).

Our Saviour And Liberator can do detail ad nauseam, which made him increasingly effective in opposition.

The problem with Mr Lansley’s reforms are that he has an utter conviction that his solutions are “absolutely right”, leading inevitably to the conclusion that his opponents are “completely wrong”. It’s an ontological world view that has completely failed to advance his arguments.

As I am almost bored of typing (and you may be of reading), Mr Lansley’s approach to NHS reform has exemplified what Yes Minister memorably defined as ‘the politician’s syllogism’:
1. Something must be done
2. This is something
3. Therefore this must be done

Unfortunately, I get a sense that the authors have walked into answering the politician’s syllogism with another one of their own reasoning.

Two main points of their piece suggest this. The first is its suggestion that the NHS is above ideology: “The NHS is far too important to be left at the mercy of ideological and incompetent intervention”.

This is odd, since the NHS is a pure product of political ideology.

Bevan was an ideologue; prescription charges and the Guillebaud Commission were ideological; Barbara Castle’s decision to try to end pay beds in the NHS was ideological, as was the Griffiths Report. Alan Milburn was really quite ideological, too. 18-week elective, 2-week cancer and 4-hour A&E waiting time targets were all products of ideology. Moving NHS expenditure up from 6% of GDP to 9% of GDP was seriously ideological.

You can argue about whether all of this was good or bad ideology, and indeed whether it was incompetent. What doesn’t seem sensible is to suggest that the NHS is an ideologically settled issue.

Ask Oliver Letwin in 2004.

Or ask Oliver Letwin and John Redwood in 1998.

So the syllogism seems to be that:
1. The Lansley reforms are ideological.
2. The Lansley reforms are shit.
3. Therefore ideological NHS reform is shit.

No, thank you.

There is also a potential concern over their call for “a broad public debate on, for example, the principles that should underpin the NHS, how decisions on priorities should be made in a cash-limited system, and what role clinicians and private sector organisations could and should play … as part of this process, Parliament should now establish an independently appointed standing commission, similar to the Sutherland and Dilnot commissions, to initiate a mature and informed national discussion on the future of our national health system”.

Um. A standing commission sounds most awfully like a QUANGO, if not a GOBSAAT (good old boys sitting around a table). It also doesn’t sound very democratically legitimate.

They also call for a rationing debate, which is always a bit likely to involve difficulty. I recall some Ipsos MORI polling data presented by Ben Page at the 2008 NHS Alliance conference. It found that when asked:
‘Should there be limits to what treatments the NHS offers?’
- 48% of respondents disagreed; 31% strongly disagreed.

Should there be limits to what the NHS provides?
• 55% disagree; 29% strongly disagree

On cost-effective and clinically effective treatment:
• 41% think the NHS should offer any drugs and treatments that work, no matter what the costs
• 31% think the NHS should offer any drugs and treatments even if ineffective, no matter what the costs

Which suggests it’s going to take quite some debate … as the NHS Commissioning Board’s Chairman Mal himself could tell the authors.

If you follow the link to his speech on nanotechnology in my original profile of Chairman Mal, you can see him tell the audience, “I had the responsibility some years ago of chairing the Government's commission on GM crops, so I know well through scars all over my back where the problems lie. Overnight, a whole generation of plant scientists developed a clear-spoken expertise on economics and monopoly power and pricing in global markets for seeds. And equally, an entire generation of organic farmers pronounced with great authority on gene flow and upon the incidents that would flow from the uncontrolled growing of GM crops in the open.

"These were two communities whose voices never overlapped; who never engaged in trying to work out what were the differences that lay between them in the introduction of important technology across the world. The consequence is that Europe still lags behind the rest of the world in the cultivation of GM crops, and there is huge opposition to them".

That was GM crops. This is the NHS.

The NHS is political. You cannot get the politics out of the NHS – indeed, of any healthcare system, as it involves the state in both funding and regulation.

Andrew Lansley is a profoundly incompetent politician, but to generalise from the particular is rarely good.