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Editor’s blog Friday 15 April 2011: Rising to The Gordon Challenge with an alternative proposal

Many readers of Health Policy Insight will know the very clever Dr Shane Gordon - a big wheel in the emerging world of commissioning.

Shane and I were having a banter over on Twitter (I'm HPIAndyCowper, say hi if you are there), and Shane suggested that I either "argue change in #nhs is not required (=myopia or dementia?) or for convincing alternative (what?)".

Let's ignore the irony of a serious GP commissioning leader asking some bloody journalist for an alternative. Because against all comfortable 'that's not my job' dodging, I'm going to have a go at it. I will even have a go at how we get there. It's a fair challenge if you have been sounding off about how bad the current policy plans are as much as I have.

Here goes. This won't be very evidence-based, but it will sketch out some thoughts about what might be an alternative. It may at least give some readers a laugh.


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An alternative
The first thing I will do is start off with a total, system-wide top-down reorganisation of the entire NHS, so that people can spend the next two years applying for their jobs back, meeting and sussing out their new colleagues, burying their mistakes, wiping organisational memories and jockeying for power and position.

Just kidding! If you think structures are the answer, you have not asked the right question.

The first thing I will actually do is abolish the timetable for all of this current change to be completed in the lifetime of one Parliament. The timescale is absurdly ambitious, and allows for no meaningful learning from mistakes. If clinically-led, clinically-accountable commissioning will improve maters (which I think and hope it will), then we should get the evidence properly and systematically. That isn't a fast process, and the pace-of-change issue appears to derive from Tony Blair's memoirs - not a great source. In structural terms, I will use the remainder of this Parliament to permit experimentation: keep the old system in some areas, try rabid competition in others (if any volunteer); permit HMO-style integration in others. Critics will of course say that this is introducing different systems and thus inequality of access and outcome: a point that would seem valid if that weren't exactly what we already have and have done since 1948.

The second thing I will do is publish all the unredacted legal advice commissioned by the DH over whether EU competition law will come to apply should the Bill be enacted as written. I would also publish the questions asked.

The third thing I will do is to affirm some of the basic, uncontroversial principles on which the Bill is based. The three main ones I would emphasise are that:
1. clinicians must become fully responsible and accountable for their resource use decisions;
2. that the NHS's focus should very much become on health outcomes and variations in clinical practice; and
3. that wherever possible, patients should be engaged in conversations and choices and decisions about their care. All three of these will radically change clinicians' roles, probably tending to make them less comfortable.

I will affirm three more principles:
1. that telecare and technology should move centre-stage (with the Government's roles setting interoperability standards and requiring annual progress statements from every NHS-funded care commissioner and provider on what progress they have made using technology and what disinvestments have resulted);
2. that NICE is to be extended and to rule on what treatments should be decommissioned; and
3. that as a general principle of reform in future, the NHS should not automatically assume that the time of service users should be valued at zero.

I will introduce a new annual survey on the Inverse Care Law. The NHS will publish a detailed authoritative, peer-reviewed study of whether the Inverse Care Law still applies, and of progress or deterioration. Data would be published both aggregated nationally, regionally and at hyper-local levels, as with Muir Gray and colleagues' excellent NHS Atlas Of Variation. The questions would be set in primary legislation with the proviso that while new questions may be added, the survey findings cannot be biased by changing the questions. (I would of course also resume full funding to the British Social Attitudes survey health questions.)

I will introduce another new  annual survey on the progress made on outcomes in the ten major disease areas affecting the population (using both prevalence and total cost as vectors). The NHS will publish a detailed authoritative, peer-reviewed study of this. Data would be published both aggregated nationally, regionally and at hyper-local levels, as with Muir Gray and colleagues' excellent NHS Atlas Of Variation. There would be an award scheme for the best improvements, with a special award category after year three for the best sustained improvement.

I will also create a new institute for CAM: the Campaign Against Micturition. The CAM's role will be to publish with Parliamentary privilege an annual report which will assess how much of our money the NHS has pissed up the wall on bullshit schemes small (risk-sharing drugs) and huge (PFI, or Pure Financial Illiteracy to give it the full title). The CAM will be required to name and shame, with fully-published documentary proof, those guilty of pissing taxpayers' money away. This would include clinical staff, managerial staff, civil servants and management consultants as well as politicians. It will work both in-year and retrospectively, working its way back through the 2000s and 1990s and starting with the biggest-spend schemes.

I will introduce an annual awards scheme for whistleblowing, which would also provide for both financial and name-and-shame penalties for abuse of the system.

I will introduce another annual award scheme for the most hyperbolic claim in healthcare.

I will steal an idea first heard from ex-CQC chair Baroness Barbara Young and adapted by NHS Confed CE-designate Mike Farrar: patients will get an emailed, itemised invoice following their treatment, which reads "Your treatment cost £TOTAL SUM HERE, paid for by the NHS out of your taxes".

I will allow patients with long-term conditions to earn a smartphone such as the iPhone in return for regularly using software to monitor and manage their condition, including email and phone support from their care supervisor. The smartphone would be lost for non-compliance, and would not be replaced if mislaid.

National conversations
I will have some of these. They will be uncomfortable.

Given the ageing population, I will open a debate on how we define quality of life at the end of life. I would want to consider whether medicine has become officious in its pursuit of maintaining life when quality of life is past, and of the ethical and legal dilemmas associated with any change such as the creation of 'living wills' and a right to die.

I will have one about the safety and effectiveness of healthcare. We are developing worryingly low levels of scientific literacy among the population - and indeed politicians. If we are to become serious about variation and outcomes, people need to begin to understand uncertainty, risk, confidence intervals and the role of human error. They need to understand how to use evidence and how to ask clinicians how likely it is that the actions ahead will cause them harm. The replacement of faith in God with faith in healthcare is quite a bad idea for rationality and for reasonable expectations. Again, this will in the short term make life more uncomfortable for some clinicians. Good clinicians will love it.

I will have one about why hospitals are not-great places to receive lots of what is modern healthcare. I will start educating the public about presumption to admit, and how to differentiate shroud-waving from pertinent argument.