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Editor’s blog Tuesday 6 October 2009: The Right way to run the NHS

I wanted to wait until shadow chancellor George Osborne had spoken before writing anything about Andrew Lansley’s speech to the Conservative Party conference in Manchester yesterday.

Osborne’s speech was interesting. We heard a great deal of “we’re all in this together”. More cynical souls than I might point out that Obsborne stands to inherit the baronetcy of Ballentaylor and the family fortune, and would no doubt point to the line “let’s face it, we all borrowed too much” and giggle.

But this is not our goal – we are looking at (or sometimes, for) policy matters. Osborne lost no time getting stuck into Gordon Brown: ”The Iron Chancellor has turned into the plastic Prime Minister. Free social care. Free hospital parking. Free childcare places. We would all like those things. But where is the money coming from?”

He sought to draw a Manichean opposition between Good Tories and Bad Labour – “the public realised the choice wasn’t cuts versus investment. It was reality versus fantasy. Prudence versus profligacy. Truth versus lies.” Countering Chalncellor Darling’s shrewd tactics in announcing his pay freeze last night, Osborne rolled out his policy of a pay freeze for all public sector workers earning over £18,000 a year in 2011, after current deals end.

He reiterated their policy on discouraging quango chiefs earning more than the Prime Minister, and announced what I think is a new policy to cap public sector pensions at £50,000 a year. Is he going to force the mega-pension pot holders to live longer? Robert Peston’s BBC blog has some useful clarifications about the detail of this: basically, existing salaries and pensions already being paid over £50,000 will be exempt, but future pots will not be able to pay out over £50,000 PA.

How to stop waste?
Osborne promised that their guiding principles will be:
“A constant process of:
- rooting out waste;
- eliminating failing programmes;
- reviewing procurement;
- publishing spending information online
- increasing productivity
- ending the constant stream of pointless eye-catching initiatives”

Shy and retiring
Osborne also grasped the nettle on the state pension retirement age: for men, it will rise to 66 in 2016 and to 65 for women by 2020. This has to be the correct decision for the medium-term. It probably feels very unfair for those who will be first affected (DOI – I’m not even 40), but it is an acceptance of reality.

It will also have some fascinating impacts on those parts of the NHS which employ significant numbers of older people, albeit that the initial change is relatively slight. Not to mention raising a portfolio of insurance and occupational health issues.

What Lansley said
Oops. Bad, bad joke when you’re meant to be in non-triumphalist mode: Lansley’s lame opening gag of "I'm looking forward to 2010. We've got the team, we've got the captain... I think we're really going to win this time. But you know I'm not just thinking about the World Cup, I'm thinking about the General Election." will surely be seized upon with alacrity by Labour’s election campaign manager.

It was impromptu, and is not on the official version. Find the transcript version here.

Other than that? It’s possible to save £1.5 billion on administration alone in 4 years. Oooeee: “we will cut the cost of health service central bureaucracy by a third during the next Parliament. Primary Care Trusts. Strategic Health Authorities. The health Quangos. And the Department of Health itself. They spend a total of £4.5 billion in administration every year.
So we will cut that bill by £1.5 billion within four years.

All this from the back office to the frontline.
We will tolerate no waste. No inflation. No poor value for money in NHS budgets.”

It sounds unduly like the first stirrings of another NHS redisorganisation, on top of recent comments to HSJ about “organic” changes to PCTs and SHAs self-justifying their existences. What larks, Pip.

A target to end targets
Lansley also remains committed to the end of targets: “We will abolish Labour's political targets.
It is a gross insult to doctors and nurses to say that without the targets, they would let patients wait and suffer. It is increasing capacity which delivered reduced waiting times. If we build capacity and patients use their choice to drive the access they want, we will see waiting times fall and standards rise”.

Yet having announced the abolition of targets, Lansley then set three more targets - sorry, “results”: “We will focus on results.
 One-year and five-year cancer survival rates at least as good as any in Europe; not just a two-week referral to a cancer specialist.
In A&E, reduced mortality after emergency admissions to hospital; not just an arbitrary 4 hour target.
Zero tolerance of hospital infections; not just cutting them by a third”.

This focus on outcomes rather than process measures is the right idea, and should be welcomed. The problem is that "results" do not happen unless they are measured, monitored, benchmarked, checked and compared (it’s wasteful bureaucracy, this stuff). Because whether you call it a target or a result, people will cheat to ‘hit‘ it if the incentives are there. Which they will be.


He also talked of “patients with more control and choice … Giving you the choice of GP.
Giving you the choice of hospital.
Not just which hospital, but allowing you to choose which consultant is to be responsible for your hospital treatment.” It is interesting that the evidence for choice as a driver of NHS service change is not abundant. There were clear successes in London in the mid-part of this decade, accelerated by UCLH’s purchase of The Heart Hospital from the private sector.

There was also a terribly unwise line about guaranteeing “a positive birth experience for all mothers”. Andrew, you’re going to have to redefine “positive” if you stick with that one.

Hard budgets for PBC
It is also clear that PBC is to be retained and turned completely back into GP fundholding, with “family doctors diagnosing, referring and continuing to be responsible for patient's care, all the way through their journey.
Using their budgets to pay for results.
The payment must support both quality and value, with prices which reflect the most efficient hospitals and services, with penalties for poor performance and rewards for quality and better results for patients”.

Lansley has signed up to the Government’s C-QUIN and QIPP agendas, then. That is good for continuity.

Policy on three Es
No, not a reference to the tedious allegations about who smoked or snorted or swallowed what: Lansley has given us three Es: “equity that lies at its core; and we will enhance that by efficiency in delivery and excellence in outcomes.

“Equity, efficiency and excellence.

These, all three, must be defining characteristics of our NHS.
What virtue in efficiency if it is not fair?
And America knows the damage done where there is excellence but not equity.
So our ambition is for equitable access to excellent health care delivered by an efficient service”.

There are some interesting ideas jumbled in there, but a plethora of unresolved and possibly irresoluble internal tensions. In particular, the line he proposes between efficiency and fairness is a highly arguable one: an example or two of the efficient but unfair would be illuminating.

Lansley knows the NHS, and knows policy detail. He is not a fool, though he sometimes has said foolish things. There were some good points in this, but there is a doctrinal-sounding faith in choice and competition. There may be a place for both in the NHS, but the evidence that it is a big place is very sketchy.