Professor Alan Maynard looks for the evidence justifying proposed new changes. And looks. And looks …
“Christianity has not been tried and found wanting; it has been found difficult and not tried” GK Chesterton
Chesterton’s views on Christianity are replicated in healthcare by policy wonks who base their works on faith rather than evidence. The left declare all things “private” to be the devil’s work, whilst the right regard government as twice cursed!
The consequences of this for taxpayers, insurance payers and patients is that their interests come second to ideological combat in the media and Whitehall village.
The pursuit of equity was a reason why both Bismarck and Lloyd George proposed legislation to increase insurance cover over a hundred years ago.
The British had discovered that recruits for the Boer war were unfit due to poverty, whilst the Germans in the late nineteenth century had feared (like Chinese reformers today) that lack of access to health care not only failed to ensure the availability of a fit workforce, it also presented challenges to social cohesion and the maintenance of political power.
The left’s lip service to equity
Nowadays the left pays sadly pays little more than lip service to equity and tacitly agree to the continuing maintenance of the differences in the length and quality of life for rich and poor.
A report on inequalities from the National Audit Office this month has shown that Labour interventions have not worked and that their 2010 target of reducing inequality will not be met. This is a product of a shower of expensive initiatives costing hundreds of millions of pounds - which were poorly designed, executed and evaluated.
The current Coalition government pays lip service to equity but there is an absence of focus on evidence-based interventions such as increasing alcohol and sugary drinks taxes.
The privateers – no smarter
’Private insurers are no better than government at controlling expenditure inflation or ensuring that their scarce resources are used efficiently.’
Groups on the right of the political spectrum would like to replace tax funding with private insurance and user charges and sell off the public hospitals. Private insurers are no better than government at controlling expenditure inflation or ensuring that their scarce resources are used efficiently.
User charges would reduce dependence on public finances - quite attractive in a time of deficit, and would disadvantage the poor and the elderly. This is attractive to libertarians, who believe that citizens should be incentivised to “stand on their own two feet” and be independent of state handouts. The left reject such contentions.
The inevitable product of the left-right ideological interchanges is faith based policymaking i.e. changes in the structures of the NHS which are believed to be efficient and equitable.
Labour abolished GP fund holding as a “failure” in 1999 and then tried to partially re-introduce it in 2006 as “GP practice based commissioning”. It abolished health authorities and replaced them as purchasers-cum-commissioners with over 300 primary care trusts; later reduced to 152 in 2006. They abolished NHS hospital trusts and eventually replaced them with foundation trusts. All these changes were evidence -free and faith-based changes, which consumed lots of resources and diverted managers from improving patient care.
Meet the new boss, just the same as the old boss
Now we have a Coalition embarking on an evidence-free journey heralded by a Conservative policy document written in 2007. PCTs are “rubbish” so let’s replace them with GP consortia, perhaps grouped into 10 area fiefdoms. Let’s have a NHS Board like that in the early Thatcher reforms, which was abolished as ineffectual.
The “Sooty” of New Labour is thus replaced by the magic wand of the Coalition’s new broom “Sweep”, but “izzy, whizzy, let’s get busy” is no substitute for piloting and evidence-based policy change!
Quietly, of course, there are those who would like to privatise the hospitals. To a government faced by a large fiscal deficit and private sector supporters who could capitalise on privatisation like their colleagues did when Mrs Thatcher denationalised the public utilities, selling off the foundation trust hospitals must be attractive.
Such a sale would mean that the NHS is maintained with public finance and consumption of care free at the point of use. It would require rigorous regulation, building on Care Quality Commission and Monitor metrics. There is little evidence about whether an altered public-private mix in provision would improve efficiency; but evidence rarely determines policy, and European countries such as the Netherlands get by with just such a highly-regulated mix of public and private suppliers of care.
Policy debate is often ideological in nature and largely evidence-free. Competing ideologues, like Christians, believe they are right and that if only their principles were applied rigorously, the promised land of efficiency, equity and expenditure control in healthcare would be achieved.
In these technical and empirical issues, faith is a poor substitute for evidence. Furthermore, it damages both patients and taxpayer’s interests.