Since the local elections and AV referendum last week, the principal victim (aside from a host of Lib Dem councillors) seems to be Andrew Lansley's health reforms, long a matter of controversy for the government. Without wanting to delve into the rights and wrongs of the political battle, let's have a quick look at what's driving the proposals (and some of the opposition).
The rationale for the reforms essentially comes down to two factors: efficiency and patient control and choice.
The efficiency argument:
Lansley tells us that, while the NHS has been delivering improvements, it has been delivering very poor value for money in exchange for those service improvements. This is a fair enough assertion and makes sense when you consider the volume of money pumped into the NHS in the last decade. Lansley blames Primary Care Trusts and the legion of middle managers that comes with them - not exactly an uncommon Tory target. He believes they suck up resources that should sensibly be directed towards patients.
Maybe this is true. However, the NHS has been in a state of Maoist permanent revolution for a long time now. Whether it has been Public Private Partnerships, the introduction of targets, the removal of targets, new PCT's replacing old PCT's, new Health Secretaries replacing old ones, patient's charters and legal rights to care, the NHS has been being formed and reformed for at least a decade. Would not an equally compelling explanation for the NHS's inefficiencies be this constant upheaval? How could any organisation function effectively while keeping up this rate of change? It might well be a refreshing boost for a Health Secretary to turn round and just run the NHS, properly, for a little while. They could spend a few years working out the kinks in the system we have now, getting to know the way it really works and improving it incrementally.
That just isn't sexy enough though. If you were an ambitious minister, why would you go for incremental improvement when you could acquire Bevan-esque fame by introducing the all new NHS panacea? Which brings us on to...
Choice and patient control:
Lansley tells us that our GP knows better how to treat their patients than the central government does. Maybe. I'm sure it's a nice "10 word" political message that plays well in the nursing home heartland of the Tory vote. Then again, as we all know from the West Wing "ten word answers can kill you in political campaigns", and this is a particularly fatuous answer.
Apparently, I will have greater control over my treatment if my GP is involved in commissioning the service. I will be able to choose which hospital to go to and which doctor should treat me. At last, I will be blessed with the final objective of the last two governments: choice in public services! Manna will flow from central government heaven as everyone is treated by their favourite doctors and taught by their preferred teachers... Hallelujah!!
A couple of things spring to mind here though:
1: Will I care?
Having recently broken my leg, I can't help but feel that most NHS users won't really care about choice. At the point where you're wheeled into A&E from your fall or your car accident you're not exactly in any mood to break out the medical journals. Are you seriously going to try and figure out where is the best place to go for a relatively routine operation? No. What you do want, however, is to rely on the fact that there will be somebody there who can perform it competently and quickly. And what do I know about my treatment anyway? I'm not a doctor? I pay for the NHS so that there is somewhere I can go to be told what needs to happen and for that to happen, not so that I can have an existential crisis over the relative benefits of an intra-medullary rod or a full leg cast.
2: Choice is bullshit anyway.
Ok, I'll admit, if I'd just been told I had bone cancer, I'd prefer to go to the best hospital available, spurning my local cheap and cheerful (but not cutting edge) oncologist. But that's exactly the point, everyone makes that choice. Nobody puts their hand up for the inferior treatment, in the same way that nobody puts the bad school down as first choice. The cutting edge hospitals fill up and everyone get indignant when they're told "yeah, you could choose to go there, but there's no way you'll ever actually get a bed there".
Maybe I have to make a trade-off between waiting time and quality. Fine, but what do I know about making that decision? How does my chance of survival alter with untreated time vs. quality of doctor? At the end of the day, I have bone cancer or leukaemia or HIV not a bloody medical degree... Wouldn't I be happier to be allocated a competent doctor by an efficient system that got good treatment to me quickly?
The whole story around choice is pure political mythology. The nature of choice is that you have to give something up to get what you want. That doesn't really work when something's free at the point of delivery...
Finally, a note on private provision:
One massive source of opposition to the bill is that "private companies will take the profitable services, sticking local hospitals with the complicated expensive services"...
So?
If the private company does take the profitable services, that will be because they can do them for less than a public provider (even though they have to factor in a profit margin). This is good news, we are saving money. We can use some of this money that we didn't have before to pay for more complicated, expensive treatments provided publicly. Result!
How on earth can this argument possibly be made in opposition to the bill? Of course, because all private companies are evil, bloodsucking vampire squid squeezing the life out of our beautiful country. Well, maybe, but more on that another day...
The rationale for the reforms essentially comes down to two factors: efficiency and patient control and choice.
The efficiency argument:
Lansley tells us that, while the NHS has been delivering improvements, it has been delivering very poor value for money in exchange for those service improvements. This is a fair enough assertion and makes sense when you consider the volume of money pumped into the NHS in the last decade. Lansley blames Primary Care Trusts and the legion of middle managers that comes with them - not exactly an uncommon Tory target. He believes they suck up resources that should sensibly be directed towards patients.
Maybe this is true. However, the NHS has been in a state of Maoist permanent revolution for a long time now. Whether it has been Public Private Partnerships, the introduction of targets, the removal of targets, new PCT's replacing old PCT's, new Health Secretaries replacing old ones, patient's charters and legal rights to care, the NHS has been being formed and reformed for at least a decade. Would not an equally compelling explanation for the NHS's inefficiencies be this constant upheaval? How could any organisation function effectively while keeping up this rate of change? It might well be a refreshing boost for a Health Secretary to turn round and just run the NHS, properly, for a little while. They could spend a few years working out the kinks in the system we have now, getting to know the way it really works and improving it incrementally.
That just isn't sexy enough though. If you were an ambitious minister, why would you go for incremental improvement when you could acquire Bevan-esque fame by introducing the all new NHS panacea? Which brings us on to...
Choice and patient control:
Lansley tells us that our GP knows better how to treat their patients than the central government does. Maybe. I'm sure it's a nice "10 word" political message that plays well in the nursing home heartland of the Tory vote. Then again, as we all know from the West Wing "ten word answers can kill you in political campaigns", and this is a particularly fatuous answer.
Apparently, I will have greater control over my treatment if my GP is involved in commissioning the service. I will be able to choose which hospital to go to and which doctor should treat me. At last, I will be blessed with the final objective of the last two governments: choice in public services! Manna will flow from central government heaven as everyone is treated by their favourite doctors and taught by their preferred teachers... Hallelujah!!
A couple of things spring to mind here though:
1: Will I care?
Having recently broken my leg, I can't help but feel that most NHS users won't really care about choice. At the point where you're wheeled into A&E from your fall or your car accident you're not exactly in any mood to break out the medical journals. Are you seriously going to try and figure out where is the best place to go for a relatively routine operation? No. What you do want, however, is to rely on the fact that there will be somebody there who can perform it competently and quickly. And what do I know about my treatment anyway? I'm not a doctor? I pay for the NHS so that there is somewhere I can go to be told what needs to happen and for that to happen, not so that I can have an existential crisis over the relative benefits of an intra-medullary rod or a full leg cast.
2: Choice is bullshit anyway.
Ok, I'll admit, if I'd just been told I had bone cancer, I'd prefer to go to the best hospital available, spurning my local cheap and cheerful (but not cutting edge) oncologist. But that's exactly the point, everyone makes that choice. Nobody puts their hand up for the inferior treatment, in the same way that nobody puts the bad school down as first choice. The cutting edge hospitals fill up and everyone get indignant when they're told "yeah, you could choose to go there, but there's no way you'll ever actually get a bed there".
Maybe I have to make a trade-off between waiting time and quality. Fine, but what do I know about making that decision? How does my chance of survival alter with untreated time vs. quality of doctor? At the end of the day, I have bone cancer or leukaemia or HIV not a bloody medical degree... Wouldn't I be happier to be allocated a competent doctor by an efficient system that got good treatment to me quickly?
The whole story around choice is pure political mythology. The nature of choice is that you have to give something up to get what you want. That doesn't really work when something's free at the point of delivery...
Finally, a note on private provision:
One massive source of opposition to the bill is that "private companies will take the profitable services, sticking local hospitals with the complicated expensive services"...
So?
If the private company does take the profitable services, that will be because they can do them for less than a public provider (even though they have to factor in a profit margin). This is good news, we are saving money. We can use some of this money that we didn't have before to pay for more complicated, expensive treatments provided publicly. Result!
How on earth can this argument possibly be made in opposition to the bill? Of course, because all private companies are evil, bloodsucking vampire squid squeezing the life out of our beautiful country. Well, maybe, but more on that another day...
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