Wednesday, December 26, 2012

Hinchingbrooke - a (very minor) correction

Mr Birrell has, correctly, pointed out that I was mistaken in saying that the Public Accounts Committee had condemned the franchising arrangements at Hinchingbrooke Hospital. In fact, the Committee has yet to issue a final report. I should instead have said that members of the Committee had condemned it. I was thinking, in particular, of the closing comments of one of their members in their report of evidence taken: “I have to say, this should never ever happen again, because it is a financial disaster for value for money and for taxpayers.
I should also have mentioned the report into the franchising by the National Audit Office, which was the basis of the Committee’s hearing. Although measured in its wording, concludes that “The Authority should work with the Department to undertake a formal lessons learned process before agreeing any further franchise agreements.” This is on the basis of a long catalogue of problems, including a lack of clarity about transfer of risk and what measures of success were being used. One of the Committee members, used to reading these reports, describes it as “probably the worst report of financial incompetence in the NHS that we have seen. The chair noted that “I haven’t read a Report as bad as this on the health service. This is probably the worst.”
The views of the members suggest a fairly consistent tone of incredulity, such as “this report is chock-a-block full of people saying, "Never before anywhere in the NHS has this level of savings been achieved." McKinsey, who are probably the consultants who are around the NHS more than anybody, say that they think it is unachievable. We accept that it is early days. We know from Mr Parsa that they have not got to where they planned to be when they put the bid in to you. We know from the document here that they added 25% savings in at the last minute to give you a viable bid that you could accept. You seriously sit here and think that that will be achieved? You are seriously doing that?
Of course, as the evidence presented to the Committee and the NAO report indicate, there are many serious concerns about the franchising process, and not just the fact that Circle has a get out clause if it racks up excessive losses. But then, maybe this is unsurprising, given the description of the calculation of risk in public-private partnerships as "pseudo-scientific mumbo-jumbo".
I do hope that this has put the record straight. The Committee has not yet reached a considered conclusion on the Hinchingbrooke franchise but, I would suggest, it is already pretty clear what it is likely to be.

NHS privatisation - we are right to be afraid

Just before Christmas David Cameron’s former speechwriter, Ian Birrell, wrote in praise of private sector involvement in the delivery of healthcare (NHS privatisation fears? Grow up). It is no secret that many members of the current government see the NHS, along with the BBC and the Royal Mail, as ripe for privatisation (or what you and I might describe as untapped opportunities for profiteering by their friends and supporters in large corporations). Yet Birrell’s enthusiasm for privatising the NHS overlooks two fundamental characteristics of private companies. They hate uncertainty (as their advocates tell us again and again) and they will invest their capital wherever they can be sure of making the greatest profits.

For health care to be attractive to them it is necessary to distort the delivery of care so much as to make it almost unrecognisable. As Margaret McCartney has set out in detail in her excellent book, The Patient Paradox, it must exclude anyone whose condition cannot be put into a tidy box and costed. Hence, the concern he voices for elderly and disabled patients seems at odds with the profit imperative to get rid of them, ideally to the social care sector where their care will be means tested. As we have shown in a recent paper, this is only part of a multipronged attachment on older people (or as certain politicians would say, sotto voce, those who have outlived their usefulness). Consequently, while no-one wants to see older people stuck inappropriately in hospital, we must consider the motives of those now suggesting that they should never be in a hospital at all. Recall that, in many cases, it is only possible to know that someone is entering the final few months of life in retrospect. The exclusion of old people from the health system will free space needed to screen the worried well until some harmless anomaly can be found and treated at a guaranteed profit.

Private providers will only contract with the NHS if the market is rigged in their favour, for example by capping their losses as happened in the deal with Hinchingbrooke Hospital, since condemned by the Public Accounts Committee. He invokes Germany as an example of a country where the private sector is heavily involved in health care delivery but seems unaware of the very different model of Rhineland capitalism in force there, with trade unions represented on supervisory boards of firms. The benefits of this approach over the Anglo-Saxon model we use have been set out at length by Will Hutton. The situation in our two countries is entirely different.

Birrell’s claim that “competition works in health, just as it works elsewhere” displays an ignorance of a literature stretching back fifty years. The theory was set out in 1963 by the Economics Nobel Laureate Ken Arrow and the empirical evidence gathered since then. He must surely know that the research he cites has generated results that are medically implausible and have been heavily criticised.

People with complex disorders, cannot be commodified. The abject failure of the market-based health system in the USA to improve health outcomes, despite spending vast sums of money, should give him pause for thought. On a whole range of measures, the NHS in the UK outperforms those in other industrialised countries. When someone is proposing something so completely at odds with the evidence, it is only reasonable to ask why and who will benefit?

Friday, August 17, 2012

My perspective on London 2012

This blog originally appeared on the LSHTM site

Something quite remarkable has happened to me in the past 10 days. Normally I find televised sport barely more exciting than watching paint dry and I share Dr Samuel Johnson’s view that patriotism is the last refuge of a scoundrel.
Yet, somehow, I’ve found myself avidly watching sports events that, if I knew they existed (omnium, keirin?) I certainly didn’t understand the rules. Now I’m even beginning to understand what the judges are looking for in gymnastics, beyond not falling off the apparatus. So what has happened?
It began even before Danny Boyle’s fantastic opening ceremony. What an amazing surprise! But there was the clue. It was a surprise even though many thousands of people, the performers, the technicians, those present at the rehearsals, knew what was going to happen.
But they kept it to themselves so that they wouldn’t spoil the surprise for the rest of us. Not because they were threatened with arrest under the many powers that the British government now has to prevent freedom of speech. Rather, because Danny Boyle asked them to.
And what a surprise! A feat of sheer technical mastery, with the most amazing special effects presented with superb timing. A combination of seriousness (the tribute to the dead in the London bombings the day after London was awarded the Olympics, even if not shown in the version on NBC in the USA) and comedy (combining the queen – not Helen Mirren but the real one – and Mr Bean). But above all, a celebration of Britain, showing where it has come from but also where it is going.
There was something for everyone, with Chelsea pensioners alongside rap artists. Well, not quite everyone.
There was Aidan Burley, the Conservative MP who complained on Twitter of “multicultural crap” and a columnist in the Daily Mail who ridiculed the idea that one could find an ethnic minority father living with a white British family in a stable family union. He obviously didn’t know who Jessica Ennis was, but presumably he does now as the story has been removed from the paper’s website.
But the storm of protest that these comments provoked showed that, at a time when politicians are doing their best to divide us, vilifying migrants (perhaps we need a few more like Mo Farah), older people (like Hiroshi Hoketsu, the 71 year old Japanese equestrian  team member who is at his last Olympics as his horse will be too old at Rio), and anyone who is different, the vast majority of the British people realises just how much we benefit from diversity and we will not tolerate those who seek to divide us.
And of course we have the actual events. For years it has seemed that there has been no association whatsoever between ability and fame in Britain. News stands are lined with “celebrity” magazines telling us the latest exploits of some sad individual plucked off the streets to be exploited by the producers of reality TV, the modern equivalent of the Victorian habit of going to Bedlam to laugh at the lunatics.
Now they are covered with images of people who really do have talent and, most importantly, have worked to develop it. The commitment that these athletes have made is remarkable. Interviewed after winning Gold in the 10,000 metres, Mo Farah said that running 120 miles a week was hard, and long distance running was lonely. What an understatement!
Yet, as Malcolm Gladwell wrote in his book Outliers, real success at anything seems to require about 10,000 hours of work. What a difference from today’s celebrities with their 15 minutes of fame.
Of course, none of this could have happened without the volunteers. People of all ages, smiling and cheerful even in pouring rain, doing everything possible to welcome the world to this great cosmopolitan city. What a contrast to those who sought to exploit the games for profit.
The reputation of G4S, which so spectacularly failed to provide the security it promised is now in ruins. Coca-Cola and McDonald’s sponsorship of the games has simply attracted attention to the contrast between the health promoting focus of the games and the health damaging effects of their products.
The involvement of ATOS in the Paralympics, given its treatment of disabled people being assessed for work has appalled those who watched recent television investigations into their practices, is beyond parody.
But here I am rather more pessimistic. Will anything change? The idea that G4S should receive any money for its lamentable performance is bizarre and, if they do, it begs the question of what was going through the mind of whoever wrote the contract. How can they possibly be allowed to bid for another government contract for many years?
And now we must look forward to the legacy. These games have surely inspired countless young people to take up sport. Few will become the elite athletes winning medals at future Olympics (although some will). But that is not the point.
In a country with rapidly increasing rates of childhood obesity, what we need is simply to move us all up a notch on the activity scale. But this means investment. We are forever being told by ministers seeking to cut spending that “it is not simply a matter of money”.
Maybe not entirely. But Britain’s success (recall the one Gold medal at Atlanta) is very substantially about money. Yet there are now real fears that as soon as the Olympics are over the budget for sport will be slashed.
This would be a tragedy and the British people must not allow it to happen. What is more important – high quality sports facilities in every school or a nuclear deterrent almost entirely under American control and which no-one can suggest a realistic scenario in which it would ever be used?
This takes me to my final point. What the Olympics have shown is that government works, whether in its investment in athletes or its stepping in, with the armed forces, when a private corporation fails (yet again).
If a government funded sports strategy can work so well, why do we seem so determined to avoid a government funded industrial strategy? The reason that politicians were given brains was so that they could learn from experience. Now is the time to break the habit of a lifetime and do so.

Monday, February 27, 2012

Politicians and media pundits from across the political spectrum have been lining up to compare the Health and Social Care Bill to the Poll Tax. The comparisons are obvious. A seemingly simple idea that was scrambled beyond recognition as it was transposed into legislation, that was hugely unpopular, unworkable in practice, and which ended the career of a member of the cabinet and his prime minister. Yet there is a much more recent analogy, Tony Blair’s decision to invade Iraq. The parallels are striking.

Few questioned John Major’s rationale for going to war with Iraq in 1990, given that it had just invaded Kuwait but, a decade later, many people struggled to ascertain quite why we were attacking Iraq, given that the countries most closely linked to the events of September 11th were Afghanistan and Saudi Arabia. Similarly, having been promised “no top down reorganisation of the NHS”, many were extremely puzzled when the Prime Minister proposed to do exactly that.

Tony Blair needed to provide evidence to justify his decision, giving the English language the alliterative term “dodgy dossier”. David Cameron had to do the same so he produced statistics that seemed to show the UK underperforming on a wide range of measures, from health outcomes to patient satisfaction and productivity. Yet within days the evidence was discredited. Although deaths from heart attacks had lagged behind France, they were catching up very rapidly and would overtake it with a year or so just by doing more of the same. The public was not clamouring for change; satisfaction with the NHS was at an all time high. And, as a recent Lancet paper showed, the story of declining productivity is a myth.

But there was other evidence underpinning the government’s case. In 2000 it was secret material that we were unable to see on grounds of national security. Now it is a risk register that must be hidden lest it alarm us.

Of course, Tony Blair could point to the widespread international support he enjoyed. Countries such as Georgia, Macedonia, Latvia and Albania, each contributed a few companies of troops to the overwhelmingly Anglo-American effort, encouraged by some judiciously targeted financial support.  Yet the big guns, such as France, were missing this time round. David Cameron can also point to support, from groups such as National Association of Primary Care, which on a good day could also contribute the equivalent of a few companies, although as disillusionment has set in even among these groups, it might be more optimistic to hope for a platoon. In contrast, the Royal College of General Practitioners, comprising the equivalent of four NATO divisions, is displaying open disdain. Almost all of the other Royal Colleges, each of which could contribute at least a few brigades, are equally perplexed, with the few that continued to believe that the government must understand what it is doing, such as the paediatricians and physicians, finally jumping ship, just as Turkey when it realised the folly it risked being sucked in to. Then there are organisations that have discovered, to their bemusement, their names listed among supporters of the Bill (or at least of its highly debated “intentions”) when they are nothing of the sort, just as Costa Rica and the Solomon Islands had to ask to be removed from the list of members of the “coalition of the willing”.

In 1990, Tony Blair made clear that, once the troops had deployed to Saudi Arabia, there was no going back, regardless of what decisions were made by the UN Security Council, in the same way that events in the first few weeks of the First World War were dictated by the railway timetables. Once started, they could not be stopped. In 2012, even though the Bill has not even been approved by parliament, and indeed if it is, it is unlikely to bear much resemblance to what it looks like now, David Cameron says that it is essential to advance and any delay will cause chaos. Those warning that chaos will instead be the consequence of advance are ignored.

In 2000 the invading troops were closely pursued by a pack of multi-national corporations, such as Blackwater and Haliburton, salivating at the prospects of the vast profits they were about to make, accompanied by organisations whose ownership and business model was opaque in the extreme. In 2012, the Health and Social Care Bill is being pushed forward by a different set of corporations, such as McKinsey & Co and KPMG, again accompanied by operations such as Circle Health, whose business model in Hinchingbrooke Hospital remains a mystery to outside observers.

Finally, there is the aftermath. Few believe that life under Saddam Hussein was perfect. Yet what came after was far, far worse. What will happen if the Health and Social Care Bill is enacted is a matter of speculation. However, virtually all academic analyses have concluded that what emerges will be more expensive, fragmented, and dysfunctional.

David Cameron has frequently claimed to be continuing policies on public sector reform begun by Tony Blair. History will judge whether this is the only thing that these two prime ministers have in common. Indeed, there may be a case for booking Sir John Chilcot and his inquiry team to stay on to explain how we failed to learn from experience yet again. 

Monday, January 30, 2012

I'm grateful to Lucy Reynolds for additional analysis of the latest YouGov poll on attitudes to the Health and Social Care Bill. The survey was of 1601 NHS staff and was conducted between 17th and 20th January 2012.

If you take out the don't knows, the figures work out like this:
Of those who expressed an opinion:
80% expect the new system to be more costly, 89% think it will increase bureaucracy, and 78% think it will be more fragmented. 84% expect quality of care to deteriorate as a result of the passage of the Bill.
91% think the reform will introduce too much competition, and 87% expect privatisation of services to increase. 83% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.
80% consider that the Health and Social Care Bill should be withdrawn entirely. 
71% think that Andrew Lansley is failing in his role as Secretary of State.
77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available.
Raw data (before correction to remove don't knows):
72% expect the new system to be more costly,
83% think it will increase bureaucracy, and
68% think it will be more fragmented.
74% expect quality of care to deteriorate as a result of the passage of the Bill. 81% expect privatisation of services to increase.
Two-thirds of people polled think that the Lansley reform will make the NHS worse (66%) and that the Health and Social Care Bill should be withdrawn entirely (65%).
84% think it will introduce too much competition.
78% expect there to be loss of access to healthcare services for some of the population and 68% are expecting it to lead to the introduction of user fees.
71% think that Andrew Lansley is failing in his role as Secretary of State.
77% feel that it is in the public interest for the Risk Registers that the government has been told to produce to made available.