Sunday, April 17, 2011


A wag has imagined how Andrew Lansley's NHS bill might be presented if it was a proposal for research:

As there is no overwhelming evidence in support of the proposed changes to the NHS as detailed in the governments' recent white paper, ethically the proposed changes can only take place in the form of a trial. I ask you to consider favourably the following study proposal which I submit without permission on behalf of the UK government.

Title: Reorganisation of the NHS in England

Background: The National Health Service in is its 63rd year. It is suffering the same demographic and technological challenges as all high income countries, specifically ageing of the population and increasingly expensive new technologies. These are major problems that we seek to address.

We also have concerns about outcomes in the NHS when compared with other countries. France spends more on healthcare than the UK, has fewer deaths from heart attacks than the UK, and will shortly be overtaken by the UK in this mortality measure. We determine from this observation that the UK healthcare system is not delivering as much as it should and must change, but not to be like France in funding or structure, and hopefully not in the trend in heart attack deaths. We do not consider this to be an ecological fallacy, and we do not consider any other differences between the populations of France and England.

Study design: Immediate full scale roll out without control or comparison group.

What this study adds to the current evidence: We offer no global, systematic appraisal of current evidence, and take no account of quality of evidence. As lawmakers evidence in the legal sense is our primary concern: oral and written statements from individuals and organisations, and we do not distinguish this from higher quality evidence. We are confident that this study will accrue a substantial body of similar (grade 5) non-evidence with which to inform future reorganisations.

Study population: The entire population of England, of all ages, is served by the NHS, with the exception of the most wealthy, who will be exempt.

Interventions: 1. A market based healthcare system; open to all willing providers. 2. GP based commissioning and the closure of primary care trusts. 3. Transfer of public health to local authorities. 4. Providers that cannot generate enough profit will close, whereas those making the largest profits will succeed, irrespective of the clinical performance. Taxpayer funding will continue, allowing successful firms to become a conduit of money from the many to the few.

Comparison group: None

Outcomes: No a priory health outcomes are specified, although multiple testing, case studies and post hoc analyses are planned by all political parties for election purposes and generation of low grade evidence.

Ethical considerations: No ethical approval has been sought. We acknowledge the risk associated with changing the health service, and are aware that small changes in important health outcomes can cause or prevent thousands of deaths. As we are certain that our approach is correct, we have no stopping criteria.

Consent: Population level consent sought and an election almost won on the basis of: "No top down reorganisation of the NHS". No consent sought on the specific interventions.

Costing: Estimated £1Bn to £3Bn, with potential future savings. Taxpayers are the sole funders.

Potential conflicts of interest: None declared although newspapers report the secretary of state for health has received £21,000 from the chairman of Care UK to fund his personal office.

Thank you for consideration of our proposal.

Dr Lee's tongue-in-cheek summary of Lansley's Health & Social Care Bill is right on the money. For all the Department of Health's talk of evidence-based medicine, no evidence has been offered to back up what is effectively the privatisation of the NHS. A few random, decontextualised and sometimes woefully out-of-date statistics about the UK's mortality rates in some areas than other Western societies have been cynically forwarded to justify full marketisation of the health service.

The NHS, we are told, simply cannot stay the way it is. Reform is essential, and this much at least is true. To meet rising demand, arising from the ageing population and higher expectations from patients, the NHS must adapt and grow. But if the DH chose to look at the evidence (in other words, if it chose not to be so blindly ideological), it would discover that opening the NHS up to the market increases the risks of poorer patient outcomes and higher costs.

A report from the grand dame of health economics, Allyson Pollock, and David Price dissects the legislation with clinical precision. It spells out the following headlines:

- while the public will continue to fund the NHS through taxation, there will be no accountability for how this money is spent. Health services will be commissioned by general practitioners, often via private companies, and provided by independent Foundation Trusts. The direct line of accountability to the secretary of state (and hence to us, the people who pay for and own the health service) will be cut.

- GP consortia, which will commission for their local areas, have the power to decide which health services they wish to purchase, and for whom. The duty to provide comprehensive healthcare will no longer apply.

- This creates a risk that some people - especially "expensive patients" with chronically poor health, or those who cannot pay - may not be covered by the health service. A "safety net" in the legislation states that these people will fall under the "provider of last resort," i.e. the Local Authority. Local Authorities, unlike the NHS, charge for services on the basis of means-testing.

- The power to charge for some health services (e.g. prescriptions) currently lies with the secretary of state. Under the proposals, this power will pass to consortia. Consortia has been given a general power (under section 7, part 2h) to charge for services, and the limits placed on hospitals on the proportion of private patients they can take on will be removed.

- Funding will be allocated to individual consortia on the basis of aggregated patient lists. Given that practices will be able to compete for patients, it follows that some consortia will be left with a less attractive and efficient group of patients. In mitigation, consortia can pool a portion of their budgets in order to share risk; however, the costs of administering such an arrangement is high, and not guaranteed to solve the problem.

- The legislation encourages the opening out of healthcare commissioning and provision to "any willing provider". Commissioning budgets are unlikely to be controlled directly by GPs, but by private corporations. Clinical decisions and referrals will become increasingly influenced by corporate business plans, most notably the need to deliver a profit to shareholders. Similarly, healthcare providers (particularly hospitals) will become independent of the NHS, and they will be regulated on the basis of promoting competition, not patient care.

- If commissioners and providers are allowed - nay, encouraged - to drift away from the NHS, what will be left of the NHS? Nothing more than a brand name, a mechanism for passing our money into the hands of corporate providers.

The RCN's overwhelming vote of no-confidence in Andrew Lansley this week marks the Government's lowest point to date. The Government has announced it will "pause" and "reflect", claiming that it has failed to effectively communicate its message. This is nonsense. Doctors, nurses and patients are quite clear about what this legislation means. It's just that until now, the media has turned a blind eye or failed to analyse the Bill's implications. Cameron's immigration speech on Thursday aimed - rather successfully as it turned out - to deflect attention away from the Government's woes.

But with the majority of doctors and nurses opposed to Lansley's proposals, and the public now starting to pick up on them, the storm is unlikely to die down. Lansley will probably have to go, if only so that Cameron (who, unlike Lansley, clearly has no understanding of the NHS and has looked very out of his depth in the last week) can regain control. It has become the new pub game: what will be the Coalition's poll tax moment? Last week, the privatisation of the NHS took poll position.


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