The TaxPayers' Alliance - Better Government

Prescribing walking to pensioners

There is something awfully patronising about this:

"Doctors should instruct those over 65 to join walking groups and take part in other exercise like swimming and dance classes, the National Institute for Health and Clinical Excellence (Nice) has recommended.

It is pushing the 'walking cure' because more old people feel unhappy now than they did 50 years ago, despite pensioners being more wealthy."

1. When did prescriptions become a forum for lifestyle advice?  They're supposed to be an instruction, primarily to pharmacies, allowing people to obtain specific treatments, not a generalised set of recommendations.  If a doctor thinks that their patient isn't getting enough exercise and should take a vigorous constitutional a few times a week then they should just say so.
2. The same research methods which show pensioners getting better off but not happier over fifty years show roughly the same result for everyone else.  Those results aren't credible.

GPs paid not to refer patients

This, from the Times, appears to be yet another example of clumsy public sector targets.  There should be a balance between keeping unnecessary referrals to a minimum and making sure that referrals are made when they are worthwhile.  The PCTs don't have any direct incentive to provide the service patients want, though, so they will focus purely on keeping down unnecessary referrals to ease pressure on their budgets and may hurt standards of care as a result:

"GPs are paid £1 per patient to spend time reviewing their decision to send someone to hospital and a further £1 for every name on their surgeries’ list if they reduce their previous year’s referral rate. An average surgery with 10,000 patients will receive up to £20,000 for taking part in the scheme.

Eighty out of 82 practices in the Oxfordshire Primary Care Trust area signed up for it this month. Similar incentive schemes have been set up across the country despite the NHS’s National Institute for Health Research (NIHR) giving a warning about the risks. “Financial incentives to encourage GPs to reduce referral rates can be effective, but this is a high risk,” it says. It concludes that reduction “may apply to both necessary and unnecessary referrals”.

[...]

“If [the payment] triggers some sort of thoughtful process, such as talking to a more experienced colleague, then that is commendable and may save unnecessary referrals,” said Professor Roland, director of the National Primary Care Research and Development Centre. “But I would be cautious about incentives simply to reduce numbers if they are not tied to some sort of clinical review. The danger is that patients who would benefit from referral to hospital would no longer be referred.”

Details of NHS staff lost in the post

Lapses in Government data security are becoming incredibly common.  Today, the Telegraph reports another case:

"Four computer discs containing the details of 17,990 current and former staff were lost in July when they were sent between Whittington Hospital NHS Trust in north London and McKesson, a firm providing IT payroll services.

They contained the names, dates of birth, national insurance numbers, start dates and pay details of all staff of Whittington Hospital NHS Trust, Islington Primary Care Trust, Camden Primary Care Trust and Camden and Islington NHS Foundation Trust."

While data security breaches definitely happen in the private sector as well, public sector breaches are increasingly far more common and larger.  This repeated failure is the result of weak public sector management.  The only answer is for the Government to do less, so services are smaller and there are fewer huge databases being sent around, and collect as little information as is necessary - avoiding unnecessary schemes like the National ID database.

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Falling NHS productivity

There has been study after study of NHS productivity since the Office for National Statistics first tried to measure health output.  Since then they have included estimates of the change in quality.  The Today programme reported this morning that their current conclusion is that in recent years there has been a roughly 2% per year decline in productivity.

Had this not taken place we would have a lot more money in our pockets and/or a lot better treatment in our hospitals.  Unfortunately, the Government's constant boasts about 'investment' in the NHS, i.e. spending ever more of taxpayers' money, show that they have only a passing interest in efficiency.  They have thrown so much money at the system that it has led to huge cost pressures, which have absorbed a large share of the extra spending.

In the end, the failure to consider real reform of the health service has wasted money and, more importantly, lives as performance in Britain continues to lag other EU countries.

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Reform release a report on the NHS with Liberal Democrat leader Nick Clegg

Today the think tank Reform have released a new report 'Making the NHS the best insurance policy in the world'.  At the launch the leader of the Liberal Democrats, Nick Clegg, also set out some details of his party's healthcare policy.

The Reform scheme is to reform the NHS to produce a system similar to that in the Netherlands (PDF).  Each person would be given £2,000, roughly the amount that Britons spend on healthcare under the NHS now, that they would have to use to buy health insurance, that met a Government standard for coverage, from a Healthcare Protection Provider (HPP).  Existing Primary Care Trusts would become HPPs and new ones would be allowed to set themselves up.

Some drugs might not be covered in the core - £2,000 - package, just as some drugs are not available on the NHS, and people could either buy those drugs on an ad hoc basis or get additional insurance.  HPPs would face a financial incentive to encourage their members to behave healthily and to buy healthcare as efficiently, getting as much healthcare per pound spent, as possible so that they could offer the best  deal and attract new members.

This system has a lot to recommend it.  It introduces competition and accountability to ordinary people.  Managers of healthcare trusts would no longer be accountable to Ministers in Whitehall, who have little real idea - beyond a small number of dry statistics - of the quality of care being delivered, but to patients.  That kind of competition delivers great results in other countries who spend similar amounts of moeny to us but get vastly superior health outcomes.  It would end the farce of all the hundreds of NHS organisations being theoretically responsible to a single minister who then theoretically represents the public and put ordinary people - who pay for the NHS in their taxes - back in charge.

The only downside is that Reform's plan leaves the NHS still dependent on taxpayer funding.  The mix they propose, where government provides most of the funding and determines the amount of provision required and NHS bodies deliver services, is similar to the way councils are organised.  It is a recipe for confusion and buck-passing if things go wrong.  The HPPs will insist the requirements are too steep or there isn't enough funding in place and the Government will insist the HPPs have to be more efficient.  There will be no way of telling who is correct.  The Dutch system, where people are left with the money to buy healthcare themselves, and the amount they need to pay is determined by different providers competing to offer the lowest price, will lead to clearer lines of responsibility and less government intervention.

Nick Clegg set out the Liberal Democrat plan.  They agree with Reform that more accountability is needed and copayments should be allowed, as it is illiberal to prevent people buying drugs the NHS can't provide.  However, they aim to introduce accountability by introducing elected local health boards (which may be taken over by councils).  The idea is that such politicial accountability will maintain the link between health providers and local communities.  That would probably be a step up from the current NHS monolith but it has serious problems.

Unfortunately, political accountability is a poor substitute for direct accountability to ordinary people who can take their business elsewhere.  Political accountability is slower, less refined (people are usually offered a limited number of slates of positions by the different candidates) and does not allow for different people with different priorities (who under plans like that put forward by Reform can choose different HPPs) - those with minority tastes or needs can't get the provision they want.

It is great to hear that Nick Clegg takes the issue of a lack of accountability in the NHS seriously, and that the Liberal Democrats now support copayment.  However, neither of the schemes offered today is the best way of satisfying the priorities we outlined in our report Wasting Lives (PDF) - an end to centralisation, political management and monopolies in the NHS.

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Debra Freedman: These NHS bugs will bite

Another day, another embarrassing report on hospital hygiene. Today’s reveals that hospitals throughout England are struggling to contain vermin outbreaks in wards and clinics.  The BBC reported yesterday that “70% of NHS Trusts brought in pest controllers at least 50 times between January 2006 and March 2008”.  The figures, brought to light through enquires made by the Conservatives, reveal that ants, rats, mice and fleas are a common feature of many hospitals.

The Healthcare Commission have downplayed the recent revelation, claiming that vermin do not pose a substantial threat to patients. But this meek response can not disguise the fact that there are indeed problems infesting the NHS, many of which are a serious threat to patients.  The day-to-day running of hospitals has been deteriorating under the current government, and will not improve until local hospitals are made accountable for their performance.  Decentralizing the current system- giving local hospitals more power to make necessary reforms and establish suitable pay and conditions - and removing politicians from crucial managerial positions - replacing them with experienced managers and senior doctors – would help move us away from the “hope the bed bugs don’t bite” approach to hospital management, to one where we actually fight the bed bugs.         

Rebrand after rebrand

The Telegraph reports that the NHS is to spend millions on rebranding Primary Care Trusts to NHS X.  This is following in the footsteps of the Norfolk Primary Care Trust that became NHS Norfolk.  This will be the fourth rebranding of local NHS organisations since 1997.  Primary Care Groups were created, replaced by Primary Care Trusts and then regrouped into bigger, regional PCTs.

All this reorganistion is expensive and often leads to administrative chaos.  The Telegraph suggest this scheme could cost £2 million, money that could be better spent on frontline care.  Unfortunately, political leadership makes showy, public phoney revolutions better than quiet, competent administration.

NHS Dentistry

The Telegraph reports on the disaster of the NHS dentistry shake-up:

"This suggests dentists are simply removing teeth rather than taking on complicated treatments because they have become uneconomical to provide.

The report said that in the two years following the introduction of the new contract in April 2006, 900,000 fewer people saw an NHS dentist than in the last two years of the previous system. Even this could be an underestimate, it said.

Ministers introduced the reforms to the dental contract despite widespread concern they would not improve access to care. The contract was so unpopular that more than one in ten dentists refused to sign it and more than a third signed it in dispute.

However, the then health minister in charge of dentistry Rosie Winterton insisted: "The reforms will improve access, encourage more preventive dentistry and provide a stable income for dentists."

So many people saw this problem coming but the politicians ploughed on regardless.  There wasn't even testing done before the system was introduced.  The unintended consequence is that a lot of people are now missing teeth that could have been saved and an increase in spending has been combined with a decrease in provision.  This is yet more evidence that government really doesn't know best.

The public want NHS reform, not more wasted spending

In our report Wasting Lives: a statistical analysis of NHS performance in a European context since 1981 (PDF) we showed how Gordon Brown had tested the idea that more money, without significant reform, would improve the NHS to destruction.  The NHS absorbed a huge increase in funding without the long term pattern in lives saved, relative to European peers, changing.  This divergence between funding and results can be seen in the graph on the right (click for a larger version).  Despite huge increases in spending 17,000 more lives are being lost in the UK relative to EU peers due to higher levels of mortality amenable to healthcare.

A new YouGov poll for the Telegraph shows that the public are now convinced that the NHS needs reform rather than ever more funding in order to really improve.  The Telegraph report that "Sixty-nine per cent of people said reorganising the NHS is more important than spending more on it, up from 38 per cent in 1998."  In our report we set out the principles that should guide such reforms:

1. Decentralisation.  Local bodies in the NHS have little real freedom as so many decisions are made by central quangos.  Decisions can be decentralised to hospitals and doctors.
2. Encouraging competition.  Competition between hospitals and other healthcare providers will hold local providers to account more effectively than national targets.
3. Getting politicians out of management.  The health service is run by politicians with little experience of management or healthcare.  Removing the day to day management of the health service from political control would allow real improvement.

How would we reorganise the NHS?

The Telegraph ask an important question, how should the NHS be reorganised?

Government plans for new polyclinics are facing furious protests and, despite spending £1 billion, government initiatives have not offered significant increases in choice that might drive improvements in standards for patients.

The problem is that the Government are trying to force what should be a decentralising agenda, greater choice within the NHS, from the centre.  Programmes like the National Programme for IT are a huge imposition on the independence of local health providers who, with so many decisions made by central quangos, have little ability to form their own policies.

Instead, as we set out in the report Wasting Lives: a statistical analysis of NHS performance since 1981 in European context (PDF), the NHS needs to be freed from day to day political control.  The NHS needs more decentralisation, competition and an end to political management.  Other European countries, with more effective healthcare systems, decentralise provision to competing social health insurers who buy services from independent hospitals.  Our report concluded:

"Failing to reform the NHS comprehensively leaves British healthcare without the decentralisation, competition and professional management that it so urgently needs. Confused and unstable policy has managed to combine the worst of both worlds through constant transitions but little lasting reform.

The poor performance of British healthcare is not preordained. It is not a price we pay for ensuring that everyone gets the treatment they need, given that the other European countries this study has examined all look after the unfortunate. Equally, our healthcare system has proved unable to make effective use of large amounts of additional resources so this is not a problem that will go away with more money. Gordon Brown has proved that.

Politicians should stop trying to do the impossible and focus on their proper role of setting high-level policy. Professionals working in the health service can enjoy greater autonomy which will make for more satisfying and possibly even less stressful careers. Patients can live longer and healthier lives. All it requires is that we learn important lessons from how other countries organise the provision of healthcare."