Health policy in the media
October 10th to 17th 2003
Convergence and divergence between political parties’ health policy
In the post conference season, clear lines between party policies are being formed, writes Patrick Wintour in The Guardian, though these seem quite subtle. ‘All three parties are now making a virtue of choice both as a lever to improve the quality of public services, but also to satisfy the demands of a consumerist age. Labour sceptics worry whether the narrow emphasis on consumerism squeezes out the wider social democratic virtue of citizenship. Some senior liberal democrats are also doubtful that parents and patients see a nation-wide choice of school or hospital as a panacea: they just want their local teacher and nurse to do better’ Patrick Wintour. As conferences end, election talk begins. The Guardian; 11 October 2003: 13..
Health policies from the main parties
Labour -
Introduce foundation hospitals with freer borrowing controls currently confined to hospitals with three star rating. Introduce DTCs with the private sector. Cut waiting times and by 2005 allow every patient a choice of four or five hospitals in which to have operation, including one private hospital with full state payment. By the end of 2005, all 12m first out patient appointments will be booked using an online system
Conservative -
State to meet 60% of cost when patients go private, including the chronically ill. Those who have the NHS through taxes, but reduce queues for others by going to voluntary, not-for-profit or private sectors should get helping hand. Patients to be able to choose any hospital they like to undertake operation in the NHS. Independent board to be responsible for allocation of NHS funds. All immigrants to be health screened
Liberal Democrat -
National insurance increases earmarked for health. Make NHS more democratic by putting authorities under the control of regional assemblies and giving assemblies powers to raise or lower level of NHS contribution. Make PCTs accountable to local councils. Accept more flexible forms of health ownership, but no foundation hospitals. People will be free to choose their preferred hospital using national waiting time database
The joining of choice and localism brings with it an inherent tension: between individual and collective preferences, consumer and political choices. The aim of policy is that ‘choice is to be the driver Nicholas Timmins. Freedom comes at high price. Op Cit’ toward responsive local organizations shaped for the public good. John Reid says, “It’s no good giving people power to exhibit their preferences if you don’t allow the providers to exercise their judgement in responding to local people” Lynne Eaton. The Clausewitz of the NHS. BMJ news; 11 October 2003: 890. The relationship between “choice” and “new localism” is now akin to “patient preference” and “organisational response”.
At the same time as politicians have come to see themselves as directly responsible for the good management of public services there is a growing realisation that politicians cannot run big enterprises. ‘The result has been the still disjointed search for a new localism’ Nicholas Timmins. Freedom comes at high price. Financial Times; Oct 16 2003: www.ft.com accessed same day and the promotion of patient and parent choice to alter provider behaviour. This week’s summary concentrates on these themes that are paramount across policy discussions.
In-house Downing Street Guru of choice-in-public-services, Julian Le Grand, is beginning to set out the intellectual stall for government policy. In the New Statesman, he explains how competition will enhance patient care if resistance to proposals can be overcome. Services will still be funded by taxation and free at the point of use so fear of private finance should not be a barrier. “Knaves” – who are fearful of change and ‘self-interestedly protecting jobs and income’ need incentives to behave differently. But others need to be reassured in different ways. They have a ‘more sophisticated’ critique of choice and competition – ‘a belief that reforms in some way damage public sector values’. Le Grand calls this group as “Knights”, ‘public-spirited activists’. This group need to be persuaded that ‘competitive forces ‘improve the position of the less well-off’ and that competition between providers for patients gives the public more power and redresses the one-sided power in monopoly relationships, manifest in ‘arrogant consultants’ and ‘insensitive teachers’. There is little equality between patients and provider ‘instead, there is deference and resignation on one side, and indifference and condescension on the other’. Drawing heavily on philosophy he argues that far from markets being destructive, ‘a positive case can be made that, with the right structures, competition and user choice have the moral virtue of encouraging a respect for users in a way other systems do not’ Julian Le Grand. Competition in public services has the virtue of encouraging respect for their users. New Statesman; 13 October 2003; 27-29..
In response, Kevin Curran, general secretary of the GMB, said Le Grands “medieval name-calling” was simplistic and missed the actual problems facing public services in this century. The answers, he said, “will not be found in the abstractions of dead philosophers” Andy McSmith. Public sector workers are ‘knaves’, says Blair aide. The Independent; 12 October 2003: www.independent.co.uk accessed same day.
For the press, the moral of the Evan Harris resignation story - from his position as Liberal Democrat health spokesman to spend what time he can with his terminally ill partner - was a grave personal tragedy and typical of ‘the doctor knows best culture’ that needs to change James Chapman. How NHS failed top MPs dying lover. Daily Mail; 13 October 2003; 1.. Dr Harris himself said he had “no doubt that the diagnosis could and should have been made earlier and the reason for this omission was a straightforward failure to take seriously the complaint of the patient and the concerns of her family. “What I want to say is that I hope this case is a salutary reminder to doctors working under pressure in the middle of the night that they should consider carefully what patients are saying” Press Association. Departing Harris urges doctors to listen to patients. SocietyGuardian.co.uk; accessed Monday October 13th.
Concerns about the promotion of choice in healthcare
Many would agree with the aim of strengthening relationships between patients and professionals. But not all think choice and competition is the way to best achieve this. A “Knightly” stance was taken by Geoff Martin – London convenor of Unison - against the introduction of market mechanisms to force providers to become more responsive. He sees the opening of Britain’s first private sector ‘casualty unit’ as ‘an opportunistic attempt to exploit public fears about the state of the NHS’. The appearance of a more user-friendly service hides huge pitfalls. For example, ‘Casualty Plus is anything but the institution the name suggests’. It ‘can only provide a service for mobile patients requiring a limited range of minor treatments, between the hours of 7am and 11pm and for an initial charge of £29 just to get the meter rolling. ‘How the entrepreneurs behind this unit…got the name past trading standards defeats me. I suppose that the more accurate description of…”first aid plus” would have fallen flat in publicity terms’. ‘Casualty Plus have also had the bare-faced cheek to exploit Bevan’s original guiding principal for the NHS of being free at the point of need, claiming that their mission is “access to healthcare you need when you need it” leaving out the two key caveats provided you can afford to pay and provided you don’t need anything very complicated’.
A retreat from mutual values
Martin cannot understand why the government has tacitly welcomed its introduction rather than opposing it and sees it as an erosion of public sector values. ‘Casualty Plus haven’t even denied that they will be poaching the government’s much needed staff from the NHS and have justified this approach on the ground that they won’t need that many – yet’. Symbolically it means those that pay can have prompt service and others that cannot afford it will have to take their ‘chances with the tattered, second tier safety net in the public sector with its demoralised and burnt out staff’ Geoff Martin. A glorified first aid post. The Guardian; Monday October 13 2003: www.SocietyGuardian.co.uk accessed Tuesday 14th October.
A doctor wrote to The Guardian noting that ‘thousands of residents in Islington and Camden appear to be receiving leaflets inviting them to become “members” of UCLH foundation trust. ‘The leaflet tells potential members that they will receive…no preferential treatment, but then goes on to list Bupa-like benefits, including “discounted health checks”. We always thought free health checks were one of the universal benefits of an NHS funded by taxation. ‘This is a stark and early example of how foundation trusts would blur the distinction between the NHS and private medicine. Be warned’ Dr Fiona Campbell. More verbals on the NHS. Letter to The Guardian; 17 Oct 2003: www.SocietyGuardian.co.uk accessed same day.
Concerns about the implications of policies to promote choice come not only from within Labour ranks. Philip Collins who is director of the Social Market Foundation – another think tank – has concerns about Conservative Party policy to subsidise the cost of private treatment. “Paying for them would cost serious money”. Collins worries how clearly policies to stimulate use of the private sector have been thought through. “If you’re a shadow minister and you criticise the government the question always comes back – what would you do? “It doesn’t particularly matter that many of these policies are not properly thought through. Apart from idiots like me – who cares?” David Smith. New Blue policies, but will they work? Sunday Times; TimesOnline: accessed Sunday October 12 2003.
Frank Dobson does. And ‘If “Real Labour” had a patron saint, it would be Frank Dobson’, according to the opening paragraph to a Guardian interview with the man. ‘As a former health secretary, Dobson’s views are particularly significant: he believes a two-tier health system will be the inevitable result. Critical of increasing reliance on abstract intellectualising in the formulation of health policy he says current plans “re-introducing competition in the health service” will set “hospital against hospital”. ‘Dobson claims that people don’t necessarily want a wide choice of hospitals – “what they really want is to have a good hospital in the area that they live in”. “We all know that where there’s a market, the people with the money get the best deals. You can’t say that promoting and encouraging individualism is part of Labour’s traditional values.” Jackie Ashley. The unofficial opposition: furry, fearless and perfectly Frank. The Guardian: Monday October 13: www.SocietyGuardian.co.uk accessed same day
Choice changing service provision
According to Jo Revill writing in the New Statesman, ‘it was always going to be a pensioner who would test the resolve of the government when it came to patient choice’.
Increasing overseas provision?
More patients may opt for overseas treatment following a court ruling in the case of Yvonne Watts. The 72 year old from Bedford lost her case against Bedford PCT to recover the money she had paid for an operation in France on a technicality. But the Judge ruled that ‘the state could not refuse to authorise treatment abroad’. He was ambiguous about time people should wait before heading abroad To go abroad patients will need the support of a GP and consultant: not as long as a year, but perhaps more than 3 months. For Jo Revill the important point was ‘waiting lists are no longer a barrier to a persons right to healthcare’. A graphic appeared in the article with the names of overseas providers and their prices – often cheaper than the NHS. John Reid responded by calling for patience, “the NHS cannot reduce waiting lists overnight”. ‘Realism is all very well’, but this attitude ‘appears to fly in the face of the government’s promise to give patients more choice’ Jo Revill. The case that alarms health ministers. New Statesman; 13 Oct 2003: 20-21..
The UK independent sector is in an uncertain behaviour
Given widespread fears of growing privatisation, it is perhaps surprising there are those that fear for the survival of the British independent sector. The Business reported a suspicion that the Government had deliberately isolated BUPA and GHC from opportunities in response to their ‘exploiting their dominance of Britain’s private hospitals’. ‘The Business understands this was an intentional snub designed to send a message that the Department of Health is prepared to wait for new entrants to build facilities rather than pay a premium or spare capacity’ Fraser Nelson. NHS puts over charging BUPA in isolation ward. The Business; 12 October 2003; 30. In the view of one analyst it is the biggest challenge the UK private sector has faced since the NHS came into existence Nicholas Timmins. Private hospitals facing their biggest challenge. Financial Times; Oct 15 2003: www.ft.com accessed same day. Professor David Hunter says they will ‘either have to defend their traditional market in the face of NHS waiting times which might be falling quite fast, or lower their costs and become a serious supplier to the NHS’.
A press release from Laing & Buisson offers an interesting view of independent sector prospects. It begins by noting the medically insured population is “static” but that incomes have been sustained by steady demand for self-pay treatment as well as ‘higher spending on private hospital services by the NHS’. However, ‘challenges lie ahead’. Self-pay income may have ‘reached a peak’ given the NHS commitment to pay for provision from different sources. And although plans to offer choice of provider present opportunities, ‘there are doubts over whether existing private hospitals will find NHS tariff prices sufficiently attractive’. While newcomers to the market - overseas providers of independent sector treatment centres - ‘may in due course be poised to eat into existing private hospitals’ core privately funded market Laing & Buisson. Healthy private hospital market – though challenges lie ahead. Press release; 17 October 2003.’
In what ways is choice likely to change healthcare provision in the NHS?
Among both supporters and opponents of choice is a shared view that the extension of choice will change service patterns in unanticipated ways. Eamon Butler, director of the Adam Smith Institute, who is a supporter of choice, argues that it can and should change the pattern of service provision. Most experience of choice has been in education. “We’ve seen in Sweden, where they’ve adopted something similar, that supply does respond to demand. “They’ve seen literally hundreds of new schools being set up, often as a result of collaboration between groups of parents and teachers. The key thing about all this is that it brings competitive pressure to bear” David Smith. Op cit.
However, a joint report from Ofsted and the Audit Commission, suggests that competition between English schools may not have had entirely positive effects. It said, ‘Parental preference exacerbates a number of problems. An unpopular and low-attaining school with spare places may lose more pupils, becoming the only school in an area with places for excluded or mobile pupils and so entering a spiral of decline. The expansion of popular schools is no panacea Ofsted and The Audit Commission. School, Places, Planning: The influence of school place planning on school standards and social inclusion. October 2003 .’ The Independent reported this as: ‘the Government policy allowing parents to choose their child’s school is polarising the education system and trapping poor children in the worst schools’ Poor pupils are trapped in bad schools, report warns. The Independent; Tuesday 14 October: 11.
Will the introduction of choice into healthcare have different consequences? The impact is unlikely to be exactly the same. Hospitals cannot cream-skim with the same precision; the nature of demand is also different. Hospitals that attract fewer referrals will as a consequence offer speedier access. They may attract patients that choose to be seen quickly. On what basis will patients be encouraged to make choices: by speed of access or quality of outcomes? How will the latter be gauged? Different motivations behind choice may distort any measure of popularity. Perhaps some patients will choose to wait. Either because they prefer to be seen locally or because they prefer to be referred to what they perceive is a better service; it will be interesting to see. Another difference between health and education is that hospitals have greater potential to specialise. Schools may build a reputation for maths or sport, but hospitals may respond to new financial flows with increasing dexterity, which is what the Government wish to see. Perhaps though this will mean some hospitals specialise in only preferred specialities; perhaps many hospitals will prefer the same areas.
Nicholas Timmins makes the point that the precise shape of choice and localism are very difficult to anticipate. ‘The new structures also bring with them new regulators – a body to oversee foundation hospitals which, depending on how it behaves could heavily constrain hospitals’ operational freedom – while the precise impact of the new, elected, governing councils on foundation hospitals can, at present, only be guessed at’. So while there is much talk of new freedoms, their real scope and impact remains uncertain. The journey from command and control to greater local freedom and accountability is only just beginning.’ Nicholas Timmins. Freedom comes at high price. Op Cit.
One of the obstacles along the road is that people within the system may not behave according to the assumptions of policy. Already, within the Cumbria and Lancashire strategic health authority, doctors have not provided enough patients ‘to allow South African surgeons to carry out more than 200 joint replacements planed over the summer in Southport, Merseyside’. Asked for an explanation, a past president of the British Orthopaedic Association said, “we do not regard it as a satisfactory long-term solution to transfer patients to private care in non-NHS hospitals”. In response, the StHA has ‘decided to “go over the heads of staff and advertise in local papers”. ‘The health authority issued a press release inviting patients across the north-west who had not been contacted by their local hospital to phone in. “The response was massive. We had in the region of 500 calls although not all patients were suitable”, said Sue Thompson, project leader Nicholas Timmins. Health chiefs advertise to attract patients. Financial Times; Oct 15 2003; www.ft.com accessed same day.
UCLH has begun to ‘treat patients from Devon, Cornwall and Birmingham after it publicised that it has spare capacity for NHS patients’. The hospital is considering advertising directly to patients, but chief executive, Robert Naylor says at the moment “I don’t think the culture is conducive to that. People would complain that we were wasting public money on advertising that could be used to operate on patients” Nicholas Timins. London hospital treats provincial patients. Financial Times; Oct 17 2003: www.ft.com accessed same day. Another report appeared about a group of London hospitals forming a trading organisation – NHS Elect – to offer its spare capacity to ‘every health authority and trust in the country at NHS rates’. The organisation is making ‘videos so that patients can see where they will be treated. Like Robert Naylor, NHS Elect has considered direct advertising but have “held off for the moment” Nicholas Timmins. NHS group offers fast-track surgery. Financial Times; Oct 16 2003; www.ft.com accessed same day.
Patient choice will impact on service patterns, but as yet it is difficult to predict how: plans are moving all the time and patient and referrer behaviour cannot be anticipated. We will learn most from next April when the first wave of foundation hospitals will be subject to new financial flows a year prior to other hospitals. This means they will have a year more experience and 12 months longer to begin to market services and test out ways in which service provision may be changed.