Health policy in the media
15 to 28 February 2005
In North Wales, Plaid Cymru Assembly Leader, Ieuan Wyn Jones said voting Labour at the General Election will give First Minister Rhodri Morgan a "blank cheque" to continue to mismanage the health service. His party, by contrast, would set up treatment centres across Wales to tackle waiting lists and introduce nurse-led walk-in centres in cities. However he made no mention of the party's stance on private healthcare and, later, parliamentary leader Elfyn Llwyd admitted to the Western Mail that senior Plaid figures had failed to agree whether to ditch their long-standing opposition to using private money in the NHS.[Go to note 2]
Scotland is where debate is most ferocious. In an article headed, ‘just where have all the billions gone?’ an article in The Scotsman (February 25th) said ‘ten years ago the average wait for an NHS outpatient operation was 41 days. Now it is 56 days - more than a fortnight longer. Over this decade, NHS spending has doubled. And this is a national scandal.
[Go to note 3]
Government’s are on the back foot as questions are raised about the level of financial problems faced by NHS organisations; the story is coming through that the cause is the high pay settlements in health professional’s contracts.
Kevin Woods, the head of NHS Scotland says the salary bill for NHS consultants, which rose by £70 million in the last financial year - including £60 million in backdated payments for new contracts - will increase by a further £31 million in 2004-5’. He admitted that the final cost of Agenda for Change ‘would not be known until all non-medical staff had been "assimilated into the new system", but estimated ‘an additional cost of £150 million to £160 million for this year alone’.
Meanwhile, confusion also emerged over the cost of new contracts for GPs in Scotland. NHS Scotland put the total cost was put at £80m while Audit Scotland put the figure at £239 million. An Executive spokesman said that the discrepancy was because it had calculated the difference between initial allocations to health boards and the actual sum, while Audit Scotland had added up the total cost.’
Brian Monteith, the chairman of the audit committee, said " we will want to look in detail at the money spent on modernisation" and that MSPs would be asking some searching questions of Executive officials over the figures.[Go to note 4]
Professionalism
The auditor general is to examine whether the Scottish consultant contract is value for money
It looks like those questions have begun to be asked. According to The Herald, Robert Black, the auditor general in Scotland is to begin an inquiry into the new contract for NHS consultants, following criticisms that the Scottish Executive has committed money for salaries without adequate improvements in productivity.
It won’t stop at consultants either. 'His plan includes a look at ministerial attempts to reduce NHS waiting times by use of the Golden Jubilee Hospital in Clydebank - value for money from the private sector - and will follow-up with an investigation of the new out-of-hours family doctor service'[Go to note 5] and look at general practice.
Other parts of the UK will watch events very closely because they are closely related to all of these questions being asked in Scotland and the outcome of the value-for-money study closely.
BMA Wales calls for doctors to be placed at the centre of Welsh reform
In the Western Mail, Jonathan Osborne, chairman of the BMA Wales’ consultants committee and Dr Richard Lewis, the Welsh Secretary outlined some challenges facing NHS Wales, arguing ‘that change will only come with investment in doctors and medical staff’.
They note the very long waiting lists and times in Wales and ask ‘why do patients from Wales have to wait so much longer than their neighbours in England?’
‘One major factor is a failure to invest in the hospital service in Wales’. Because of ‘record bed occupancy’ levels surgeons are prevented from managing their waiting lists effectively, ‘while physicians do "safari" ward rounds visiting their patients in far-flung corners of the hospitals, usually cared for by nurses not geared up to manage the acutely ill.’
Doctors are working to a higher intensity, under considerable stress while waiting lists grow longer. They are fast approaching breaking point.
‘Every patient would agree that he or she would like more time with the hospital consultant. Most hospital outpatient appointments are severely time limited. Sometimes only a few minutes are available, though in the private sector much more time is allocated, giving the consultant plenty of time to talk things through with the patient and describe treatment options in depth. Time for explanation for both patients and relatives gets skimped on and exhaustion can lead to sub-optimal care and error. As a result, doctors are concerned that patients are not getting the service they deserve.’
‘Consultants who are on call for emergency admissions, or booked for operating sessions, cannot at the same time be seeing patients in outpatient clinics. Bigger teams of consultants would allow more outpatient clinic sessions to be booked so that patients could be seen faster.’
Before the new consultant contract was negotiated between the BMA and the Welsh Assembly Government, almost every consultant employed worked beyond their contractual obligations. On average, consultants worked more than 50 hours a week for the NHS, with one in three working more than 60 hours. This did not include the time spent on emergency recalls to hospital. Consultants were routinely working beyond the 48-hour maximum set by the EU working time directive as a health and safety limit, to the extent that the pressure for quantity was undermining quality.
Although the new contract has clearly defined working hours, consultants are still under a great deal of pressure to see as many patients as possible. Ten per cent of consultant posts in Wales remain unfilled with consultants having to work harder to fill the gaps in the service.
Over the past few years the health service in Wales has been disrupted by an expensive reorganisation that has created a massive bureaucracy of 22 local health boards and with 18 members. No country within Europe has such a complex decision-making process. As a result large amounts of money have been spent on administrative costs.
‘All right, I can hear you saying, where do we go from here? In our view it is about time health stopped being a political football with constant reorganisation letting down patients, nurses and doctors at the sharp end. Doctors who are at the forefront of developing new services and innovation need to be able to help decide where the money is going in a slimmed-down structure where getting a decision is no longer like wading through treacle.’[Go to note 6]
More female surgeons are needed, says the Royal College of Surgeons
According to Royal College of Surgeons (RCS) more female surgeons are needed to help overcome a projected 2,760 shortfall by 2010 because of early retirement and new working practices.
This is a huge number - half the current number of surgeons and the research takes into account surgeons who will graduate from training in the coming years. The RCS study said action was needed now as it takes 10 years to train a surgeon. The government cannot continue to rely on short-term measures such as international recruitment.
There are worries that many surgeons could take early retirement by 2007 as they had reached their maximum achievable pension entitlement and that more surgeons will also be needed as the effect of the 56-hour working week demanded by the European working time directive kicks in.
RCS president Hugh Phillips said the government needed to act straight away if the demand for 6m operations a year was to be met in the years to come.
Dr Alan Russell, deputy chairman of the British Medical Association consultants committee, said: "It is extremely difficult to see how the government can meet its proposed 'patient journey' waiting list target of no more than 18 weeks if the NHS does not have enough surgeons to carry out operations"[Go to note 7]
Barriers to woman doctors entering cardiology
The absence of women role models is turning female doctor off from careers as heart specialists, perhaps the same problem exists in surgery.
According to research from the British Cardiac Society ‘too few women work in this area because of the long hours and the sexism that persists’.
The report says, 'women now comprise 59 per cent of medical school applicants and the quality of female applicants to all specialist registrar posts appears to be better than that of their male peers . . . ' But in cardiology, women make up only nine per cent of all applicants to the posts. In 2002, they comprised less than 17 per cent of trainees in the speciality and just over seven per cent of consultants - figures that have changed little in a decade. This is set against a rising number of consultant cardiologists over the same period - from 381 to 665.'
One female consultant who was interviewed for the research said she had had to change to part-time work because of children and was discouraged from pursuing a cardiology career. Another was told "by a senior consultant not to do cardiology because I was a girl". A third said: "I now realise it's difficult for women to succeed in this field as it tends to be dominated by the boys playing with their toys."
One of the researchers, Dr Flint, called for a raft of measures including the establishment of mentors, more flexible training and part-time consultant posts, and a refusal to tolerate sexism in the speciality. "With the new European Working Time Directive stating that no one should be working more than 48 hours a week, it [cardiology] should not be any more difficult for women than it is for men"[Go to note 8]
Performance
Newpapers reported that doctors work trying to "block" publication of patient mortality rates
The introduction of the Freedom of Information Act last month has accelerated the call for greater openness about individual outcomes. According to the Daily Telegraph 'a number of NHS trusts, including the Royal Brompton and Harefield, in west London, St George's, in south London, and Guy's and St Thomas's in central London, have started to release the figures'.
But until these are perfected, Sir Bruce Keogh, the president-elect of the Society of Cardiothoracic Surgeons, and Neil Moat, director of surgery at the Royal Brompton and Harefield NHS Trust, say there is a real danger that forcing publication everywhere will ‘put intolerable stress on patients, surgeons and the NHS’.
Sir Bruce is working alongside the Government to produce a meaningful national performance table ‘and so is no averse to publication of outcomes’, describes current releases as having "jumped the gun".
"We have been working for some time on establishing a formula that will allow a fair comparison of mortality rates but we are still some way from achieving that. "The last thing we want to happen is for surgeons to turn down certain operations to preserve their record. That is what happened in New York and we should learn from it and prevent it happening over here. "We also do not want to discourage surgeons from undertaking innovative surgery. We need to find a way to give credit to those who push the boundaries whilst obviously preventing any maverick behaviour.[Go to note 9]
Fears expressed by the National Association of GP cooperatives over the quality of out of hours care
The National Association of GP Cooperatives say PCTs have started to cut corners and compromise the quality of the service by failing to keep enough doctors on duty during the evenings and weekends.
The Association’s chairman, Dr Mark Reynolds accused PCTs of being "cost focussed, with quality almost off the agenda". He said resources for out of hours services varied too widely with some ‘spending £5 per patient and others up to £15 for everyone in their catchment area’
PCTs "are not usually funding OOH to the level required. The contracts [they] wish providers to sign are too complex and too bureaucratic" and the resulting insufficient funds lead to "rushed, stressed and unsatisfactory consultations". He cited the North Yorkshire cooperative employing 500 GPs that has already gone into administration.
Chris Town, senior negotiator for the primary care trusts and chief executive of Greater Peterborough said: "The world is changing. GPs stopped having to provide OOH cover in December. This means that a market has been created for the provision of OOH services and "as new providers come into this market, we will see changes in both the way services are provided and who provides them. "Primary care trusts have a balancing act. They need to make sure that OOH services are high quality and they have to make sure that they get the best value for money."[Go to note 10]
Dr Michael Crow of Thamesdoc, which covers 1.5 million people in the South East, said that on their busiest day they handled 2,400 calls in 24 hours. He said: "We are just about managing to cope but if the funding is cut we would struggle. "There is a chronic shortage of money. The PCTs tell us they are strapped for cash and do not have money to give us."
But the chief executive of a South East provider, who asked not to be named, said PCTs were trying to get the service on the cheap: "I pay more to the AA each year in case my car breaks down than we are paid for each patient."
Dr Reynolds plans to ask the National Audit Office to investigate.
The Department of Health said: "PCTs have a legal responsibility to organize out-of-hours services and to enter into appropriate contracts with providers. Providers who have concerns should raise them with the department, but primarily this is a local issue" Julie Wheldon. How out-of-hours system for GPs could cost lives.[Go to note 11]
Healthcare Commission survey finds discrepancies between users experiences of A&E and official statistics
The Healthcare Commission has undertaken one of the largest surveys of NHS patients (n=55,000) and its findings do not fit with the Government's claim that 97 per cent of patients spend less than four hours in the emergency department - only 77 per cent of patients said their visits to accident and emergency departments lasted four hours or less.
The Department of Health insists that the difference between the figures was due to the way they are compiled by the department and the alternative approach used by the Healthcare Commission. Rosie Winterton, the health minister, said: "Our data covers the experience of every attender at A&E, whereas the Healthcare Commission survey only covers adults, excluding children who make up 25 per cent of attenders".[Go to note 12]
A second Commission survey says patients want suggests it is choices about treatment that patients most value
A second survey found that patients think doctors do not give them enough information to make sensible choices about how they want to be treated. It is based on 850 patient completed questionnaires at each hospital between last June and August - and so it pretty comprehensive.
Almost a third of the total (n=144,000) did not feel fully involved in decisions about their medical care.
‘Three-quarters of outpatients thought the doctor fully explained the treatment being proposed and 69% got answers they could understand when they asked questions. Nearly a quarter were not told how they would find out test results; 39% said they were not given information about possible side effects of medications; and 37% were not told about danger signals to watch out for regarding their illness. In A&E departments, 36% said they were not fully involved in decisions about their treatment and 44% of those in pain thought staff did not do everything possible to control it’.
‘Nearly half said doctors and nurses did not address their anxieties as fully as they would have wished. And 49% received no information about the side effects of medication’.
The Guardian said ‘the findings are likely to influence the political debate about giving NHS patients more choice which is set to be a key theme at the general election. They also raise an important distinction. While the Commission did not ask patients' views on whether they wanted choice about where they were treated, it found many wanted more of a say about how they were treated once in hospital. Perhaps the latter reflects choices that are more valuable to them.[Go to note 13]
Scotland treatment rates well behind England’s according to new academic study
Right at the end of February a report from researchers at the University of Glasgow compared Scotland’s progress unfavourably with England’s in seeing new outpatient appointments.
According to Scotland on Sunday, ‘the report has concluded that the English health system has powered ahead of its Scottish counterpart in many vital hospital services, seeing more patients, despite costing less and having fewer doctors.’ ‘English taxpayers pay around £200 less per person for the NHS than do Scots. The English also have only 2.1 doctors per 1000 people, compared to Scotland’s 2.5’.
Dr Matthew Dunnigan, senior research fellow at the University of Glasgow, said: "The difference is in NHS management. If you speak to English doctors they tell you that although it is not perfect, there is a drive and initiative and coherence which is lacking in Scotland."
The new revelations come after damning waiting list figures emerged last week, showing that 113,000 people are on the inpatient waiting list - the highest figure ever.
‘A further 240,371 Scots are currently awaiting outpatient treatment, 45,000 of whom have been waiting for more than six months. By contrast, the number of patients awaiting treatment for more than 6 months in England - with a population 10 times Scotland - is a mere 2,452.’[Go to note 14]
The Scotsman have been encouraging further private involvement in Scotland for some time. They say recent reports all amount ‘to declining productivity after a spell of massive investment by the Scottish Executive. Extra billions are flooding in to the system but patients are finding the returns hard to identify. While England is moving towards reform - emphasising patient choice and radical thinking in the delivery of services - Labour ministers in the Executive are reluctant to follow’.[Go to note 15]
Trade-offs between short and long-term goals
Devolution in health policy expert, Scott Greer, wrote in The Scotsman that waiting lists shouldn’t be the only priority for Scotland’s NHS.
‘The first truth about waiting lists and times is the most easily forgotten: shortening them is a good priority, but not the only one . . . Care for the elderly, improved quality, dental services, vaccinations, medical education, sexually transmitted disease clinics and good post-operative care are all good things that any health service should do that will have no short-term impact at all on waiting lists.
If attention to them means longer waiting lists, that might be a fair trade-off. If moving heaven and earth to reduce waiting is the main thing a system does, everything else might suffer'.
[Go to note 16]
Scottish Executive told to push on in involving the private sector
The pressure continued on Jack McConnell. This time, The Scotsman revealed it was from Labour ministers at Westminster who are furious over his failure to tackle Scotland’s growing health service crisis.
The intense private criticism has been revealed by a senior Labour backbench MP, Eric Joyce who said there is a lot of frustration: "MPs are impatient for improvements in Scotland. "They recognise that it is a difficult political challenge, but because John Reid is a Scottish MP they see what he is doing in England and say ‘Why can’t that happen in Scotland?’
Ross Martin, the chief executive of the Centre for Scottish Public Policy and a former Labour Holyrood candidate, says ministers are "scared" to bring in reform such as foundation hospitals in Scotland. He says, "Scotland’s complete reliance on the state is simply unsustainable" and there is "no coherent programme of public service reform in Scotland" with none of the political parties able to put together progressive measures for change.
A spokesman for the First Minister said "One area where we do agree with Ross Martin is that more should be done to increase choice and diversity in Scotland. "But we are starting from a position where we have a tiny independent sector. Attempts by Andy Kerr to stimulate and grow that private sector are being resisted by most of the political parties".[Go to note 17]
Plurality
John Reid announced the NHS will spend an extra £1bn on buying diagnostic tests from the private sector
As The Guardian noted the move to secure such a large amount of diagnostic activity ‘confirms that Labour is now committed to using the private sector permanently’.
‘Ministers presented the first wave of private sector treatment centres, specialising in cataract surgery and joint replacements, as a temporary measure to bring down waiting times. Contracts were limited to five years.’
‘But the new independent diagnostic centres are a permanent part of NHS provision. The Department of Health said the aim was to create "a sustainable independent sector provider market that can offer innovation, increased capacity and compete with the existing NHS providers".’
This shift in policy and its implications are not being fully debated within the Labour party or in the public domain. It is quite a shift from using the private sector in a strategic way to meet public sector goals and paying for the construction of a market.[Go to note 18]
At least the new contracts have been signed on a better contractual basis. They are "pay as you go" rather than mass purchased slots, which are often paid for and not used. This change, said the HSJ was sign the DH ‘had taken on board the message that PCTs need flexibility when it comes to contracting with private providers’.[Go to note 19]
Reid says NHS is resistant to the private sector
John Reid admitted on Radio 4’s Today Programme that there is a "culture of resistance" in the NHS to private contractors.
In response to warnings from the BMA about mistakes and delays in diagnoses because the company has had to beam scan images abroad, Dr Reid ‘acknowledged that there had been "teething problems" with the contract but said it was leading to big reductions in waiting times for patients’.
Dr Gill Markham, chairman of the BMA's radiology sub-committee, said: "I think everyone acknowledges that it has been a complete disaster." She said doctors did not trust the results they were receiving from Alliance Medical and were being forced to turn to NHS radiologists for a second opinion.
But Dr Reid told the BBC Radio 4 Today programme: "Whenever we change from being entirely reliant on a monopoly of NHS provision and bring in extra capacity, which has been sitting there for generations domestically and internationally, from outside the NHS, we get resistance inside the NHS.
The Guardian noted that senior healthcare managers have written to the Department of Health to complain that the contract, signed last summer, was rushed through and failed to specify proper standards.[Go to note 20]
The NHS reviews thousands of scans sent abroad for analysis following problems
Reports from The Observer that the NHS is reviewing thousands of scans by a private medical company following problems with long delays in diagnosing illness should worry Dr Reid and his private procurement team.
‘The scans were mostly sent abroad for analysis, but because of misunderstandings, language difficulties and other problems, some hospitals experienced long delays in getting results back. In one case, it took four weeks for the company to report on the scan of a woman with a brain condition that can be fatal.’
‘Henry Marsh, a London neurosurgeon, said: 'Normally, a radiologist would have seen this immediately and got her to us quickly. But the delay meant she wasn't seen for weeks. It is pure chance that she survived. My colleagues operated and luckily she is better now.'
‘It is not yet known how many other patients may have had their health affected by delays. More than 27,000 scans have been performed by the private company since last summer.’ By the end of last year it became clear that problems were emerging and the Royal College of Radiologists is now at the centre of efforts to redress the problems.[Go to note 21]
Sam Everington warns that English market forces could soon spread to Scotland
Speaking in Scotland, Sam Everington warned of creeping privatisation of the NHS taking hold in Scotland.
He said the profession faced a fundamental shift in the balance between public and private provision.
"How odd that we should be defending an integrated NHS against the Labour Party that created it in the beginning." ‘He said treatment centres were a "wonderful idea on paper" as they give patients more choice, quicker treatment and release NHS capacity to meet Scottish Executive targets. But the reality was different because reducing NHS activity runs down hospital services and their sustainability’. "They are forcing NHS hospitals to compete with the private sector and in a market, as we know, there are winners and losers. NHS trusts will lose money. The natural consequences are for units to close."
The Press and Journal noted that Scottish Health Minister Andy Kerr is leaning towards greater involvement of the private sector. He recently publicly he praised NHS Grampian for cutting waiting times for heart patients through a joint effort with the company Cardinal In health.[Go to note 22]
An argument for more private involvement in Scottish health provision
Writing in The Scotman, Fraser Nelson says rapid rather than creeping privatisation of provision is just what Scotland needs.
He is optimistic that a new way of presenting the public-private balance could be a vote winner in Scotland.
He notes that Scottish ‘Tories are having something of a Scandinavian love-in’. Their recent seminar on "education and health" in Edinburgh starred ‘various Swedish speakers spelling out how the Tory policies aren’t so mad after all’. ’Their agenda is to persuade Scotland that their voucher scheme for schools and hospitals is actually forward-looking and European. The result is, perhaps, the most successful policy the party has had since its 1997 wipe-out’.
Sweden is a brilliant example for the Scottish Tories because it is a living rejection of the normal left-versus-right labels. Its tax is the highest in Europe, but private companies run Stockholm’s underground system and many of Sweden’s main hospitals.
In health ‘Sweden has an enviable reputation - but not one it bought’. Its health spending per head is £1,300, against Scotland’s £1,600. But again, it’s spent differently - as witnessed in the St Göran’s, Stockholm’s largest hospital. Cut free from the state control six years ago, it became a foundation hospital and its private team started efficiencies. Soon, X-ray costs halved and overall costs dropped 30 per cent. Its average wait for a hip replacement is ten weeks: in Scotland, it’s ten months’.
Any decision not to include the private sector, says Nelson ‘is a political decision - not a financial one’. ‘If the NHS were to allow hip-replacement patients to take the £6,240 cost of their operation and go anywhere, they could have it done in ten weeks as well. But that would be ... well, too right-wing’.
Holyrood’s political arguments remain locked in the past. In the NHS Scotland debate seven weeks ago, the Scottish National Party was up in arms about any hint that ministers would "boost profits of the private sector". If the SNP looked at England, let alone Sweden, it would see its waiting list is in freefall because of the private foreign clinics that have been invited in. But the SNP is starting to view England as the Wee Frees view Las Vegas: a den of sin, with private firms profiting everywhere.
Is this left-wing? Would the pioneers of Scottish socialism - nationalist or unionist - look down at Scotland, with its rising waiting list and say: "Well, at least they’re not boosting the profits of the private sector?"
Nelson says if Scottish Tories pioneer the private sector within clear national goals, ‘it may allow Scots to say, for the first time in a generation: "I’m voting Tory because they’re the only ones with fresh ideas. "If the Scottish Tories make this their own, they will finally give Scotland a reason to vote for them again’.[Go to note 23]
Conservatives unveil health policy manifesto for England
The Conservative manifesto promised "A Right to Choose" any hospital in the UK and "A Right to Supply for any company that could meet NHS standards and prices."
Michael Howard promised health spending per patient would rise by a total of £34 billion, from £1,450 a head to £2,000, under the plans in the Tory health manifesto.[Go to note 24]
Howard's plan to subsidise private operations was seized on by Labour as a threat to the goals of the NHS. They warned the plans would privatise the NHS and introduce basic charges for operations. Neither allegation is particularly strong: the Conservative proposals are not dissimilar to Labour plans and there is no suggestion of NHS patients paying.
Labour accusations incensed The Times. In a Leader they said Labour had responded to Tory proposals with ‘shameless lies’.
‘The proposals unveiled by Michael Howard yesterday contain no such threat. The Tories are promising free treatment for all, in a hospital of the patient’s choice, whether in the independent or private sectors’.
They did, however, note that Labour and Conservative health policies are more marked by their similarities than by their differences. Mr Howard has conceded the need for Labour’s vastly increased expenditure on the health service and has even agreed to surpass it. The central, tax-based funding system has not been challenged.
‘One could say something similar about Labour and the Tories. Yesterday they screamed their differences in order to disguise their similarities. For in health policy they are denying voters the choice they promise patients’.[Go to note 25]
Incentives
Choice of provider not as popular as imagined in France, Germany and Denmark and the practice of policy is not fulfilling theoretical expectations
An article in WHO’s EuroObserver looks at the experience of choice policies in Germany, Denmark and France.
Emerging evidence of the impact of choice policies suggests that most patients are conservative, often preferring the existing level of choice available to them. A low proportion of people exercised choice which and as a result, policy objectives rarely have been fully met.
The factors shown to contribute to low take-up of choice policies include ‘lack of adequate incentives for patients and/or providers, lack of sufficient information, the high costs of obtaining and processing information, institutional resistance and cultural norms’.
At the same time, several of these policies have had unintended or unforeseen consequences, such as risk segmentation. The fact that choice is more likely to be exercised by certain groups of people suggests that policies to extend choice of provider could lead to polarization in other ways, for example between affluent and poor areas, where providers in the former are able to attract better quality personnel.
Other unanticipated consequences include high transaction costs and political risks for government.
Some governments have commissioned independent evaluations of the implementation of choice policies, but on the whole it seems that initial enthusiasm for these policies has been based more on theoretical assumptions about the potential benefits of choice in promoting managed competition within the public sector to encourage them to operate more efficiently and to be more responsive to patients.[Go to note 26]
Simon Stevens argues the market should be protected from government interference
Policy makers in England hope choice will have a greater impact because a much larger proportion of activity will eventually be paid under the tariff.
Writing in the Health Service Journal, Simon Stevens says the government should resist any temptation to get involved in the market. He clearly sees government interference as a threat to formation of a market, which from his perspective, must be competitive if it is to have the desired effect of forcing providers to develop services that are more attractive to patients.
He says three functions in particular need insulating from ‘the inevitable tendency to fiddle. They are
- Regulation of anti competitive behaviour, which ‘might be placed within existing competition structures’;
- ‘patient choice, which might be placed ‘on a legislative footing’;
- ‘payment by results’
Rather like Gordon Brown handing over the setting of interest rates to the Bank of England, Stevens wants the market rules outside political influence. He says ‘the time has come to consider vesting NHS tariff construction in an arm's length technical agency.[Go to note 27]
NHS organisations set to market themselves with advertising to attract patients or - as HPERU’s Peter Simpson put’s it - "goodbye NHS statistics. Hello market intelligence"
According to the Financial Times, the Department of Health is expecting National Health Service hospitals and treatment centres to advertise for business as the private sector becomes increasingly involved in providing NHS services, and patients are given more choice over where they are treated.
"With the extension of choice, hospitals might want to advertise to attract patients and we are looking at the implications of that," said the department. It is also considering approaching the Advertising Standards Authority to decide whether further regulation of advertising to patients by both NHS hospitals and their private sector rivals is needed.[Go to note 28]
Showing it means business the FT noted the government’s appointment of ‘a former marketing director of the electrical goods retailer Comet to prepare NHS hospitals in England to compete with each other to attract patients’. He will head a Customer Insight Unit
‘Stephen O'Brien joined the NHS board in June after seven years with Kingfisher, the international retail group that owns B&Q, Woolworths and Comet. He has now been asked to head a "customer insight unit" (the Health Service Journal said it would be called the ‘Marketing Intelligence Unit’) at the Department of Health to prepare the NHS for the new era of patient choice’.
‘Sir Nigel Crisp, the NHS chief executive, told a conference in London that NHS organisations would have to become more savvy in marketing and advertising themselves if they were to succeed in the new climate.’[Go to note 29]
Crisp is apparently the Advertising Standards Authority about ground rules for NHS trusts to promote their services. The Health Service Journal wondered if it would mean bus adverts reading, "I got a new hip at the Hammersmith", "No MRSA at Mary’s" or "stay loyal to the NHS at the Norfolk and Norwich".[Go to note 30]
According to the DH, the unit is only just beginning work and will be ‘properly up and running by late summer'.
Sir Nigel crisp told a conference in London that organisations would have to become much more savvy in marketing and advertising themselves if they were to succeed as the NHS rolls out patient choice and payment by results.[Go to note 31]
A market for healthcare is becoming nearer by the day.
And finally ... Polly Toynbee says politicians should stop meddling with reform and making enemies of the profession
Writing in The Guardian, Toynbee notes that although politicians say the NHS is "unreformed since 1948" - the fact is ‘the NHS has been pulled up by the roots roughly every five years’.
‘As districts, areas, regions, primary care trusts (PCTs) and strategic authorities come and go, managers waste a year applying for their old jobs under new titles to fit the blueprint of the day. In opposition, Labour vowed to uproot Tory reforms so health authorities and GP fundholders were replaced with PCTs - which looked like GP fundholders and are now rapidly turning back into health authorities. After eight years they still lack the purchasing expertise of what they replaced. Now Tories and Lib Dems promise to tear up the roots again for the same bad reason: to have an eye-catching policy. So if the NHS has a tendency towards inertia, politicians have a far worse tendency towards reform for purely political and ideological reasons. Every time New Labour mouths its reform mantra, the NHS shudders - quite rightly.’
‘Although John Reid is less pugnaciously ideological than Alan Milburn, he still relishes confronting what every impatient health secretary always sees as NHS institutional inertia. Sitting in their Whitehall crow's-nest, they all itch to prod and poke it, do something "new", because they can. But in these days of plenty with tough targets to hit, it would be wiser to work with the professionals who (mostly) burn with an equal desire to make it better.’
‘This week Reid laid into the NHS "culture of resistance" to using private contractors, castigating its "monopoly". It was another negative message, instead of stressing the £1bn more he was putting into diagnostic tests to ease long waits for MRI and other scans. The cash will buy some private scans, but more within the NHS. The total number of private scans will be just 11%. In Reid's vision, the whole backlog will be gone: bottlenecks for scans in Ipswich came down from 35-week to five-week waits by using private contracts. But his other agenda is a strong belief that competition gingers up dozy NHS departments, though he says the gigantic NHS will only ever use 15% private treatments.’
‘He is persuasive, driving towards more capacity, diversity and choice. Private scans, he claims, are far cheaper at the moment. (The NHS protests that contractors only do the simple ones, with no teaching.) Prices are tumbling in a private sector that has had the fright of its life: many fewer patients are paying as NHS waits fall, and consultants' private fees are falling fast too.’
‘But Reid knows the next two years will be bumpy. New blueprints that look fine on paper may cause chaos on the wards. The original plan has been criss-crossed with contradictory add-ons. Since PCTs purchase all care, this is where local democratic accountability should be. Instead, votes are given to transient and faraway users of foundation hospitals. The idea was local autonomy, so how come the micro-managing centre buys all this private provision and forces localities to use it? It has led to spare capacity in some places - and centralised arm-twisting to get it used.’
‘Payment by results sounds good, money following the patient, but ‘no system in the world has done that 100%’. ‘Bankruptcies already loom, as some hospitals might close while others flourish. In theory, Reid celebrates over-capacity: how else do you get choice? In practice, ostentatious waste will be attacked as NHS failure.’
‘All this is political stuff - clever ideas driven by No 10. If using the private sector does act as competitive grit in the NHS oyster, well and good. Perhaps this apparent chaos will prove creative, but there are so many inbuilt contradictions . . . that the NHS trembles.’
‘Her plea is to ‘hear no more cage-rattling calls for more NHS reform during the election. Instead, let Labour start celebrating the undoubted improvements now coming through.’[Go to note 32]
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