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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The danger in picking rotten cherries
- Mark Struthers (7 October 2005)
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Universal or selective healthcare?
- Paul J Clift (9 October 2005)
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Anti reform rhetoric requires outrageous assumptions
- Stephen I Black (12 October 2005)
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Why are the privatisers so certain?
- Rodney G Bullock (13 October 2005)
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cars and people
- Ian D Nesbitt (17 October 2005)
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Cars, people and evidence
- Stephen I Black (21 October 2005)
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Mark Struthers, GP Bedfordshire, UK
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Robert Lane and Alex Paton present the basest evidence that the NHS is being taken over by big American business. The overwhelming force of evangelism would appear to be that it is necessary to destroy in order to achieve healthcare salvation. When, I wonder, will UK political ‘Cherry Pickers’ realise that the US is not a ‘Cherry Orchard’ for the NHS. Competing interests: None declared |
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Paul J Clift, Patients' Representative (HIV/AIDS) Lawson Unit, Royal Sussex County Hospital, Brighton, BN2 5BE
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Dr. Mark Struthers wonders when UK political ‘Cherry Pickers’ will realise that the US is not a ‘Cherry Orchard’ for the NHS, and as a patient, so do I. At the heart of this debate is the question of universal healthcare versus selective healthcare for those patients who can afford it. It is the latter that we see in the American system, in which impressive care and treatment is often available to those who can afford it, but denied to those who cannot. For example, in my field of HIV/AIDS c. 125,000 people in the USA with HIV who know that they have this infection and who need medications to control it are denied treatment because they can't afford it. My fear is that the creeping privatisation of healthcare in the UK will lead to a similar situation becoming the norm here. With healthcare in the hands of private and/or corporate shareholders, who cares if individuals go without care and treatment if the dividends are high enough? Competing interests: None declared |
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Stephen I Black, Management consultant london sw1w 9sr
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It is distressing that the debate on reform hasn't moved beyond the rhetoric in this article. It is a good rhetorical point to bring up the experience of health in the USA. But, unless you subscribe to some bizarre conspiracy theory requiring deeply corrupt politicians and private contractors, nobody in their right mind regards the USA as a model of anything good in health. The subtle point behind the rhetoric is to disparage any element of reform that is also present in the US health system. But is simply doesn't follow logically that, because something is part of the US health system it is automatically bad. The more substantive piece of rhetoric--and the one capable of doing far more damage to our ability to improve healthcare--is the antipathy towards private sector involvement and profit. It sounds plausible that "money that could go towards clinical care is diverted to corporations and their shareholders" but the assumptions and implications of this rhetoric are dangerous and unsustainable. The idea that profit is bad is, or ought to be, ludicrous. Apply it to the cars we drive or the food we eat and you can see why. We don't say that Toyotas are bad cars because money that should have gone into making better vehicles has been diverted into shareholder's dividends. Toyota makes money (and Rover is bankrupt) because Toyota is better organised than Rover at making good cars. We get better, cheaper cars AND the shareholders make more money. Tesco is not an enormously profitable supermarket because it diverts money away from serving us quality food at good prices in convenient locations, but because it is better organised to do those activities than its competitors. The idea that competition and profit are obviously bad in health relies on the assumption that everything in health is as efficient as it can be so the only source of profit is cutting services. This is the dangerous piece of the rhetoric because it distracts us from the manifestly obvious point that not every hospital in the NHS is equally well organised. Those of us who bother to read Audit Commission, Healthcare Commission or NAO reports and who work trying to improve how parts of hospitals are organised, know very well how big the variability in performance in the existing system is. The way you organise a hospital (eg, how you schedule staff in A&E or how you coordinate the flow through beds) makes an enormous difference to how well the system works. The implication of this is that dramatic improvements in the efficiency of healthcare are possible. The opportunity for profit (or whatever the surplus is called in organisations like Foundation Trusts who don't have private shareholders) comes from those efficiency improvements. The rationale for reform is to incentivize the system to pursue those improvements. The problem with an unreformed centrally-planned NHS is that the allocation of resources actually disincetivizes such improvement (we allocate more money to hospitals with problems and take money away from those who underspend their budgets). Good ideas about organisation may be developed but they don't spread or flourish. Medical staff can work diligently for long hours in a badly organised system and deliver poor quality care. The same staff organised differently can deliver more, high quality care in less time. There is plenty of hard evidence of this and it makes a much more convicning case for reform than aggregate comparisons between whole health economies (which, as Allyson Pollock points out, are not convincing). The real debate on reform should be about whether the new reforms are likely to lead to incentives that encourage continuous improvement in how we organise our healthcare. If we continue to stick to the rhetoric of the current debate we will deny that improvement is even possible. Competing interests: Management consultant working in health |
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Rodney G Bullock, Retired general practitioner N/A
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Am I the only one heartily sick of hearing about ‘market forces’. Not because it has replaced ‘42’ as the answer to all things in the universe but because it is the last thing that corporate capitalists believe in. They much prefer the much more profitable mechanisms such as cartels, hidden subsidies and predatory pricing. When competition is introduced into the NHS, the level playing field disappears for mysterious reasons. When the Tories encouraged outsourcing of cleaning services in hospitals, some in-house cleaners formed cooperatives and bid against the private firms. Suddenly the government introduced an ‘x-factor’, which, applied in the specified way, always made the outside contractor the more competitive even though they were more expensive. A similar gnomic figure always made PFIs better value than financing hospital building in the old way. Allyson Pollock was scurrilously attacked in a cowardly way by the Commons Select Committee on Health, under the cover of parliamentary privilege, for pointing this out. These ‘correction’ factors have now been abandoned when calculating the money NHS and private hospitals will get for an identical procedure. The private concern simply gets more despite avoiding complex cases and much lower overheads. That is transparent, at least. The ‘marketisation’ of the health service is being driven by a small coterie of ideologues in Downing Street. Alternative voices are deliberately shut out. Tony Blair, in his ever-accelerating drift to the right, has taken it all on board and is now obsessed with his ‘legacy’ and accelerating the changes to the point of destruction. It is redolent of the Conservatives’ haste when they privatised the railways. I suspect there has been little cabinet discussion (nothing new there). Someone said that the most dangerous people in the world are those who think they are always right and I fear that the hubris of the prime minister is going to cause terrible harm to the NHS. Patricia Hewitt seems to think that some destabilisation is a good thing, a bit like the old ‘if it’s not hurting, it’s not working’ cliché. That she can say this without causing uproar amazes me. If voters see their hospital close because of this experiment in neo-liberal economics, New Labour will be out. If the changes survive, those who are watching ‘Bodies’ on TV at the moment might view repeats in ten years and sigh with an aching nostalgia, ‘Ah, those were the days!’ Mr Blair talks constantly of ‘reform’, a word he has rather devalued. I always think of people like Wilberforce, Fry and Nightingale – and Beveridge. The marketeers suffer from the TINA syndrome (there is no alternative): it is either central control and inefficiency or marketisation. There are other ways. If central control is no good, why not devolve control to the periphery? If you are going to reform, why not consult the work-force or even, heaven forbid, the electorate? The government’s reforms so far have not been a massive success. Targets distorted clinical practice and led to some absurd situations in A & E departments, and PFIs seem to be on the way out. The PCTs have been created, merged and morphed, all within a couple of years. For all their use of ‘business-speak’, with its ‘tranches’, ‘roll-outs’, ‘stake holders’ and ‘re-engineering’, the government is hopeless at managing and would not last a week in business. Competing interests: None declared |
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Ian D Nesbitt, consultant anaesthetist Newcastle NE7 7DN
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Stephen Black feels that the NHS should be more like a car factory. It is very telling- and disappointing- that a manager involved in healthcare makes such a comparison. Profit is not bad, but people are not cars. Toyota sells cars only to those with money to buy them. If you can’t afford it, you do without. The NHS provides care for those who need it. If you can’t afford it, you still get it. If Toyota do well, they make a profit-and keep the money to use as they see fit. The NHS is given whatever amount of money the Government sees fit. The structure of a hospital is more interwoven and interdependent than a car factory. Toyota can subcontract far and wide, can pick and choose where to build factories, can import cheaply made parts from overseas. Most NHS hospitals have significant “must have” departments, often uneconomical (elderly care, mental health, Accident & Emergency etc). Without these pivotal departments, whole hospitals can fail through lack of clinical support or training recognition. Additionally, NHS hospitals do not have the luxury of being planned and built where the profit is, but must be placed where the service is required. Perhaps a better model of efficient hospitals in Mr Blacks view is that of Independent treatment centres (ITCs)? As described in Lane & Patons article, ITCs cherry pick cases, fail to provide a full range of clinical services (sometimes even fail to provide services for which they have already been paid), and fail to adequately train medical and nursing staff. They are not even on the same playing field as their local NHS Trusts, let alone using the same rules. No wonder they are seen as efficient models of care delivery. Inaccurate official statements (like those of Patricia Hewitt about ophthalmic surgery) do little to help. I suspect that much of the vaunted money for front line services simply leaches out the back door of the NHS to private consultants, advisors, and diverse healthcare organisations, rather than funding internal reforms on the real frontline. How much has been spent on waiting list initiatives, Alliance Medical and the like, rather than improving the ability of the NHS to deliver? Mr Black states that “The real debate on reform should be about whether the new reforms are likely to lead to incentives that encourage continuous improvement in how we organise our healthcare”. Incentivizing the service may be part of the solution, but the constant, unremitting, ideologically driven (not evidence based) reforms that make our NHS resemble more and more the health care system in the USA does nothing to motivate the majority of healthcare workers in this country. Competing interests: NHS worker |
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Stephen I Black, Management Consultant london sw1w 9sr
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Here are a couple of comments on the responses above. Dr Bullock characterises me as a "privatiser". I'm not: I believe that market forces offer a way to drive improvement in parts of the NHS even while most of the system stays under public ownership. One of Dr Bullock's statements is that reforms so far have not been a success. But the performance of English A&E departments has been transformed in the last 4 years (unlike their Scottish, Welsh and Irish (N&S) who didn't try incentives and targets). While there have been reports of distorted clinical practice there have not been many and the overall experience of patients has improved dramatically (5 years ago about 1 in 4 waited more than 4 hours for admission or discharge, in the last 6 months fewer than 2 in 100 have waited as long). Dr Nesbit choses to misread my analogy with car manufacturing. My original point was that we cannot argue that profit is universally bad or incompatible with the general good of consumers or patients. While I didn't say that hospitals should be like car factories, perhaps I should have. Dr Nesbit is wrong to assume that hospitals are more complex than factories. What they are is far better organised to perform their activities. Toyota's factories take a good deal more care about how they make their cars than the some hospitals take over treating their patients. Patients' are far more important than cars, but the NHS takes a good deal less effort to ensure their well being than Toyota does with its cars. Toyota thrives because it understands how to continuously improve how it organises what it does; anti-reformers in the NHS more or less deny that improvement through better organisation is possible. Dr Nesbit is also wrong in assuming that hospitals have inherently uneconomical departments. The evidence behind the introduction of Payment By Results suggests something different. For any given department (eg A&E) some hospitals seem to be able to operate much more efficiently than others. The payment system is designed to reward the efficient and create an incentive for others to become more efficient. By design there cannot be sytematically inefficient departments. The idea is that the good departments should be an example to the bad and drive overall improvement across the NHS. There is plenty of detailed bottom-up evidence that some hospitals are much better organised than others. If the bad ones were to copy the good ones both the experience of patients and medical staff would be better. But the anti-reformers continue to deny that better management is needed or that incentives might promote improvement. Competing interests: Management Consultant who has worked in health |
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