A productivity challenge too far?

It is ironic that this short but hard hitting paper comes in the same week that the priority setting debate between politicians hits an all-time low. The Labour Party’s offering for the week was the NHS Check Report while the Conservative Party’s offering was its response: that no care should be rationed on cost.

Trying to understand the reasons for such derisory contributions to the financial challenge facing the both NHS and Society is hard but the following are offered:

• Wilful or neglectful ignorance of the facts.

• Delusion because politicians appear to genuinely believes that 2 and 2 equals 5. The political tactic of creating ‘facts’ and ‘self-evident truths’ by repeating statements over and over again may have resulted in self–delusion.

• Deception because politicians want votes and keeping the public believing that they can have everything they want seems to be the best way of getting them.

The ‘shock’ and outcries of ‘unacceptable’ from the mouths of politicians last week at the suggestion that any treatment should be rationed are likely to be viewed as being little short of disingenuous by anyone holding a budget anywhere in the NHS.

The postcode variations which have the most impact on inequity of access arise from: inequitable distribution of resources (with Chelsea and Kensington PCT, for example, getting 20% more funding than has been allocated to it while other PCTs serving poorer populations get less than they have been allocated), inequitable distribution within the locality with GPs serving wealthier populations being more likely to overspend their budget allocation while those serving poorer areas under spending and, finally, clinical variation. To illustrate the last point - if clinicians in one area do 100 more caesarean sections in response to patient demand (as the politicians would have the NHS do) than another area – about £100,000 additional funding will be required. Such practice will have a ‘post code’ knock on effect on other services as it reduces the overall funding available. These important issues are barely discussed in the context of rationing within the NHS le alone in the public domain.

And the politicians are not prepared to acknowledge the current scale of rationing. One year a PCT had to decide how to distribute the £5 million across £46 million of worthy service developments that were needed. In the end there was little decision to be made as NICE’s mandatory technology appraisals came with a bill of £5 million.

At no time over the last 20 years has the NHS been able to look to politicians for leadership and guidance on the issue on priority setting and none can be expected to help deliver the ‘Nicholson’ challenge (let alone the ‘Douglas’ challenge which is staggering if true). Politicians' behaviour will not change. The public will remain in the dark, in part because of Society’s own ambivalence about facing up to the implication of scarcity. Civil servants will continue to praise the Emperor’s new clothes and keep their private thoughts to themselves. The NHS will continue to be asked to turn straw into gold (through ever increased productivity). The only rationing allowed will be covert (which means only affecting those without a voice). Industry will be kept happy at all costs regardless of the relative value of their products. Everyone will kick the commissioner. What is the chance that we will face up to the relative reduction in funding available for health care with honesty and courage? And if we do not how can Society and the NHS make the best and fairest of decisions?