Des Spence's latest piece is a strange mixture of sharp insight and
complete nonsense.
He sees through the government's argument that the NHS must improve
because its outcomes are not as good as others' in europe, but fails to
see that there may be other good arguments that suggest the NHS does need
to improve. He correctly sees that aging is not itself suggestive of
increasing demand, but doesn't recognize the real drivers of morbidity or
its cost implications for the NHS. He opposes ideologically driven reform,
but buys the simplistic ideological case against reform.
So how do the arguments stack up?
The government tried to make a simple case for reform based on the
idea that the NHS has poorer outcomes than many other health services in
Europe. This has been shown to be a simplistic and weak argument. But
there is a far better argument that the NHS needs to get better: the
degree of unwarranted internal variation in activity and outcomes across
England (it is not clear whether the government doesn't understand this or
whether it just judges the argument to be too complex for public debate).
As the NHS Atlas of Variation and the Recent Kings Fund report on
variation show clearly, there is far too much variation inside the NHS and
it tends to persist.
The conclusion from the analysis of variation is that the NHS could
be much better than it is, but that movement to improve comes slowly if at
all (suggesting a deep seated failure to learn from experience or to
constantly strive to improve).
It isn't age that drives demand, as he points out. It is Long Term
Conditions (LTCs). These are growing and will cost more, though the reason
why is a lack of a mature relationship between primary and secondary care.
The NHS spends far too much on hospital treatment and too little on
managing LTCs in primary care (this is not so much prevention but better
monitoring and early intervention). When done well this saves cost and
saves it quickly by keeping people away from expensive hospital
admissions. But hospitals have tended to grab too much investment compared
to primary care, making the long term cost position worse.
Des Spence also feels confident in opposing ideological reform which
he interprets as being about pushing the private sector and profit. But
opposing reform on these is at least as ideological as supporting it and
his view misunderstands the thrust anyway. Far more crucial than profit is
competition (which people also oppose for purely ideological grounds). And
there is good recent evidence that profit is neutral and competition is
clearly good for patients. Where he is right but confused is that
government funding of healthcare is cheap and efficient compared to
alternatives, but there is little or no evidence that this means the
government has to run all the provision (would GPs or their patients be
better off if they were all salaried employees of government?)
The crux of reform is a well regulated market where providers compete
for contracts and patients and where expert GPs work with patients to make
sensible choices. This is not a vision of the badly regulated mess of the
USA or the socialist paradise of Cuba.
Rapid Response:
Confused ideology opposes reform
Des Spence's latest piece is a strange mixture of sharp insight and
complete nonsense.
He sees through the government's argument that the NHS must improve
because its outcomes are not as good as others' in europe, but fails to
see that there may be other good arguments that suggest the NHS does need
to improve. He correctly sees that aging is not itself suggestive of
increasing demand, but doesn't recognize the real drivers of morbidity or
its cost implications for the NHS. He opposes ideologically driven reform,
but buys the simplistic ideological case against reform.
So how do the arguments stack up?
The government tried to make a simple case for reform based on the
idea that the NHS has poorer outcomes than many other health services in
Europe. This has been shown to be a simplistic and weak argument. But
there is a far better argument that the NHS needs to get better: the
degree of unwarranted internal variation in activity and outcomes across
England (it is not clear whether the government doesn't understand this or
whether it just judges the argument to be too complex for public debate).
As the NHS Atlas of Variation and the Recent Kings Fund report on
variation show clearly, there is far too much variation inside the NHS and
it tends to persist.
The conclusion from the analysis of variation is that the NHS could
be much better than it is, but that movement to improve comes slowly if at
all (suggesting a deep seated failure to learn from experience or to
constantly strive to improve).
It isn't age that drives demand, as he points out. It is Long Term
Conditions (LTCs). These are growing and will cost more, though the reason
why is a lack of a mature relationship between primary and secondary care.
The NHS spends far too much on hospital treatment and too little on
managing LTCs in primary care (this is not so much prevention but better
monitoring and early intervention). When done well this saves cost and
saves it quickly by keeping people away from expensive hospital
admissions. But hospitals have tended to grab too much investment compared
to primary care, making the long term cost position worse.
Des Spence also feels confident in opposing ideological reform which
he interprets as being about pushing the private sector and profit. But
opposing reform on these is at least as ideological as supporting it and
his view misunderstands the thrust anyway. Far more crucial than profit is
competition (which people also oppose for purely ideological grounds). And
there is good recent evidence that profit is neutral and competition is
clearly good for patients. Where he is right but confused is that
government funding of healthcare is cheap and efficient compared to
alternatives, but there is little or no evidence that this means the
government has to run all the provision (would GPs or their patients be
better off if they were all salaried employees of government?)
The crux of reform is a well regulated market where providers compete
for contracts and patients and where expert GPs work with patients to make
sensible choices. This is not a vision of the badly regulated mess of the
USA or the socialist paradise of Cuba.
Competing interests: No competing interests