The desperation to leave a legacy, after 13 years in opposition, seems set to plague the current Conservative government as poor reforms are hastily implemented. Michael Gove has struggled to find support for his restructuring of the education sector, and so too has Andrew Lansley for his projected changes to the NHS. It is not so much the objective – after an age of fiscal ill-discipline it is a necessary requirement to work to a smaller budget – that is objected to, but instead the speed of the ill-thought out reforms with, seemingly little consultation or evidence to support them.
Despite the coalition government’s agreement to “stop the top-down reorganisations of the NHS that have got in the way of patient care”, Lansley intends to restructure the healthcare system by abolishing 152 primary care trusts and 10 strategic health authorities. He intends to set up consortiums of GPs in their placeto commission the £80 billion a year of healthcare. In his plan, GPs choose the providers; inducing competition in order to improve efficiency.
Yet the proposed NHS transformation has fuelled fear of an impending piecemeal privatisation as the government opens up a part of its vital welfare programme to the free market. It represents a “profound shift in power away from the NHS and the principles that underpin it” says trauma surgeon Catherine Blake in a blog post for Channel 4, and “the end of the NHS as we know it” according to the chair of the Royal College of GPs it is. This is surprising considering the Conservatives appeared to be pro-NHS pre-election.
The fear comes from the price-based competition being implemented. But will variable-price competition work in healthcare markets? It seems counter-intuitive to compete on price rather than quality in healthcare, yet this is the direction proposed by Lansley.
Surely there is compelling evidence to suggest that these proposed changes would be effective. The Tory government certainly believes there is and have flooded the media with data condemning previous results and supporting a competition-driven change. In reality though, there is little evidence to support this.
In his Bad Science column for the Guardian, Ben Goldacre recently highlighted four papers that studied GP fundholding (which is similar to the proposed GP consortiums):
- Kay (2002) found it was introduced and then abolished without any evidence of its effects;
- Greener and Mannion (2006) saw varied results, but no evidence that patient care was improved;
- Coulter (1995) found no sign of any improvement in efficiency, responsiveness or quality
- Petchley (1995) found insufficient data to make a judgement.
The evidence so far is ambiguous and in no way supports the argument that shifting the onus onto GP consortiums will be any more efficient than the current set up.
In fact, some academics believe that the actual process of restructuring is counter-productive in itself. The argument goes that the perceived failures of healthcare commissioning are the result of constant change and disruption over the past 30 years, in which health bodies have been created, merged, and abolished at least 15 times.
According to Kieran Walshe, professor of health policy and management at the University of Manchester, these changes were often “initiated in advance of formal legislative approval, the details of reforms being worked out as they are implemented, and the timetable for hasty consultation and implementation being a matter of weeks or months.” And of the latest reforms? He believes they “look likely to make all these mistakes again.”
Furthermore, the transition faces further costs in terms of both money and service. Closing down, merging, and creating different bodies in the NHS will be expensive due to redundancies, redeployment, and finding new premises. Using the National Audit Office’s survey data, Walshe estimates that this may well cost between £2bn and £3bn. The transition also creates a distraction that can affect service performance. It not only demands managerial and clinical time and effort, but employees will also be uncertain of their future.
So are reforms necessary? If we rely on the evidence given by Cameron and Lansley, the need seems great. According to the official ministerial briefing for the Health and Social Care Bill, the UK spends the same amount on healthcare as France, yet it has double the rate of death from heart disease. This data is deceptive though when taken out of context, as John Appleby, the chief economist at the British medical Journal, noted recently: “not only has the UK had the largest fall in death rates from myocardial infarction between 1980 and 2006 of any European country, if trends over the past 30 years continue, it will have a lower death rate than France as soon as 2012.” Appleby further observes that this trend was achieved with a slower rate of growth in healthcare spending than France. The most recent OECD spending comparisons (2008) showing that the UK spent 8.7% of GDP on health, whereas France spent 11.2%.
The government’s cherry picked statistics misrepresent the performance of the NHS and, far from highlighting the need for drastic restructuring, points towards the need to persevere with the current system. It also exposes the changes as far more ideological rather than a reaction to any great need, with the data being employed for political expedience.
Improving the NHS through structural reform is a decent objective, but not if it undermines the foundation of the institution through privatisation. Changes need to be scrutinised carefully and debated openly, in and outside of parliament. Many reforms instigated through ideology are left open to reform every time a new government comes in. Therefore, as an open letter from a doctors’ campaign group explains, the government needs to implement a “pragmatic, centrist philosophy for a sustainable state-run healthcare that could command widespread support for many years to come”.
This is not done by hurriedly bundling together an ideological reform package that attempts to revolutionise the NHS, as Lansley is attempting. This already has widespread opposition and carries a huge risk of major failure. As Catherine Blake says, in her damning assessment, “it is a phony revolution, driven not by patients or clinicians, but by business interests. Less of a cure, I would say, more like a second dose of the same poison.”
<— Article first published in Equilibrium during Spring 2011