The Hon L de Mocrat MP
House of Commons
5 February 2011
Dear Mr de Mocrat,
I am writing to you to express my serious concerns about the Health and Social Care Bill (2011), in the hope that I – along with many others who are similarly concerned - can prevail upon you to vote against it. I would also like the opportunity to discuss this with you further at one of your constituency surgeries.
I have been a doctor for five and a half years and as such have seen how the NHS works (and how it doesn’t). I am currently a surgical trainee, working at Bristol Royal Hospital for Children. In common with all trainees, I have previously worked in various specialties; including cardiothoracic, intensive care, colorectal surgery, vascular surgery and ENT.
In my view the Health and Social Care Bill presents a plan of reform that is unnecessary, unworkable, unwanted and ultimately counter-productive. Whilst I do not agree with some who view the bill as the ‘death of the NHS,’ it is – in my opinion – a dangerous step in that direction.
The primary justification used by the government is that the NHS is expensive and delivers poorer outcomes than comparable countries.[1,2] This analysis can charitably be described as flawed or perhaps, more precisely, as very misleading. The NHS is surprisingly efficient, delivering comprehensive healthcare coverage for around £1700 per person. A recent report noted that the NHS is the most efficient healthcare system in the seven countries they looked at. (The seven countries were The Netherlands, Germany, The USA, New Zealand, Canada and Australia). Most of the developed world uses insurance-based systems requiring another level of bureaucracy that the NHS does not have. Only a small part of NHS care is provided by for-profit providers. Taking these factors into consideration, it becomes less surprising that the NHS is more efficient than alternative systems and that so much of the NHS budget is spend directly on patient care. It is also worth noting that the widely-reported flat-productivity of the health service is not necessarily correct. A more detailed analysis by the University of York shows that productivity is actually improving and that the ‘flattening’ was in part due to external influences such as the Working Time Directive and that some of the spending was on longer-term investment and hence the output from that spending will not be seen immediately. Furthermore, healthcare productivity should always be interpreted with great care as crude productivity can always be improved at the cost of quality. A good example from the acute surgical ward that I worked on until recently was the decision to reduce the number of trained nurses on the morning shift from four to three. Simplistically this will look like a productivity gain as the same number of patients are being cared for, the same number of operations are being performed, and yet the unit now has lower costs. However, the nursing staff themselves will tell you that the quality of care has fallen and they are frustrated that they do not have the time to deliver the level of care they want to.
International comparisons of healthcare outcomes and conclusions about the healthcare systems must be approached with caution. Not least because there are several factors that impact on outcomes at least as much as healthcare itself, such as poverty, genetics and cultural factors like smoking and drinking. Furthermore, changes in healthcare systems and spending often take time to feed-through to changes in outcomes. Two noteworthy articles in the British Medical Journal challenge the government assertion that the UK is lagging behind our European neighbours: Analysis of cancer survival data shows that fundamental differences in the way that countries collect the data may significantly affect the interpretation, this combined with the fact that it is well documented that UK patients present later than in other parts of Europe may mean that the NHS is actually over-performing relative to other European healthcare systems. Similarly John Appleby, from the independent Kings Fund wrote the following:
“The official ministerial briefing for the Health and Social Care Bill states that despite spending the same on healthcare, our rate of death from heart disease is double that in France. Although statistics from the Organisation for Economic Cooperation and Development (OECD) confirm that in 2006 the age standardised death rate for acute myocardial infarction was around 19/100,000 in France and 41/100,000 in the United Kingdom, comparing just one year-and with a country with the lowest death rate for myocardial infarction in Europe-reveals only part of the story.
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. These trends have been achieved with a slower rate of growth in healthcare spending in the UK compared with France and at lower levels of spending every year for the past half century”
Despite the fact, that until very recently the UK has spent less on healthcare then comparable countries, the death rates from heart disease are falling faster than other countries and similarly the UK has the most rapid improvement in cancer survival of all European countries.
At a time when the NHS is being asked to make unprecedented savings, it seems to me, ludicrous for £2-3Bn to be directed towards reform. Even supporters of these reform measures admit that the promised medium-to-long-term savings of these reforms are optimistic and that the reforms have with them significant dangers. Inevitably, patient care will suffer as a consequence.
It is good politics to talk about given more power to clinicians – in the form of GPs - to decide on patient care. Whilst I work in hospital medicine and therefore do not have direct experience, I know that most of my GP colleagues are not enthusiastic. Doctors are trained in patient care, they are not trained in administration. It is misleading to think that the decision making will be made solely by GPs. They do not have the time or the training to commission services effectively. Many do not have the inclination. I am fully in favour of more clinician involvement in management, and particularly strategic planning. There are some GPs who are very keen to be involved in this. However, forcing this role on all GPs will simply mean that the consortia either employ those laid-off by the Primary Care Trusts or contract it out to the private sector. This will result in a multiplication of work for the hospital trusts who currently have contracts with a small number of local PCTs, who will now have to have contracts with multiple consortia.
Similarly, training is being squeezed. As a doctor in a training post, my basic salary is paid by the Severn Deanery, who are responsible for post-graduate training and appointed me. My hospital only pays a third of my salary. Already, training posts are being slashed. The hospital trusts still have to fill their rotas – to ensure patient care, therefore they have to directly appoint doctors to what are known as ‘trust-grade posts.’ The full costs of these doctors is paid by the hospital. Therefore, with less training posts, the trusts costs are increasing, whilst their income is static. This is one of the indirect methods in which hospitals budgets are being cut. It also means that in five to ten years-time there will not be enough consultants or qualified GPs. The lack of consultants will cause waiting lists to increase massively – and we have just spent a lot of money to bring them down. (It is much cheaper to keep them down than to decrease them). Insufficient access to General Practise results in an increased burden on A&E departments. The increased role of private providers is also concerning as they already cherry-pick services. This is problematic as hospitals inevitably have to cross-subsidise services in order to function and the private sector does not share the burden of the cost of training. One estimate of this is that training costs the NHS £5Bn per year. With the increase in competition, especially from private providers who do not have the same responsibility for training, there is a very real risk of training being squeezed out. Training is expensive but obviously, absolutely vital to long-term planning.
Public satisfaction with the NHS is at an all-time high. The NHS is much better than it was a decade ago. The more the public know about these reforms, the less they want them. Similarly, doctors, nurses, managers and professionals-allied-to-medicine are all against the reform. It is unusual that all these different groups agree.
There does seem to be an unshakable belief that competition and free-markets are the solution to all problems. We know that privatisation does not work when it comes to armed forces. Similarly I would argue that the market does not really belong in healthcare. The extreme example of this, of course is the American system with astronomical costs and around 20% of the population without healthcare. Similarly detailed analysis by the University of Bristol of the effect of competition in the 1990s with fund-holding GP’s showed that direct competition between hospitals resulted in a reduction in the quality of care. Using mortality after myocardial infarction (heart attacks) for their analysis they showed that death rates were increased by competition. Whilst, it may be emotive, it is not inaccurate to say that competition in the NHS led to more deaths. This evidence of a reduction in quality along with the reasons to believe that costs will increase leads me to view these reforms with extreme foreboding. The previous government introduced some competition to the NHS system, however, this was specifically competition on quality and not cost. This fundamental difference is vitally important. Furthermore, so much of healthcare relies on cooperation between services. This is one area in which the NHS needs to improve. The fragmentation of, and competition between, providers risks making this much worse.
My great fear is that the great strengths of the NHS will be lost. Healthcare will get more expensive and less effective. I am not opposed to reform per-se. There is much that can be done to improve the NHS. There is also much that should be done. However this bill is not going to improve healthcare in the UK, it will only have the opposite effect.
Dr alienfromzog BSc(Hons) MBChB MRCS(Ed) DCH
1. “Already our health outcomes lag behind the best in Europe.” David Cameron The Times January 31th 2011
2. “Modernising the NHS is a necessity, not an option, in order to meet rising need in the future, we need to make changes now. We need to take steps to improve health outcomes, bringing them up to the standards of the best international healthcare systems.” Andrew Lansley, The Conservative Party Website
3. Commonwealth Foundation Report 2010
4. Office for National Statistics
5. University of York Centre for Health Economics
6. Beral V, Peto R. UK cancer survival statistics. BMJ (2010) 341:
7. Appleby, J. Does poor health justify NHS reform? BMJ (2011) 342:d566
8. Nuffield Trust
9. Liberating the NHS: developing the healthcare workforce. Department of Health (2010):
10. British Social Attitudes Survey
Royal College of Nursing
Royal College of Surgeons
Chartered Society of Physiotherapy
12. Propper et al. Competition and Quality: Evidence from the NHS Internal Market 1991-1999 CMPO Working Paper Series No. 03/077 (2003)