Monday, April 04, 2011

Writing to my MP again... I know, I really should get a life....!

Alien Castle

The Hon L de Mocrat MP
House of Commons
 3 April 2011

Dear Mr de Mocrat,

Thank you for taking the time to write to me again. I also appreciate the inclusion of Lord Howe's response. However, I did not find your response or that of Lord Howe reassuring. If you forgive the analogy, if someone proposes to make holes in a perfectly serviceable boat, then the simultaneous offer of installing pumps to keep the water out will inevitably lead me to suggest that not making the holes is the more sensible option. And this is how I feel about the Health and Social Care Bill. Whilst some of the changes made to the bill are an improvement, fundamentally it is flawed and risks destroying the NHS.
I wish to raise some specific points from Lord‟s Howe‟s letter.
  • 1. Lord Howe states in his second paragraph that England‟s healthcare outcomes lag behind other countries.
As, I have said previously, this analysis is very simplistic and dangerously misleading. I would encourage you to read the British Medical Journal article I mentioned to you before (if you haven't already) by John Appleby of the Kings Fund. [Appleby, J. Does poor health justify NHS reform? BMJ (2011) 342:d566]. The article is freely available to all on the BMJ website. As Professor Appleby explains, point comparisons of healthcare outcomes do not tell anything like the whole story. To quote from the article;
“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”
Despite the fact that until recently the UK spent less on healthcare than comparable countries will have seen the fastest improving outcomes in both heart disease and cancer. I fully accept that healthcare outcome statistics are not straight-forward and it is very common for them to be misunderstood – often in the media. However surely, those responsible for healthcare should have a much better understanding of the data, otherwise it is impossible to formulate any kind of workable policy
  • 2. In that same paragraph, the minister describes falling productivity in the NHS (presumably, based on the Office for National Statistics data.)
These data demonstrate a fall based on a simple comparison of input of funds compared to output – measured in terms of  'activity.' The problem is that this is meaningless without some concept of quality of care. The report itself says:
“The measurement of quality needs further development to become comprehensive and relevant. We may be underestimating quality improvement.” 
The University of York's report on NHS productivity that I referred to before is a far more comprehensive study [University of York Centre for Health Economics] There is a need to always look to maximise productivity, although this is far from straight-forward to actually measure. Healthcare is not like a factory, outcomes must be very carefully defined.

It is very difficult for me to take seriously anything that Lord Howe says, after he begins his response with two statements that I know to be inaccurate. Why should I trust any of the reassurances that he gives?
  • 3. It concerns me greatly that the minister responsible for this cannot tell whether the bill opens up the NHS to EU competition law or not.
This is clearly of fundamental importance and whether it is an intended consequence or not, surely this should be known before the House votes on the bill.
  • 4. The use of competition to drive up standards is something that all three political parties broadly support.
However, there is nothing in this bill that prevents independent providers from 'cherry-picking'profitable services. Furthermore, according to the White Paper from 2010, there will be something around a 14% weighting towards private sector providers compared with NHS trusts due to the supposed financial advantages NHS organisations have. Whilst I am not necessarily against all competition per se (I would like to see hear more debate) as things stand, it is a system that will be significantly biased towards non-NHS providers. NHS trusts rely on cross-subsidising to cover the costs of services that cannot make a surplus and to cover the costs of training (estimated at around £5Bn/year for the NHS).
  • 5. The argument for increased efficiency is at best confused.
As I have described to you previously, major hospital trusts will have to go from having contracts with a small number of PCTs to having contracts with multiple GP consortia. This will inevitably multiply the work and administrative costs. In order to ensure quality for a multitude of suppliers and to commission more complex treatment whole new layers of bureaucracy are being created such as the Care Quality Commission, Lord Howe referred to. It remains to be seen whether these changes will actually save any money at all.
  • 6. The government claims that the number of GPs that have signed up to become 'pathfinders' demonstrates broad support for their plans.
This is plainly untrue. There are two more significant reasons why GPs have signed up. Firstly, they have a deep commitment to their professional responsibility and know that providing the best care for their patients necessitates being involved in shaping the plans. Involvement is not the same thing as enthusiasm. Furthermore, the way the DOH has structured things, any consortia formed before April this year will not be responsible for PCT debts. Any formed later will have to carry that burden.

I am not by nature cynical about any politician, however there is indeed significant dishonesty on the part of the government in response to questions about the NHS. On 8th February, in Prime Minsters Question Time, David Cameron was asked whether the NHS was safe in the Government's hands. Mr Cameron replied:

On the NHS, I can do no better than quote the shadow Secretary of State for Health. This is what he said about our plans:
 "No-one in the House of Commons knows more about the NHS than Andrew Lansley... Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley... these plans are consistent, coherent and comprehensive. I would expect nothing less from Andrew Lansley."
That was said by Labour's shadow Health Secretary. I could not have put it better myself.[Hansard 9 Feb 2011 : Column 299]
This is what John Healey actually said (I think the missing words are quite important):
“This is a Conservative plan for the NHS. This is Andrew Lansley's plan. No-one in the House of Commons knows more about the NHS than Andrew Lansleyexcept perhaps Stephen Dorrell. But Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley. 
The Health select committee concludes – in so many words – and as I believe, that these are the wrong reforms at the wrong time, “blunting the ability of the NHS to respond to the Nicholson challenge” to improve services to patients and make sound efficiencies on a scale the NHS has never achieved before.

But these plans are consistent, coherent and comprehensive. I would expect nothing less from Andrew Lansley.
[John Healey's Speach to the King's Fund only the words in bold were read out by the Prime Minister.]

One could describe the Prime Minister's response as in-keeping with theatre-poster writers who excel at quoting critics out of context. However, like the references to healthcare outcomes in other countries it is entirely misleading. I am not trying to make a party-political point here, simply to emphasise that the arguments in favour of this bill are a mixture of flawed logic and misleading information. I work in the NHS, I am aware of its weaknesses and issues. However, I also know of its great strengths which are hugely threatened by this bill.

I thank you again for inviting me to your constituency surgery; I will find one that I can attend, in order to discuss this with you further.

Yours sincerely

Dr alienfromzog BSc(Hons) MBChB MRCS(Ed) DCH

Saturday, April 02, 2011

As promised, my MP has written to me again in response to my letter...

Below is the follow-up letter I received from my MP. As promised he has forwarded the reply from the government after he wrote to Andrew Lansley to share the concerns of me and my fellow constituents who have written to him.

Voting Systems - why I don't like PR.

Now, Britain is in the grip of referendum-fever. The excitement over the potential change to the voting system is palpable. It is also non-existent. In a very British way there is a general sense of apathy. For the record, I think AV (The alternative vote) is a good system and I will be voting for it. Whilst, I will probably end up writing more at some point, for today I wanted to explain that I don't want Proportional Representation. That despite its advantages, I don't think it's a good system.

Firstly, I need to expand on my thoughts about democracy. The idea of democracy is that government exists for the people and by the people. (To coin a phrase). The principal of representation is of course at the heart of all this. For me, the genius of democracy is not that people get what they want per se. Mob-rule doesn't work very well, but that it holds leaders accountable to the electorate. It is in this context that I would evaluate any potential voting system.

In the UK, we have a relatively simple 'First past-the-post" system. The reasons for this are in-part historical but the idea is very straightforward. Each constituency has one MP. Of the candidates who stand, whoever gets the most votes wins. Whichever party has the most seats in parliament then forms the government. Either on their own if they have an 'overall majority' or in coalition is they don't have enough MPs on their own. It is also possible to form a minority government but that is a rarity in the UK. Given that most people vote for a party rather than an MP, this system favours bigger parties over smaller ones and favours parties with 'concentration' of support in particular areas. This distortion means that parties can have 100% of power with only about a third of public support, and that parties with as much as a fifth of popular support have much less representation in parliament.

So, one of the alternatives is Proportional Representation (PR). This is the simplest system in theory. Quite simply, the number of votes are counted nationally. And the proportion of MPs is then allocated to each party according to the proportion of votes.

Proponents always begin their argument by explaining how inherently fair such a system is.

My objections to PR are as follows:
  1. PR makes coalition government very statistically likely. This in itself is not necessarily a bad thing but does have implications. Especially when it's a coalition of lots of parties.
  2. In order to make a working majority such coalitions often have to include multiple small parties. These parties will seek concessions from bigger parties in return for their support. This often, in practise means that a party with 5% support has more power than one with 30% support. Extreme parties regularly hold the government to ransom in Israel. This for me undermines the fairness argument.
  3. PR makes the parties more powerful. Before each election, each party will produce a 'list' At the top of list will be the party leader, and then the rest of candidates are listed in order of priority. If a party wins enough votes for one seat, then only the leader becomes an MP -  if they win enough for 100, then the top 100 become MPs and everyone from 101 downwards misses out. In the real world, many of the most effective parliamentarians are ones prepared to dissent and stand up to their party leaderships, the relatively independent MPs are often best able to represent their constituents effectively. The party whips have an important role in delivering on a manifesto. However, I do not think that making the party machinery more powerful would be good for democracy. How many members would stand up to their leadership if it means being moved from the top 50 on their party's list to the maybe 250 where they have much less of a chance of being elected?
  4. PR breaks the link with the constituents and their MP. Arguably, the greatest strength of the current system is that each MP represents ~100,000 people. If you have an issue, you can write to or visit your MP to raise it. This constituent-MP relationship is one of the best things about representative democracy.
At some other point, I will probably talk about my thoughts on AV, STV and FPTP, but I think that's enough for now.There is no such thing as a perfect system, but I think AV is actually pretty good. FPTP has some strengths but also significant weaknesses.

One other very good reason to vote for AV is the no2AV advertising posters; if this is the best they can come up with then there can't be any good arguments!

Baby Poster
Soldier Poster