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


Anonymous said...

Brilliantly said.
I actually never knew that any consortia formed prior to April guarantees no involvement with PCT debts!? It does make sense.
It is so ironic that a man who claims that his health was threatened because of bad judgements made by his GP, is actually prepared to provide them with a enormous financial power!

George CA Talbot said...

I see you posted this two days after I put my third comment on your February 2011 letter to your MP. A pity you did not reply!

I welcome your challenge to the veracity of the PM. I know more about finance and macroeconomics than healthcare and am sure government’s claims about the budget deficit and Labour’s policies are false.

Labour’s monetary and fiscal policies were optimum for keeping the show on the road and the huge budget deficit is not the main problem but a symptom of the failure of deregulation that Government denies as do almost all Anglo-Saxon politicians.

This is important because Lansley’s bill to liberate the NHS is based on the same ideology. But as you know, complex, asymmetric medicine is not well served by the pursuit of self interest subject to competition and choice even without EC competition law that could be used to challenge any cooperative decision Monitor had not blocked.

I definitely don’t have a life but have posted a few good comments on DH’s Listening exercise threads where some were well informed and most were hostile to the bill.

And I have just put a neat summary comment on the Watford Observer’s Your Say:

I have come to your site because Chris Booth, a surgeon from Colchester, said the RCS was broadly in favour of the reforms; Any Answers?, BBC Radio 4, 4th February. I could not validate this on its website and, like you, it seems to have given up. If true, a pity!

I have written several letters to my MP and put lots of comments on 38 Degrees’ sites. I suspect my letter and disc to Stephen Dorrell copied to my GP had the most impact.

Governments’ deficits result from unemployment caused mainly by low global wages. Their unsustainable monetary and fiscal policies are attempts to restore demand that has been inadequate since deregulation took hold in the 80s. Deeper causes are the free labour market, free capital, usury...! The banks restored demand by recycling excess savings then failed causing the credit crunch. Richard Wolff neatly explains this in seven minutes in Economic History: See also my many comments on finance and the economy and a few on the NHS on the Guardian’s Cif:

alienfromzog said...

Thank you for that George.

I really haven't given up. Am watching current developments with interest.

The position of the Royal College of Surgeons disappoints me. I was at the Association of Surgeons of Great Britain and Ireland's international conference last year. Mr Lansley was an invited speaker. I was very disappointed by the gentle ride that the heads of the 4 Surgical colleges (England, Edingburgh, Glasgow and Ireland) gave him. But then I think that surgeons as a body are somewhat self-serving, which bothers me greatly.

It is an interesting point of history that when Bevan sought to set up the NHS, the medical profession as a body were completely shameful in their opposition. I hope that we as a profession can live up to the moment now when the NHS is so threatened. It seems that the GPs and physicians, as well as the nurses and physiotherapists are indeed speaking out.


George CA Talbot said...

Interesting, thanks!

I guess you know Scotland and Wales are going the other way by ending the purchaser/provider split. I support KONP and NHSCA when they say it makes bad decisions. Splitting is seen as a fault by psychiatrists and even economists are admitting that ‘market’ answers may not be optimum! Sadly they barely recognise mature good and bad, long term, overall.

Until a few days ago, I believed doctors opposed the introduction of the NHS but Dr Hamish Meldrum said recently "It is a shame that the health secretary has decided to repeat a 70-year-old myth, The BMA called for a national medical service decades before the government established the NHS in 1948. Doctors' opposition to parts of what was proposed at the time was related to the detail of the then government's initial plans for how the system would operate, not to the principle of a publicly funded and comprehensive service that was free at the point of use for all patients,"