Opinion: Where is evidence based decision making about the NHS?

One of the great things about growing old is that life becomes much simpler. Those raging passions of youth give way, very gradually, to an acceptance that, in the grand scheme of things, we are pretty insignificant. Imagine my surprise when I found my blood pressure rising and my normally equitable mood being replaced by a growing sense of outrage. What exceptional event caused this? Well, it was the  Health and Social Care Act, 2012.

I am not sentimental about the NHS, or any other public body for that matter, and believe that we should constantly be trying to improve our services. What worries me is that ideology seems to be driving this, rather than evidence-based decision making. Some commentators say that the Health and Social Care Act, 2012 effectively lets the private health care sector take over the NHS. The secretive  Section 75 of the Act ensures, among other things, that it will be prohibitively expensive for any future government to renationalise it. But, as Polly Toynbee says, ‘the LibDems still have a chance to stop this becoming the most indelible legacy of their time in government‘.

This all seems to have taken place without mention in the coalition agreement and a severe lack of public debate. I have lived in many countries, including the USA and Germany, and have sampled what national healthcare can provide. The German model, which does include the private sector, seems to function quite well. The USA model, which is more expensive with poorer outcomes, is not the one that we should attempt to imitate.

We should, of course, be looking to improve safety and quality of care, to improve efficiency and value for money, but whether the use of private providers and the profit motive is a suitable vehicle for this must, based on the USA model, be in doubt. While the NHS will remain ‘free at the point of contact’, the cost will still be paid by the taxpayer, only now we will have to pay for the cost of the treatment together with profits for the private sector. The NHS has been using private funding and services for a number of years, just look to the PFI débâcle and Serco’s out of hours general practitioner service in Cornwall, but this new bill  leaves the door open to expand this with the clause, ‘the making and recovery of charges is expressly provided for by or under any enactment, whenever passed‘.

For all its faults, the NHS is an institution that is valuable to us as a nation and probably one that deserves getting our passions aroused. A good starting point would be to get the Department of Health to publish in full its own assessment of the potential impacts of the Bill. Perhaps then we would not have to rely so much on other professional bodies, such as the Royal College of Physicians, to publish quite damming risk assessments (PDF). It may well be that ‘market forces’ are the way forward but, as with everything, there must be risks involved. What are these risks? How can we mitigate them? How can this new model, which often costs more while delivering less, be allowed to pass uncritically? Give us the evidence so that we can make informed choices rather than just accepting our fate.

* Anthony Hawkes worked mainly in the oil industry around the world. Since retirement he has become a Human Rights Activist and joined the LibDems to start fixing the world. He blogs at Crustry Old Codger.

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  • Martin Lowe 22nd Feb '13 - 4:51pm

    Currently, there are two evidence-based decisions being made by the Conservatives with regards to the NHS:

    a) can my friends get rich from a decision I make?
    b) can I get a directorship out of this when I leave Parliament?

    I just wish that we’d had someone like Julian Huppert lead the Lib Dem scrutiny of Health & Social Care Act 2012, rather than Shirley who let Andrew Lansley off the hook.

  • Richard Dean 22nd Feb '13 - 5:25pm

    What is “evidence”?

  • @Richard Dean
    Were you one of the jurors in the Vicky Pryce trial?

  • Old Codger Chris 22nd Feb '13 - 6:13pm

    If section 75 isn’t stopped I won’t be voting Lib Dem in any future parliamentary election. Those who are still members of the party should make their views crystal clear to the leadership. 2015 isn’t so very far away.

  • Oh How silly of us to think that the private sector will not cherry pick and put profits before patience.

    Just like how the private sector companies delivering the workfare programme are not cherry picking claimants that are easy to place and “creaming” referral fee’s. A scheme that is adding £5 Billion to the welfare budget and achieving under 4% success rate.
    I will repeat that again
    {£5 Billion added to the welfare bill, paid to “private companies” It’s such a relief though that this coalition government managed to slash the welfare bill by real terms cuts in the uprating, The bedroom tax, abolishing DLA and changing to PIP moving the goal posts on eligibility}
    Thank god we have a coalition government that puts the need of the people before the profits of private companies.

  • that should of course said patients and not patience lol, perhaps I should get some before hitting post lol

  • Richard Dean 22nd Feb '13 - 6:46pm

    The jurors in the Vicky Pryce trial may have had a difficult task – is marital coercion disprovable? -, but the task of deciding what is evidence for the NHS is probably far harder. Things will be said like

    Doing X costs Y and has benefits Z.

    Which raises the immediate questions – how reliable are the measurements of X, Y, and Z? How independent are they of other aspects of the NHS system. And how do we evaluate this statement anyway, on a cost-benefit basis or what?

  • Stephen Donnelly 22nd Feb '13 - 9:11pm

    @Matt : Usual sniping about the private sector.

    The Francis report demonstrated that the public sector was just as capable of delivering poor quality health care. It is time to move on from these knee jerk reactions and consider the best way of providing heath care without applying out dated prejudices.

  • I dont class “objecting” to the Government cutting (Billions} of pounds from the welfare Bill which is having devastating consequences on the most vulnerable people in our society, whilst at the very same time they are “Giving” {£5 Billion} from the same welfare budget to “private companies” to operate a workfare that has totally failed.

    And you want to call that outdated prejudiced.

    If this is the kind of obscured view that Liberal Democrats have acquired during their short time in Government, then the sooner they return the opposition benches the better.

  • John Broggio 22nd Feb '13 - 10:43pm

    Old Codger Chris , matt +1 (or should it be +2?)

  • If only someone had pointed the possibility of this out when the H&SC act was going through parliament. Maybe some more MPs could have voted against it.

  • Richard Dean – these are reasonable questions, but not unanswerable ones, or else few decisions on public issues could ever be evidence-based. For example, there may be solid evidence that imposing a target drives up performance in respect of that target – but is the target really what you were trying to achieve or just a pointer to it, and can action to achieve the target have disbenefits to people’s health in some other way? The evidence that stopping smoking benefits health is overwhelming, for example, and various initiatives to reduce smoking have been tried so the evicence base is quite strong. Some issues, though, involve questions of values and priorities that a mechanistic approach can’t answer. For example, how much priority in terms of resources should be devoted to keeping a terminally ill person alive a bit longer compared to action that can prevent large numbers of painful but not fatal accidents, compared to action that can prevent a very few children getting an onerous lifelong disease? All are important, but when you have all the figures and evidence and a limited budget, you have tools to help you decide, not a ready-made decision.

  • Richard Harris 23rd Feb '13 - 2:29pm

    I think the definition of “care” should be discussed also. Following a recent personal experience involving an elderly relative, I can say without reservation that the missing part of her treatment was any sense of “caring”. Staff came and went, never the same people, always in a rush. Meals were missed, medication was missed, information was missed but worst of all a sense of care of the individual was totally lacking. When choices about the NHS are discussed, please, please, please look further than just the cost of a medicine, or the success of a procedure. Think about the ability of a nurse to sit with a patient for a few minutes and find out about them – people die, but it’s harder to pull through if nobody seems interested in your name.

  • If you’re in any doubt about the future for a privatised health care system, have a look at what has happened in the USA. This TIME article should be a wake-up call to anyone who still believes that the profit motive has any place in healthcare provision: http://t.co/eNKCJKDLOS

  • Richard Dean 23rd Feb '13 - 5:37pm

    There’s nothing wrong with a profit motive, but, like any motive, it needs to be managed properly. Evidently they’re having difficulty doing that it the US, but a little difficulty doesn’t invalidate the whole thing.

    What other motives might there be? One is altruism, or doing best for the patient. But that also has to be managed properly, otherwise costs will escalate and damage other aspects of the national social services.

    It’s always a balance, and the management of motives has itself to be managed. Mid-Staffs seems like an example where the cost-cutting motive was too dominant and the pride-in-service motive not strong enough.

  • So how will the party be voting on this issue? Seriously, I’d love to know. Will this go through? It goes through next week doesn’t it? What are the Lib Dems up to on this?

  • Old Codger Chris 23rd Feb '13 - 9:36pm

    Thanks to Mark Scott for the link.

    Although it seems unlkely that the UK or any other country (except Russia perhaps?) would be stupid enough (corrupt enough?) to let the healthcare industry threaten an entire economy in this way, it is a warning that even a “caring profession” can be infiltrated by monopolistic shysters.

  • Erm, how is the NHS threatening the entire economy? Yes, PFI schemes (not limited to the NHS by any means) are costing us a fortune (and so hooray that the coalition aren’t signing on to any more! Oh wait…) but I’m still missing the bit where the cost of the healthcare system is somehow bankrupting the country. Compared to say, subsidising the costs of massive banking failures or allowing large organisations making record profits to decide they should pay no tax. Although I’m sure replacing the system with one that costs far more in administration costs will help. Especially as the Tories campaigned specifically on not doing this (“No more top-down reorganisations of the NHS”?).

    So yeah, what are the Lib Dem MPs up to on this?

  • Robert Wootton 25th Feb '13 - 12:15am

    Letting the market into the NHS in a mistaken ideological belief that market efficiency would bring about clinical efficiency and save money is the Thatcher legacy.

  • John Carlisle 25th Feb '13 - 8:58am

    Herein lies the biggest failure of the LDV. This elephant and education has been in the room for over a year while we fiddled. It i time to break up the Coalition on this issue. Only then will the public forgive us.

  • Richard Dean 25th Feb '13 - 10:50am

    Is it agreed that professional such as doctors, surgeons, nurses, and lab staff need support and need to be managed? Their strength is in their profession, not in the quite different profession of organizing things in general.

    And they need a lot of support. Hospitals also need cleaners, beds, machinery including anything from vehicles to water dispensers to anaesthesia machines. They need people to maintain machinery, people to manage the bricks and mortar, fix potholes in the car park, paint the walls, fix the heating, drains, loos,, and people to manage purchasing, public relations, payments, and finance.

    All of this myriad of support actions are familiar in commercial and industrial organizations, so there is expertise available through the market. Provided there is an appropriate working interface between commercial and medical authority, and appropriate feedback and oversight, putting these things out to tender might surely achieve great things in helping medical staff deliver clinical excellence?

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