NHS

May. 17th, 2013 03:35 pm
liv: cast iron sign showing etiolated couple drinking tea together (argument)
[personal profile] liv
This post is full of UK political detail; please feel free to skip if that's totally irrelevant to you!

So I was chatting to a senior academic who works in health policy and she mentioned that about a third of the people who used to have senior roles in the now-abolished Primary Care Trusts have resigned. Some on ideological grounds because they strongly disagree with the political climate regarding health and social care, some just in disgust at having put all that work into building up the PCTs and making them function well, only to have the whole system swept away and replaced by something new. I was already pretty worried about the NHS situation, but hearing that from an insider has definitely reinforced that.

Then I went to a talk by Prof Paton, a political scientist, about the political context in which our health reforms are taking place. I shall write up some of my notes, because I think people other than me might find some of this interesting, though it's admittedly speculative, it's too soon for anyone to do a serious academic analysis of an Act that's only a few weeks old.

Paton is a lefty of the old school, like political science professors are. He thinks the new H&SCA is a terrible idea, at least partly because he thinks market economics in healthcare delivery is inherently terrible. In spite of that bias, he made a very interesting, and to me surprising contention, that he thinks Cameron, Lansley and Hunt are actually driven by ideology and not in fact by populism or personal financial gain. He thinks that the meme floating around about how the NHS is being "sold off" because all the influential politicians want to increase the value of their shares in private healthcare companies is mostly just a paranoid conspiracy theory. Cock-up, not conspiracy, was the Leitmotif of his talk.

What ideology, then? According to Prof Paton, Lansley especially but the other senior Conservative drivers too, sincerely believe that devolving budget decisions to Clinical Commissioning Groups run by GPs will really genuinely lead to more patient choice and better individualized care. Unfortunately, in Paton's view, it's not actually possible to balance patient choice with the degree of central planning and risk-spreading that is completely essential for running healthcare delivery. Hence the new structure of the NHS is inevitably going to be a bad compromise between fundamentally incompatible needs. Essentially the the H&SCA abolishes all intermediate levels of regulation and governance between central government acting in a top down way, and the CCGs, if the GPs are actually willing to put their time into making commissioning decisions when they could be treating patients. He thinks that GPs who are keen to actually try to make financial decisions in the interests of their local patient populations will get frustrated because it's not feasible for them to have as much freedom as the government is promising, due to the need for central planning. And that the bureaucratic institutions that have been abolished will end up having to be reinvented, at great cost.

The marketization thing: on the optimistic side, Paton thinks that private healthcare companies such as Virgin are finding it a lot harder than they might have expected to slice off the profitable bits of the NHS and turn them into shareholder profit, though a little of that is going on at the edges. He also thought that the only way that England and Wales ends up in a situation anything like as bad as the USA is if businesses decide that the NHS is inadequate and that they are likely to lose too many key workers to poorly treated illness and injury, and therefore start purchasing private health insurance for their employees. A more serious problem is that, in spite of attempts by the House of Lords and lobbying groups to tone down the H&SC Bill, the act we've actually ended up with as legislation still insists that there must be competition, that everything must be put out to tender. And that Hospitals are now (at least according to the letter of the law) businesses subject to EU and international competition law, so they may not be allowed to do things like band lots of CCGs and hospitals and service providers together to negotiate as a large unit, or designate preferred providers, because that would be anti-competitive if a healthcare institution is in fact a literal business.

Paton had rude things to say about the government trying to legislate as if to run a "banana market" (lots of different traders set up their stalls side by side and try to hawk groceries to you) when they should be running an industrial market, if they must have a market at all. Theoretically the legislation states that the tenders must be on the basis of quality, not price, but how enforceable is this? Also it doesn't deal with the problem that having to commission all services in a competitive way creates loads of friction and wastes money that could be better spent on actual healthcare provision, if you made the non-market assumption that basically what happens is that the NHS provides care as well as funding care. Paton also expressed concern that this competition scenario may make it difficult to provide integrated care, given that all the different organizations involved in treating a particular individual are legally supposed to be in competition with eachother!

The political history of how we got to this point: New Labour was not seen as ideological, they did a lot of fiddling and reforming, which cost / wasted a lot of money because they kept tinkering with how the NHS runs, but it was all done with very short term aims, either making money by selling off NHS assets, or gaining popular support at significant moments in the electoral cycle. The Lib Dems apparently wanted elected health commissioners like the irritating police ones we've ended up with, so that there would be direct accountability to the electorate for the people who ultimately controlled the budget. Since it isn't really possible to compromise between this and abolishing the PCTs in order to transfer control to GPs (directly electing GPs would be a complete non-starter!), this gave the Conservative party the excuse to essentially throw out all the Libs' policies to give an almost purely Conservative H&SCA. However, the Lib Dems, the House of Lords and people who have substantial influence in medical politics did tone down the Bill as originally proposed to make it less aggressively market-ish. So now nobody is happy; the old-school dyed in the wool neo-liberal Tory backbenchers think the reforms don't go nearly far enough and there's still too much central control, and the left (broadly defined) obviously thinks that marketization is way too much like privatization for comfort.

Paton thinks that the best outcome if we get a swing to Labour at the next election is that Labour will replace full-on competition with "contestability," allowing the NHS to be more protected from the EU and international laws meant to regulate for-profit business. He thinks that Burnham would favour a model fairly similar to what the Tories are trying to implement, but with NHS having a default "preferred provider" status rather than insisting that absolutely everything has to go out to tender. He also pretty much dismissed the National Health Action people as naively idealistic; in order to accomplish their goals they'd pretty much have to tear everything down and start again, which they're unlikely to be able to do even if they are implausibly successful at the ballots. He mentioned that Labour peer Lord Hunt of Kings Heath is about the most committed and most effective NHS defender currently in the political system, so that's something useful to know.

I am so very much not a natural Labour voter, for a large number of reasons. And I'm really angry with the party for lying to Parliament and to us about weapons of mass destruction and committing our troops to an illegal war in Iraq with massive loss of civilian life. In spite of this, I am sort of considering voting Labour because the NHS is such a huge issue for me. But Paton kind of confirmed my impression that Labour really don't have a great track record on the NHS recently (even though, yes, the NHS was a Labour policy under Attlee's government in the 40s; that was a long time ago, though!) And the promise to repeal the damaging H&SCA sounds like it's probably not worth much, though I'm not going to base my voting decisions purely on one talk by one guy, just because he happens to have an academic title. But I don't know whom I can vote for to mitigate the threat to a functioning, truly national, truly public NHS, even if I make that my sole voting issue.

(no subject)

Date: 2013-05-17 05:30 pm (UTC)
kaberett: Overlaid Mars & Venus symbols, with Swiss Army knife tools at other positions around the central circle. (Default)
From: [personal profile] kaberett
Thank you so much for writing this up.

(no subject)

Date: 2013-05-17 05:31 pm (UTC)
tig_b: cartoon from nMC set (Default)
From: [personal profile] tig_b
This reads as a good analysis, even though I'm not completely convinced about the reasoning behind the Tory decisions.

Others warned about introducing a competitive market under EC laws during the debates, but were ignored. I think I am becoming suspicious enough to wonder if the first major failures due to competition will be blamed on the EU, just before they vote to leave?

(no subject)

Date: 2013-05-18 05:46 am (UTC)
lilacsigil: 12 Apostles rocks, text "Rock On" (12 Apostles)
From: [personal profile] lilacsigil
more patient choice and better individualized care. Unfortunately, in Paton's view, it's not actually possible to balance patient choice with the degree of central planning and risk-spreading that is completely essential for running healthcare delivery

Yes, this! The centre-right in Australia keep pushing this angle (and this is why we have government-subsidised private insurance on top of the basic system, blech) but they don't seem to realise that it's not actually based in reality.

(no subject)

Date: 2013-05-18 10:00 am (UTC)
iddewes: (animal)
From: [personal profile] iddewes
Living in Germany I really appreciate the NHS, as they have the insurance system here. It's still better than the States, but it's not so easy to get onto the public insurance so I have private and am paying loads for it and it doesn't cover my asthma as that was a pre existing condition. I also hate all the pfaff of having to sort out getting the bills paid for any care I have so I rarely go to the doctor here despite having quite a few health problems at the moment, even though we have a nice doctor who speaks English. I REALLY miss not having to worry at all about how it's paid for.

(no subject)

Date: 2013-05-21 11:51 am (UTC)
iddewes: (animal)
From: [personal profile] iddewes
If I was working for a German firm or I wasn't working but was married to Dirk, I could get public health insurance. It's a bit complicated - I used a health insurance broker who specialises in helping expats in Germany to find out what to do. If you get GERMAN private insurance then existing conditions have to be covered, by law, BUT they charge through the nose for giving you that 'privilege' so I went with a British based insurance firm that covers Germany - the other good thing about going with them apart from the cost is that I still find the process of getting the care reimbursed very complicated, so I am glad to be able to discuss it in English with a call centre based in the UK. I DO notice a big difference in the care I get - for example my GP decided I should have an X-ray and all I had to do was walk down the hall to the x-ray department and get one right away - I'm sure you know how much longer it would take to get an x-ray done under the NHS and that the radiographer would not be based in the same building as your GP - however, I just find it a pain and expensive having to use this system.

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