David Gordon Bristol 28/1/06
The reforms are inter-related and mutually reinforcing. There are four connected streams of work:
"The imperative for reform is urgent and growing. People want more from their public services, to match the choice, customer service and personalisation they can get from their bank, supermarket or on-line shopping".
Patricia Hewitt Secretary of State for Health December 2005
A 2002 Harris Interactive telephone survey of 1,013 U.S. adults, which asked
whether they had seen or responded to ratings of hospitals or physicians, found
that only 1 percent of respondents had made a decision to change health plans,
doctors, or hospitals on the basis of performance evidence
"Ultimately, choice comes at a price. As consumers, we are expected to
pay for the privilege of choice, and if we cannot pay, we do not get to choose
and, more than likely, do not get at all," ….. "I left the U.S. convinced
that having less choice in health care is a price well worth paying for universal
coverage.“
Blind
Faith and Choice, Rhiannon Tudor Edwards, D.Phil., M.A., Health Affairs
November/December 2005 24 (6): 1624–28
NPM theory originated in the private sector
OECD & UK government are promoting NPM in the public sector
NPM is rooted in neo-classical economic assumptions that every person is actuated
only by self-interest. From this, everything else follows. If people are self-interested,
they have to be motivated by incentives. Different self-interests lead to endemic
conflicts.
To resolve conflicting interests efficiently, markets are best. Self-interest
and markets favour competition rather than co-operation, and mandate hierarchy
to keep people in line. They also empty management of all moral or ethical concern.
The NHS could never successfully function if self-interest became the main
motivating factor for its staff.
The Health Service works on the basis of collegiality, co-operation and trust
- what Richard Titmus termed the ‘Gift Relationship’ (Titmus, 1970).
New public management undermines co-operation and trust and promotes competition
and vested self-interest in their place.
“Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you’ll die sooner because you’re badly off”
Frank Dobson, 1997 (Secretary of state for health 1997-1999)
Age at death by age group, 1990-1995 Source: The State of the World Population
1998
“The world's biggest killer and the greatest cause of ill health and suffering
across the globe is listed almost at the end of the International Classification
of Diseases. It is given code Z59.5 -- extreme poverty.
World Health Organisation (1995)
Seven out of 10 childhood deaths in developing countries can be attributed
to just five main causes - or a combination of them: pneumonia, diarrhoea, measles,
malaria and malnutrition. Around the world, three out of four children seen
by health services are suffering from at least one of these conditions.
World Health Organisation (1996; 1998).
Expectation of years of life, at birth UK
|
% Deaths among recorded baptisms
|
||
|
Under 5 years
|
Under 21years
|
|
|
British Dukes
(Hollingsworth, 1965) |
20
|
27
|
|
Bedfordshire peasants (fairly prosperous) (Tranter,
1966)
|
24
|
31
|
|
Lincolnshire peasants
(Chambers, 1972) |
39
|
60
|
|
District
|
Gentry and professional
|
Farmers and tradesman
|
Labourers and artisans
|
|
Rural
|
|||
|
Rutland
|
52
|
41
|
38
|
|
Urban
|
|||
|
Bath
|
55
|
37
|
25
|
|
Leeds
|
44
|
27
|
19
|
|
Bethnal Green
|
45
|
26
|
16
|
|
Manchester
|
38
|
20
|
17
|
|
Liverpool
|
35
|
22
|
15
|
Standardised
Mortality Rates - From the 1920s to the 1990s, men 20-64 | Year | SMR by Social Class | |||||
| I | II | III | IV | V | Ratio V:I | |
| 1921-23 |
82 | 94 | 95 | 101 | 125 | 1.5 |
| 1930-32 |
90 | 94 | 97 | 102 | 111 | 1.2 |
| 1942 |
88 | 93 | 99 | 103 | 115 | 1.3 |
| 1949-1953 |
86 | 92 | 101 | 104 | 118 | 1.4 |
| 1959-1963 |
76 | 81 | 100 | 103 | 143 | 1.9 |
| 1970-1972 |
77 | 81 | 103 | 114 | 137 | 1.8 |
| 1981-1983 | 66 | 76 | 100 | 116 | 165 | 2.5 |
| 1991-1993 |
66 | 72 | 113 | 116 | 189 | 2.9 |
Tackling Health Inequalities: lessons from the UK
In the European Union;
“most countries with quantitative targets have set them in terms of reducing
gaps between the poorest and the more affluent, but Scotland and Wales appear
to be unique in terms of emphasising the importance of improving the position
of the poorest groups per se.”
In Wales & Scotland the targets do not focus explicitly on ‘closing the
gap’ but emphasise relatively faster improvements for the most deprived groups.
Source: Judge et al (2005)
Very little of the mortality gap by social class can be explained by known
‘risk’ factors
The solutions? - What can the health service do
Ending the Inverse Care law - equitable, accessible and inclusive health care
and health resource allocation
The term 'inverse care law' was coined by Tudor
Hart (1971) to describe the general observation that "the availability
of good medical care tends to vary inversely with the need of the population
served."
A primary aim of health inequalities audits and impact assessments should be
to identify the best method or methods of allocation in order to distribute
resources on the basis of health needs and thereby alleviate the problems caused
by the ‘inverse care law’.
1. Don't smoke. If you can, stop. If you can't, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and making
time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practice safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC : airways, breathing, circulation.
1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.
2. Don't live in a deprived area, if you do move.
3. Be able to afford to own a car
4. Don't work in a stressful, low paid manual job.
5. Don't live in damp, low quality housing or be homeless
6. Be able to afford to go on an annual holiday.
7. Don’t be a lone parent.
8. Claim all benefits to which you are entitled
9. Don't live next to a busy major road or near a polluting factory.
10. Use education to improve your socio-economic position
Summarised below is the evidence that there is not a 'snowballs chance in hell' that the choice/marketisation agenda will reduce inequalities in health.
The Government argues that introducing choice into the NHS will drive up standards, improve efficiency and eliminate inequalities (DoH 2005). Its favoured mechanism to attain these goals is to introduce market mechanisms into secondary and tertiary care e.g. to force hospitals in the NHS to compete in a regulated market - sometimes called a quasi-market.
A lot of the literature in this area has been produced by academics at Bristol University (Will Bartlett, Carol Propper, etc.) including Julian Le Grand when he was a professor in Urban Studies. The term the Bristol researchers use is Quasi-markets but others have used the terms 'the contract state' and 'New Public Management (NPM)' to describe similar sets of ideas (see Hood 1990; McMaster 2001; Minogue 1999; UN 2005). There is both theoretical and empirical evidence that the marketisation of the NHS will not reduce inequalities in health.
1) Theoretical reasons - Quasi-market/New Public Management theories are rooted in neo-classical economic assumptions about human behaviour - that every person is actuated only by self-interest (Homo Economicus). From this, everything else follows. If people are self-interested, they have to be motivated by incentives. Different self-interests lead to endemic conflicts.
To resolve conflicting interests efficiently, markets are best. Self-interest and markets favour competition rather than co-operation, and mandate hierarchy to keep people in line. They also empty management of all moral or ethical concern.
Julian Le Grand clearly spelled out these ideas in an article in 1997 based on the inaugural lecture he gave on becoming the Richard Titmuss professor of social policy at LSE;
'a fundamental shift in policy-makers' beliefs concerning human motivation and behaviour. People who finance, operate and use the welfare state are no longer assumed to be either public spirited altruists (knights) or passive recipients of state largesse (pawns); instead they are all considered to be in one way or another self-interested (knaves)'
and
'The knavish strategy implicit in the quasi-market agenda is rather different. This is not simply a coercive mechanism to repress knavery; rather it is an attempt to harness the knavery - or, to put it less pejoratively, the self-interest - of those working in the system to the public good.'
In the quasi-market/New Public Management view of the world a whole range of mechanisms are needed to ensure that the self-interest of the individual doctor, nurse or manager is aligned with the interest of the NHS - these mechanisms include market competition, performance management at the bottom and financial incentives including performance related pay at the top.
This is an absurd, one-dimensional and naively deterministic view of 'human nature' and the motivations of NHS staff. In the mathematical models that underlie these policy proposals everyone acts primarily out of self-interest, as isolated individuals who respond in a linear manner to incentives (a bit like Pavlov's dog?!). Even if the motivation of all NHS staff were entirely self interest - a pure greedy lust for money and power - the quasi market models would still not work - not even in theory. The reason for this is because they are non-sociological models - NHS staff do not act as isolated individuals they work with each other. The behaviour and actions of an individual at work are influenced by their colleagues and therefore their response to incentives cannot be described by simple linear models as even in a purely selfish universe interaction between people would add complexity (see Coleman, 1973, 1990 for detailed discussion).
There are of course whole libraries full of sociological studies, anthropological studies, business organisations studies, etc. which show that individuals actions are not primarily motivated by self-interest but by the requirements of conforming to social and institutional norms (for example see Cook and Emerson, 1978). Each individual's behaviour and motivation is affected by their work colleagues and the institutional rules of the organisation (NHS and professional rules). This fact is fairly easy to understand - it is not rocket science - but it has seemed to have been largely ignored by the quasi-market gurus advising the New Labour government.
The NHS could never successfully function if self-interest became the main motivating factor for its staff. The health service works on the basis of collegiality, co-operation and trust - what Richard Titmuss termed the 'Gift Relationship' (Titmuss, 1971).
Marketisation undermines co-operation and trust and promotes competition and vested self-interest in their place. To quote Le Grand (1997, 162), "the introduction of a knavely-directed strategy may make the knights behave more knavishly."
Titmuss (1971, p243) argued that 'man has a sociological and biological need to help, then to deny him opportunities to express this need is to deny him the freedom to enter into gift relationships.' There is now strong mathematical support for Titmuss's contention that there is a biological and sociological need for people to co-operate (for example see Axelrod 1980a,b; 1984, 1997). The marketisation and choice agenda actively undermines the freedom to enter into the 'gift relationship' by providing sharp incentives to act 'knavishly'.
Yet the 'good will' and expertise of NHS staff is the most valuable asset of the health service - far more valuable than the buildings and equipment. The quasi-market strategy/ choice agenda will inevitably undermine the good will, cooperation and collegiality amongst NHS staff as this is what it is designed to do. It will make NHS staff compete (not co-operate) in the hope that this competition will through the 'invisible hand of the market' lead to a more 'efficient' health service and thereby a 'better' health service for rich and poor alike.
Unfortunately, we know from many studies that marketisation in health care will also introduce financial incentives for;
a) unnecessary treatment and prescribing (Radical Statistics Health Group 1977);
b) fraud - false claims, kickbacks and self-referrals (Kalb 1999)
c) Increased exclusion - markets always produce incentives to exclude the most
expensive and vulnerable patients who are not 'cost effective' to treat. In
this way they increase the efficiency of care for the population as a whole
but not the effectiveness of care. It is inefficient to treat the least 'cost
effective' group of patients - universal health coverage is inefficient. Unfortunately
the least cost effective group to treat are often the 'poorest' people and this
is one of the primary ways that marketisation increases health treatment inequalities.
Research in the USA has shown that choice always comes at a price. For example
Tudor Edwards (2005) argued;
Ultimately, choice comes at a price. As consumers, we are expected to pay for the privilege of choice, and if we cannot pay, we do not get to choose and, more than likely, do not get at all," ….. "I left the U.S. convinced that having less choice in health care is a price well worth paying for universal coverage."
2) The empirical evidence - Primary care in the NHS has always been almost entirely
private. Despite the fact that the NHS has had the powers to employ salaried
GPs for almost 20 years the overwhelming majority of GPs are private businesses
which competed with each other. The health service reforms of the Thatcher and
Major governments (which began in 1989) increased the amount of regulated competition
amongst GPs by providing increased financial incentives for GP practices to
compete. If this marketisation resulted in more equitable health care then we
would expect that there would be more GPs in the 'poorest' parts of England
where there is the greatest health need (i.e. the most patients to treat).
The Inverse Care Law: Average number of GPs per 100,000 by area deprivation, 2002 & 2004
Figure 1 shows that in 2004 there were 54.2 GPs per 100,000 people in the most
deprived areas of England and 62.5 GPs per 100,000 people in the least deprived
areas. There is a linear gradient by deprivation - the more deprivation the
fewer GPs. Faced with a quasi market GPs have chosen to preferentially practice
in the richest areas of England not the poorest. In the poorest areas there
are fewer GPs to provide a primary care service to the population with the greatest
health needs. Consequently the 'poor' often receive a 'worse' service from their
GPs than the 'rich'.
Secondary and tertiary care in the NHS has largely not been subject to the same
degree of quasi-market competition that has occurred in primary care. In contrast
with the distribution of GP practices, hospitals and other similar NHS facilities
are often concentrated in the major cities close to the most deprived areas
(see maps in Damiani, Dixon and Proper 2004). The people who are most likely
to benefit from the choice agenda are those who live in areas where there is
high demand for additional secondary and tertiary health care but currently
a lack of available beds. If the quasi-market mechanisms work then the areas
with the greatest demand relative to supply will get new health care facilities
and the areas where there is less demand relative to supply may see hospitals
close down.
Figure 2 from Damiani, Dixon and Proper (2004) shows highlighted in 'red' the areas of England where in 2001 there were the greatest numbers of people waiting for inpatient care relative to the number of available beds i.e. the greatest unmet demand relative to the supply of hospital care. If we ignore the red areas on the border with Wales which is largely an artefact caused by not including the Welsh hospitals - then all the red areas are in the most wealthy parts of Britain - the home counties around London and the richest parts of the West Country around Bristol and wealthy areas of East Anglia. The people living in these areas have the best health in Britain (Shaw et al, 1999). By contrast the blue areas on the map show where there is the least demand relative to current supply of inpatient care. These blue areas are concentrated in some of the most deprived PCTs in England.
If the 'choice' agenda is implemented and the NHS is marketised along the quasi-market lines being advocated by Julian Le Grand then the wealthy 'red' areas in Figure 2 will gain additional secondary and tertiary care facilities and the 'inefficient' blue areas on the map may see hospitals closing i.e. the 'rich' will get more health care facilities and the 'poor' will get fewer health care facilities.
I therefore do not believe that there is a 'snowballs chance in hell' that the marketisation of the NHS will lead to a reduction in inequalities in health.
last updated 1/09/07