Seven fallacies of English health policy
Steve Harrison
Honorary Professor of Social Policy, University of Manchester
Honorary Research Fellow, London School of Hygiene & Tropical Medicine
Fallacies?
- I’ve studied health policy for over 35 years (& worked in the NHS for 5 years before that)
- I spent the first 7 or 8 years of my academic life essentially as a commentator on policy, but became frustrated with the huge volume of commentary in relation to the much smaller volume of evidence, & since then have largely eschewed such commentary & concentrated on doing research
- But, since I’m now retired & this is intended to be my final academic seminar, I’ll allow myself the luxury of some commentary. Views expressed are personal, not those of the HiPPO group or its funders.
- I use the term ‘fallacy’ loosely to signify that I question seven of what I perceive to be received wisdoms in English health policy
NB that several of my fallacies are highly interconnected
1. ‘Yes, Minister’
The joke perpetrated by Antony Jay no longer has purchase – ‘Yes, Minister’ means just that!
The traditional post-1850s civil servant, politically neutral, non-specialist but of considerable overarching intelligence, initially leavened post -1960s by some technical experts, has been largely replaced by a combined force of managers & partisan political advisers (Greer’s picture of DH as ‘Dept of Delivery’, dominated by NHS managers.)
2. Professionalism = self-interest
- The concept of professionalism has a chequered & often ambiguous history, eg
- Medieval notion of occupation as divine gift to be exercised for common good
- C17th association with monopoly & mystification
- –Modern ambiguity – compare ‘professional foul’ & ‘professional finish’ from DIY product
- Pre-WW2 academics generally uncritical
- professions as bulwarks of tradition against change
- From 1970s, ‘professional dominance’ theories (Friedson, Johnson) dominate wider discourse – profession as means of occupational monopoly & more general dominance
Professionalism – the possibilities
- Addressing some problems of market failure
- Asymmetry of information - professional expertise usable in patient’s interest accompanied by a level of explanation that doesn’t exceed patient desire
- Trust should allow lower transaction costs & perhaps more appropriate rationing decisions
- Addressing some problems of bureaucratic failure
- Avoidance of goal displacement resulting from incentivisation of rule-following
- Use of clinical discretion to provide more appropriate treatment than routinised pathways or protocols
3. Valid knowledge is always explicit
•Post-1990s developments in conceptualising clinical work (& indeed work & skills) more generally have placed overwhelming emphasis on explicitness,
- eg–Evidence-based medicine/ professional practice,
- Professional education & training
- Notion of ‘competencies’ [sic]
•This approach permits shortening of professional training (complete when all boxes ticked) & expression of knowledge as guidelines & protocols etc
•But ‘tacit knowledge’ (a concept largely developed by Michael Polanyi at the University of Manchester) is a crucial resource for making judgements in uncertain &/or complex contexts. (Even Peters & Waterman recognised that you can’t write protocols for every eventuality!)
•Some experimental psychology findings suggest that tacitly acquired learning facilitates accurate decision making about novel situations (eg Reber 1989)
4. Health care should be conceptualised as a commodity
•Tendency of policy makers to cite surgical examples
•Formalisation of this notion into casemix measures (DRGs, HRGs) & pathway specifications
•These conceptual devices permit health care interventions to be counted, costed, traded & used to measure workload & performance.
•They are essential to allow the purchaser/ provider split to operate as intended.
•This approach has become steadily naturalised since the 1990s, perhaps an example of Habermasian ‘colonisation of [our] lifeworld[s]’
5. NHS reorganisations can be triggered by a few general ideas
•5 major NHS reorganisations in my time (1974; 1982 & Griffiths; 1991 quasi-market; New Labour 1998-2004; current Coalition)
•Only the 1974 reorganisation was thought through in advance, with genuine attempts to consult interested parties & secure political consensus, & to specify in concrete terms how the new systems would work & why it would be an improvement on the old.
•But high levels of abstraction (which are essential to academic work) do not allow proper assessment of the plausibility of claims about benefits of reorganisation & how the system will work.
•An example? HiPPO research & other discussions with NHS staff suggest that no-one knows what commissioning really is supposed to be! Or how it’s supposed to co-exist with patient choice.
•We (the public) have a right to concrete information that allows us to judge whether we want changes that might affect us in important ways.
6. Patient choice is desirable
•With many goods & services, bad choices allow learning (I’ll never buy another Nissan)
•But if my chosen health care provider maims or kills me, such learning isn’t much use to me (though it might be to others)
•And just what am I supposed to choose? Logically I should be choosing between local health care systems, not individual operators. But the complexities are daunting, even for a retired professor with some knowledge of the field!
7. Patient & public ‘involvement’ is good
•Arguing against this is taken as tantamount to killing fairies
•Most academics who study the topic start from the premise that PPI is good – their research findings typically identify ’promising’ developments which just need actors to try to little harder in order to get results
•There is barely a shred of evidence to support claims that PPI makes any difference - & it won’t do to argue that it’s OK because people feeling involved is a desirable outcome in itself