Public Need before Private Greed

Political Engagement: how far can we go? – Eric Watts

Dr Eric Watts is a retired Consultant Haematologist and a Vice President of the Association of Clinical Pathologists.  This article was commissioned by the  Association of Clinical Pathologists

Email:  Eric.watts4@btinternet.com

As charities ACP and RCPath can’t behave like trade unions – but we can have a view and as responsible people we must have a view as only we really understand what we do and how it contributes to patients’ care. We have sapiential authority i.e. the authority which comes from the thorough knowledge of our work and we as pathologists must promote our role.  To be blunt, if we don’t who will? The College has made excellent progress with its strap line- “The Science Behind the Cure” and all the educational events in National Pathology Year that help to raise our profile.

But what happens when the going gets tough and we feel the services we provide are under threat?

Getting involved with politicians is best done if we can understand something of the dark arts. Starting with the Mr. Nice approach one politician, who took an interest in blood transfusion, invited all hospital chief executives (CEOs) to comment on his plans to improve the lot of patients requiring transfusions. Most of the CEOs passed his letter to haematologists – some replied and were invited to a meeting in the pleasant and impressive surroundings of the Palace of Westminster. He stated that he wanted to gather as many allies as possible to help to build his case. He had been advised by a company which produced erythropoietin that their drug could help prevent patients with anaemia from the inconvenience of attending hospitals for transfusions.  We were able to advise him that the situation was a lot more complex than they had made out. We saved him the embarrassment of making a big issue for change without having the supporting facts.

More recently a plan to radically transform the NHS was unleashed without any form of wider discussion with practitioners who could have introduced a measure of reality testing – the result is the longest passage of a Bill through parliament and the most changes (over 350 amendments) in parliamentary history. It took over a year and had hundreds of changes in the final few weeks it became heated and we saw less of Mr. Nice as email petitions gained momentum and the temperature rose further.

It is now clear that the NHS will change but not as much as in the original plan – which shows the effectiveness of taking political action, the question remains how best to get our points across?

When people disagree

It would be a dull world if everyone agreed all of the time and we have several ways of resolving conflict ranging from the polite agreeing to disagree to full blown argument where Mr. Nasty may emerge and it ends up in a shouting match – both parties going away angry.

Political arguments easily degenerate to opponents resorting to their personal philosophies resulting in an impasse – was that the case with the NHS Bill – that we’re for or against the NHS and want to slug it out on that basis alone? It often seemed that way. Can we learn how to be more effective i.e. get more of our views across with less effort? We can learn negotiating skills, the art of compromising on one or two issues (of minor importance to you) in order to get want you really want from the deal. We could also learn the art of concentrating on the achievable rather than wasting effort on a lost cause such as fighting the Bill as a whole in the last few weeks.

Want to make a difference?  Learn the game

I’m a keen supporter of the NHS, this goes back a long time to my teens when I was treated  for a neuroblastoma. Illness can focus the mind and knowing the problems that exist in other countries for people with prolonged illnesses, I felt fortunate to be in a system which really did look after people from cradle to grave. Then during the Thatcher years I joined the Labour party to do my bit to help preserve what’s good about the NHS and also joined the National Health Service Consultants Association (NHSCA) dedicated to preserving the NHS. The NHSCA has as a key message:

 

The NHS is the world’s greatest ever example of a population agreeing to provide care for the sick.
It exemplifies the ethos of civilised society, setting an example worldwide.
Were it to become further eroded, it would be virtually impossible to recreate

That explains my personal position (or baggage, some would say) but I’m also aware of the dangers of sentiment and creating sacred cows; as head of department I had a budget to keep and was keen to learn the skills of management. I enrolled in the Keele course to obtain the Diploma in Healthcare Management, which was lead by Prof Roger Dyson who had been a member of Thatcher’s think tank that produced the 1991 white paper that saw money following patients – most radical change in the NHS in 40 years.

Professor Dyson had a clear political bias but could rise above it, was intellectually honest and would enjoy robust debate – happy to acknowledge points scored against him (as no politician would) so it was a good learning environment.  He introduced us to senior managers, accountants and hard-nosed businessmen who were moving into hospital management. One of the issues we discussed was motivation – how to get the best out of the workforce, discussed in much more detail in Charles Handy’s book Understanding organisations.

Hard Nose or Soft Center?

There is a consensus amongst the top businessmen that people perform best when they are working for a purpose.  The stronger the belief, the better they work together for a common goal – nothing too surprising there;  “team spirit” is a vital ingredient in sports. But what did surprise me was how much they used the NHS as an example of a motivating force. Using the language of management consultants, seeing how much has been achieved by the NHS with its limited resources they would say “this is marvelous, how do you do it ? – if you can find the magical ingredient then bottle it and sell it!”

Successful companies have had a core message, or mission statement to give their employees a sense of direction to aid cooperation and some of the managers I’ve heard talking about “identifying our purpose, differentiating our product etc” are missing the point that we do know what we wish to achieve – health for all – and we did choose to work for the NHS for many reasons including the wish to work in a firm that embodies civilised values. Talking of values often provokes the response, “That’s soft!”   Perhaps, but it can also be powerful if we are prepared to move away from the big stick school of management towards one that really does get the best out of people.

Why change a winning team?

The last government poured money into the NHS but productivity did not increase proportionately.  However, rather than being a sign of failure of the service this is good evidence of the harm of creeping privatisation. Much was spent on Independent Sector Treatment Centers (ISTCs), privately owned and run, carrying out a limited range of services with the great bonus that they would not have any emergency admissions to disrupt planned surgery schedules. Also they selected the less complex cases and yet they were 12% more expensive than the NHS equivalent. This is not surprising when we appreciate that these were companies out to make a profit and the NHS does not.

How much profit should be made from healthcare?  It depends on whether you see health as a business or as a right. As funds for healthcare are limited one argument is that any money that is lost from the system in profit to an external company is a lost opportunity to spend it on patient care. The opposing argument is that if a company can provide the same service more cheaply then more patients will benefit but the experience is that too often the NHS loses out through poorly negotiated contracts and short-termism.

The classic example of short-termism is PFI, which is costing us dear and was described by the (Tory) chair of the Finance Committee as the “Unacceptable face of capitalism”. ISTCs are another example – we don’t pay the capital cost of building them but we pay handsomely to use them.

An ISTC for my hospital?

At Basildon we badly needed more space for our haematology day unit and as our CEO advised that we would only get a new build by getting an ISTC, I agreed. It would also provide a medical day ward and endoscopy suite. The Trust placed the required adverts and the proposals came flooding in. It would have been hilarious if it had not been serious, we made it plain that this was to be a medical unit but we were swamped with proposals for operating theatres. We had a shortlist of suppliers, consortia of building companies and private health companies and you could only admire their optimism and powers of self promotion.

They confidently sat down and told us they could provide what we wanted for a given price then showed they knew next to nothing of the services they had been bidding for. A typical example was that as the service would replace our day unit it would have to provide all of the current services including open access to patients with complications of treatment. “No,” they replied, “Such patients will have to join the queue at A&E” but that is not the way to manage complex haematology patients who often do need direct access to haematology units. Our endoscopists had a similar problem – the unit would be closed at night, urgent GI bleeders would have to join the queue.

At that point we pulled the plug and developed the services in house 2 years later.

That dented my belief that Labour were truly committed to supporting the NHS and some at the top of the party were talking of the NHS as if it were merely an insurance company which would use any provider, favouring the private sector which was more efficient – a myth that still exists in the minds of some. There is information collected by the Healthcare Commission and benchmarking companies which is confidential but it shows that there are many, highly efficient NHS laboratories and it makes sense to see how they do it so we can generalise the best.

I later heard Nigel (now Lord) Crisp, CEO of the NHS at the time, talk about ISTCs. Although the amount of work they did was “tiny” we saw a dramatic drop in waiting times because (he said) patients had been given the chance to go and NHS hospitals suddenly realised they had competition and got to work. One example of the sudden change, once DoH started promoting choice and competition, was cataract waiting times, which were 2 years in Surrey and 4 months in London. When the rules allowed the Surrey patients to go to London the Surrey hospitals soon increased their throughput.

He gave that example of using competition to help to induce a will to change within NHS hospitals that had not responded to the call to cut waiting times or who had claimed it could not be done. He also gave examples of improvements by collaborative working within the NHS such as reducing the time to treatment with clot busters for patients with myocardial infarction. The waiting list example was a good example of judicious use of the private sector! We should not get complacent.

In 2007 there was widespread concern about piecemeal privatization. An amalgam of health unions launched “NHS together” and had a big march and rally in London. There I am with my home made placard setting off through the leafy suburbs and getting dirty looks from  salesmen as I walked past the Jaguar and BMW showrooms, but getting supportive comments from fellow travelers on the train and tube. (Arriving at the start of the march on the embankment I saw that everyone else with a placard had come in a hired bus or had had the placards taken there by van). It was a good day out, meeting many new people but the rally was simply preaching to the converted.

I was puzzled and embarrassed by Labour’s position so off I went to change it. I took a motion to my local branch calling for an end to a policy of increased privatisation and it was passed nem con with one abstention. I waited to hear how policy would change – it didn’t. I tried to find out what happened to motions from branches – it seems very little unless you’re part of a coordinated national movement.

I spoke to our MP who was riding high in the party at the time and she got me into No10 – that’s me outside trying to look serious. I met Gordon Brown in the corridor, he was waiting to meet the Sarkozys, he directed me to an advisor who listened to me, thanked me for explaining the home truths and agreed they would do better next time.

Would the Tories have been more responsive to medical advice? I had an interesting meeting with Tom Sackville, Minister for Health when Virginia Bottomley was Secretary of State. As a cancer survivor I’m active in many cancer charities and at one meeting he had given an excellent speech with great aspirations of improving cancer care. I thanked him for the wonderful future he had displayed for us and invited him back next year so we could review progress. His reply? “Well I would very much like to but I can’t as no politician knows where they will be next year.”

So engaging with politicians is a long learning experience – they’ve heard it all before, they know what they want to do and they’ll humour you when they’re being nice and ignore you when they’re not.  The best way to influence a politician? Find the Minister with the most marginal constituency and move there for the election.

As an individual it’s hard to make a difference but as a group we should find it easier. Many Colleges and medical associations made their views on the Health and Social Care Bill known and one of the most common themes was that the Bill would undermine the NHS through fragmentation and that privatised services will be too selective to allow free services for all. Evidence of the benefits of integration has been published by Professor Chris Ham, current CEO of the King’s Fund.  (Curry, N and Ham, C (2010) Clinical and service integration: the route to improved outcomes.) In particular they cite the Kaiser Permante’s move towards increasing integration.

It is a simple truth that money is limited and therefore we should use the most efficient services but how do we measure efficiency? The World Health Organisation have done it and published their league table in 2002. Although France and Italy faired better than the UK, we were at that time spending 6% of our GDP compared with 9% in most of Europe and we were more effective than other large countries. Lord Carter acknowledged that UK pathology was good value by international comparison and most recently the Commonwealth Fund (a New York-based independent agency) commented that we out perform other high income countries.1

One college which chose to lobby on the Bill both publicly and privately was the Royal College of Physicians, London (RCP) and in their commentary their president states that the RCP’s lobbying has led to a series of real improvements in the Bill, including: the inclusion of hospital doctors on the boards of clinical commissioning groups; ensuring the secretary of state has responsibility for education and training; coordination of education and training at a national level; and a commitment that all providers will pay, via a levy, for education and training.

Their lobbyist, at a recent meeting on global healthcare talked about the value of lobbying, which sometimes has a poor image but is both legitimate and expected by politicians. In the UK the lobbying industry employs 14,000 people and has a turnover of £1.9 M. Her top tips for successful lobbying to be precise about what you want, be prepared to be challenged, engage with as many people as possible, use local media (your MP will), be prepared for the long haul and, above all be persistent and courageous.  Lord Crisp spoke next and endorsed her comments adding that he paid most attention to lobbyists who knew the practicalities of their subject and had a good track record.

In pathology we have sweeping changes resulting from the Carter report and it would have been a political own goal to complain collectively about increased privatisation under this government if we did not under the last (at least I did my bit). A major problem with sweeping changes is a lack of proper before and after evaluation. Doubtless the administration will prioritise one key performance indicator which will trump the others when results are announced – the smart politician will await the result, see what’s come out best and trumpet that triumph.

One of the new features that will particularly affect pathology will be services provided by “any qualified provider”.  Experience with out-sourcing such as during the GP fund-holding years and the current round of out-sourced ultrasound services is that the service may not be up to the standard of the local hospital and GPs will requests repeats, leading to increased costs.

What next ?

The key to the next round is commissioning.  The College is leading the way and I hope they will go further to get the commissioners to review the performance of providers against the contracts. I think we should promote benchmarking as a means of producing meaningful data on which to evaluate performance.

The major weakness of pathology is the behind the scenes, backroom boy/girl image or mentality. Now, both as individuals and collectively it’s time to get out and ensure our colleagues and the commissioners know, not only what pathology is but what good pathology is and to be sure that they get it.

How far can we go?   It’s a matter of judgement and as an association we haven’t tried to test the limit. I don’t believe we have even tested the water. We could make political statements but we would need to find ways of surveying the membership to give a formal statement of our position and this could be expensive. In the short term we can use our meetings to discuss topics and gauge opinion, then as individuals we can advise our MPs that we are seeing them in our position as constituents but that meeting with fellow pathologists achieved a consensus view which we could then present.

There have been informal discussion at ACP meetings on the Bill. We also had discussions on Carter but I don’t remember coming up with a collective response. So far we haven’t consulted with government; we’ve kept our heads down and got on with the day job. Next time a government plans wholesale reform will we move faster to form a view and communicate it effectively.

Reflecting on the stance other organisations have taken, at least we haven’t made any influential enemies so, should we now choose to be bold, we can go into the next round unscathed!

Reference

1.      D Ingleby, M McKee, P Mladovsky, B Rechel.  How the NHS measures up to other health systems. BMJ 2012; 344: e1079. 22.02.2012

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