We need better policy for the NHS. But we are not going to get it if the entire debate is a Manichean point scoring contest conducted entirely in shibboleths and lacking reasonable analysis of alternatives. Too many serious people seem to believe that everything in the NHS would be fine if we undid the Lansley act and spent a bit more money. That analysis is naive, is stopping serious discussion of what the real challenges are and is distracting people from improvement that could come right now.

I went to the recent Royal Society of Medicine event (the one where Stephen Hawking condemned Jeremy Hunt’s selective use of evidence on weekend mortality generating a flood of media commentary). There were a lot of serious, senior thinkers on stage and in the audience. I naively assumed that a debate about the past present and future of the NHS would contain some disinterested assessments of the real problems and their causes. What I found was a desire to blame all the problems on the government and/or longstanding conspiracies to destroy the system. There was a remarkable lack of serious analysis and a widespread belief that every problem would miraculously go away if we simply reversed government policy.

Once you have adopted this position, you are clearly absolved from doing any serious analysis of the state of the NHS and you don’t have to do any thinking about how to improve it. This is a catastrophic position for the NHS as it desperately needs some better thinking about how to improve.

The debate consisted of shibboleths not substance

Here are a few examples of just how futile that debate was.

Richard Murphy made some good arguments about the limits of government spending (in a sovereign currency area, he argues, we don’t need austerity at all). But he then argued that the reason why we have austerity is because of a neo-liberal conspiracy to shrink the state. Maybe some people want to do that, but this government are about as useful as a one-armed trapeze artist with an itchy bum and are not credible organisers of such a conspiracy. Assigning the blame to a deep rooted conspiracy lowers the credibility of the argument and absolves true believers from any further need to engage or analyse the difficult details of policy.

Many speakers, including Hawking, condemned any private sector involvement in the NHS as if undoing it would suddenly improve things. Nobody mentioned that the largest sector of the NHS run by the private sector (the GPs) has the highest patient satisfaction. Supposedly we must have public provision as we can’t trust the private sector’s motives. Somehow, though, the even more severe conflict of interest of working for the NHS while also running a competing profit making enterprise (as perhaps half of NHS consultants do) was raised once and then completely ignored.

Audience members heckled Nigel Edwards for pointing out that the “we must spend a higher % of GDP on health because our neighbours do” argument was undermined by the latest OECD statistics. There are good arguments for spending more but this isn’t one of them. Rather than recognise this, the audience and many commentators prefer to quote the old numbers because they bolster their argument in a way the better numbers don’t.

And a disturbing number of people advocated solutions to the current crisis that involve major legislative and organisational change. So reversing the current Lansley bill to make the Secretary of State directly responsible for the NHS and abolishing the purchaser provider split were widely supported. This is extraordinarily naive for two main reasons. Jeremy Hunt, despite not being directly responsible for NHS management according to the legislation, has been the most interfering SOS in recent history, directing individual hospitals to do what he wants in a way that would make even stalinist central managers like David Nicholson jealous. Secondly, the one thing we are certain of about major legislative and structural change is that it is extraordinarily disruptive and costly to the the NHS in the short term. We have had so many reorganisations in the last two decades that we still don’t know whether any of them have made any sustained difference to NHS performance. Despite this many are still arguing that we need another one.

Then there is the response to STPs. Simon Stevens (wisely I think) opted to try to do significant change in the NHS without new top-down structural change or legislation. But the panels and the audience broadly disliked the STP plans. Not because they are often poorly thought through or lack evidence that what they propose will work (though this is usually true) but because they are a trojan horse for American style Accountable Care Organisations which are a part of the conspiracy to privatise the system and put profits into the hands of american capitalist scumbags. Once you have a good conspiracy you don’t need to think any more about the actual content of STPs. Simon Stevens is clearly a trojan horse for United Health. Conveniently this absolves anyone from having to engage with the nasty operational details of STP plans (which would be well worth doing given how many consist of fairy-tale wish-fulfillment fantasies).

Many argued that the NHS was facing serious staff shortages. And this may well be true in many places. But Sarah Wollaston’s claim that this might be due as much to problems with retention as it was due to any lack of supply was ignored. The idea that weak operational management leading to high staff turnover might be the core problem didn’t seem to occur to anyone: it’s all about the supply of doctors and nurses and we can blame that on the government.

Again the debate ignored several relevant facts that would require actual analysis and thought. For example the biggest cause of increasing hospital deficits is the reliance of expensive agency staff to fill rotas. That’s not a staff shortage, that’s an inability to recruit or retain people on permanent contracts: a very different problem with the need for very different solutions. And it is hard to reconcile the belief that the major problems in A&E waiting times are primarily a staffing issue with the actual facts. Medical staffing in A&E has grown faster than demand for more than a decade while performance has declined. And it is hard to see how more A&E doctors can magically create more free beds (lack of free beds is the major cause of A&E delays not a lack of staff in the A&E). Anecdotes about the pressures and overwork facing front line staff point to a symptom of the problem not the cause of the problem.

Even the revered Stephen Hawking broke his own rules not to selectively quote evidence. He was right to condemn Hunt for his selective use of data on 7-day mortality. But then he proceeded to recommend NHS policies based on a highly selective analysis of the international evidence. Private provision of services is evil (because the USA’s health system is evil). But many health systems in Europe seem to do well despite much of the provision being run by organisations other than central government. The NHS is being pushed towards private insurance and we must resist that trend. But, though I hate to agree with Hunt on anything, there is no evidence this is happening. Moreover, though private insurance for health funding is bound to be less efficient that funding from taxation (so there is no good reason to move the NHS to that model) there are plenty of systems in Europe where compulsory insurance works well and has none of the damaging effects it has in the perversely badly designed US “system.”

In short the event was not a debate but largely consisted of a bunch of people exploring shibboleths that helped them decide whether they were on the right side in the argument. The trouble with shibboleths is they are arbitrary and irrelevant and seem to form a shield that avoids any need to discuss matters of substance about what policies might actually improve the NHS. Which side you are on is all that matters: whether you have anything of substance to add is irrelevant.

The NHS needs a serious debate on how to improve.

For example, how big should the key organisation units be? Nigel Edwards pointed out that we do have evidence for this and that the best-performing systems have units that are 10 to 20 times smaller than the NHS. If the NHS is run centrally, any policy mistake will affect nearly 60m people. That means mistakes have really big consequences (it also means that there will be pressure never to admit they were mistakes greatly inhibiting the speed of learning). Imagine a system where the organisational units were maybe 2-4m people (we could call them SHAs as we haven’t used that unit name for a while or we could just call them STPs). The scale of mistakes could be limited and the effectiveness of different policies could be compared, greatly increasing the possibility of learning and improvement.

But the audience and panellists would mostly have preferred a centrally-controlled monolithic system where the SOS always magically knew the right policy for everything. The idea that variation and experimentation with policies could be used to greatly increase the amount of learning and therefore drive much faster improvement was condemned as an excuse for a “postcode lottery”. This convenient shibboleth avoided any need to engage with that important issue of how we structure of the system.

Or, consider the problem of variation in quality and efficiency across the NHS. The evidence we have suggest that there is far too much variation and that the system isn’t good at learning from it or improving. The cause of this variation isn’t top-down structures or Jeremy Hunt, it is bottom-up operational management. For example, some parts of the system are good a diagnosing and treating patients who need hip replacements and other parts are not. Most significant improvement in the NHS probably comes because people find better ways to organise and coordinate the work in some single operational area. Even some GPs, who are supposedly overwhelmed because of staff shortages and government indifference, have found that reorganising how they receive and manage patient demand can create a lower workload, faster patient access and much improved patient satisfaction. All without central government having to do anything.

But the idea that improvement are possible is essentially ignored in the current debate. Even the idea that there is too much variation across the NHS is regarded as part of the conspiracy to undermine the system rather than an important metric that can point to what needs to improve and how to improve it.

In short, the widespread belief that the current government is the source of all problems has become an excuse not to bother thinking about how the improve the NHS now. Worse, even if the current government is replaced at some point in the future, there will be no good ideas on how to make the NHS better and we will likely be faced with yet another round of disruption that will deliver no tangible improvement when the smoke has cleared.

I’m no fan of Jeremy Hunt who has been a bad SOS. But his opponents are are as bereft as he is of good ideas to make the NHS better. What a woeful place the debate on the future of the NHS has become.

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  1. davidakirby says:

    Modernisation, reform and efforts to improve the NHS over the past thirty years in the UK and especially in England have been systematically distorted by the neoliberal drive to bring the buildings (via PFI schemes), the planning (via consultancies) and the services (via privatisations) into the expanding realm in which corporate profits can be made. This sort of private ownership which serves the needs of finance capital and multinational corporations – for a return on investment, for permanent enrichment and for speculation – has little to do with the situation in which elements of the NHS were provided by small partnerships, such as GP practices ( although in fact improvement in primary care would ideally involve the ending of such ownerships as well, as they have been a locus for relatively small-scale profiteering and associated uneven standards). It is absurd to advocate for a future for the NHS free of these burdensome inefficiencies and distortions without substantial further legal and organisational change – of which the bill to reinstate the NHS would be a start, with a radical approach to ending the PFI profiteering scandal. Such changes would seek to protect the NHS as a whole from commodification and marketisation, whilst recognising that there are limits to the extent to which you can have, as it were, socialism in one country, or in one set of institutions. There always was a boundary with the market – with private medical practice stealing skilled labour, for example, or Big Pharma always seeking to increase its profits.

    Steve Black is dismissing as stupidity what he, apparently, cannot see – that the market has its limits, its serious limitations and the perils inherent in its tendencies to crisis. it is possible and necessary to resist the marketisation of social life – the bringing up of children and sexual relationships, for example, are areas where the limits of the market are obvious, presumably, even to him – we do not need Richard Branson to be making his 5% out of those areas of our lives. We could extend this to consider whether it has been wise to allow education and training of older children and adults, and their health care to be rendered into vehicles for such a charge. Nobody would argue that once this vulnerability to profiteering has been curtailed, there will be no need for further change, adaptation and improvement. Arguing for the government to be responsible for providing a comprehensive health and social care service is not to argue against experimentation in different methods and institutional arrangements for their delivery – for myself I would be for experiments in collectively worker-controlled institutions accountable to local democratically elected councillors, funded by taxation that relies less on VAT and more on taxing wealth and financial transactions. Decreasing wealth and income disparities quickly is undoubtedly the best way of starting to reduce demand on health and social care services.

    For most of its sixty years the NHS was an outstanding achievement of practical socialism, in spite of its disabling but necessary interfaces with the market – its success was clearly a matter of disgust for neoliberals everywhere, and particularly in the US with its bloated and failing health care system. It is thus easy for the critics of its privatisation and marketisation to be labelled by Black as conservatives, wanting to return to some golden age of public service. The 2008 crash proved that the famous invisible hand leads only to economic meltdown and a rescue by the state, but this intellectual defeat and discrediting has paradoxically strengthened neoliberal hegemony by denuding the public sphere, increasing the drive to sell off public assets built up by generations of taxpayers, leading to our current crises in housing, education and in the NHS. The rich have got richer and the spheres of human activity from which they profit have got more diverse and more global. As Thomas Piketty showed, we could end up within 50 years or so with Branson or his beneficiaries in the Virgin Islands owning everything and making 5% out of everything we do, including procreation and child care, defaecation as well as food and drinking water, health and social care, and education. We actually need radical change indeed to reverse this trend.

    1. davidakirby, I agree with you, and I’d like to thank you for telling it how it really is. As a retired nurse I can confirm the changes that hindered the NHS started to show in the mid 80’s, and it’s been downhill ever since. All it takes is for you to write replies like this and for others to agree with you and things will change. So keep up the good work and keep writing your replies.

      1. Steve Black says:

        I hate to disagree but, however people feel about how the NHS works, objectively it is better than it was in the 1980s, even now.

        Before the major Blair reforms in the 1990s (which brought in many reforms but also doubled the budget in real terms) waiting times for elective activity were measured in months and years not weeks. Now, despite 7 years of conservative control they are still measured in weeks. A&E waits averaged more than 4hrs routinely. Now they average much less and (despite the decline in performance since 2010, more than 85% are less than 4hrs). The 1980s were not a golden age, at least for patients.

        Many things (including waiting times) are currently getting worse. But the extent to which that could be reversed by legislation, changing NHS structures or revising the small extent of privatisation is extremely doubtful.

        Wishful thinking about a golden past is both untrue and unhelpful. And assigning blame to the wrong ideological causes will divert attention away from fixes that might work.

  2. Steve Black says:

    You assume that the prime motivation for PFI and increasing private sector involvement was the Neo-liberal drive to move more public sector assets into the profit-making sector. I disagree that this is what drove those trends.

    PFI was mostly driven by a government desire (mostly under Labour governments) to increase investment in public bodies without the money appearing on the governments accounts. Or, in more memorable terms, to apply Enron-style accounting to public sector spending. It was and is a bad idea, but the reasons why it has had a distorting effect are not because the private sector was “ripping off” the government (as Alyson Pollock’s otherwise good analysis of PFI assumes) but because, when your goal is to obscure public sector spending, public sector managers make very bad investment decisions. Specifically, they build fairly-tale long term plans with no flexibility in them and get locked into 30-year commitments that burden them with the wrong assets as soon as the real world deviates from the fairy tale. This major problem is ignored (meaning nobody can learn from it) if we assume the prime motivation is the Neo-liberal conspiracy.

    And the small injection of private sector activity into the NHS (e.g. the Blair era ISTC programme) was very specifically a limited plan to inject new ideas into the way the NHS organised high-volume elective treatment. The idea was to pay private firms the same as NHS hospitals and see whether they could do a better job (which was the only way they could make a profit). If they did, the NHS could copy their innovations and this would drive up the rate of improvement. This isn’t a Neo-liberal idea at all, just a sensible one promoted by a Labour government.

    And your idea that only structural or legislative change can lead to a better NHS suffers from two big problems. One is that the Jeremy Hunt has essentially ignored the current legislation, structures and rules in the way he manages the system (so, presumably, could a Labour SOS in future). Second, the only think we are certain of about major legislative and structural changes is that they are expensive and disruptive. We still don’t know whether any of the previous 4 or 5 major changes have led to any improvement in the way the NHS works. That’s a hell of a bad investment case for doing another one (despite the deep flaws of the Lansley bill).

    Most things that get better in the NHS come from bottom-up operational improvement not from top-down legislative fiddling. Focussing on legislative and structural changes is a major distraction from seeking improvements that actually work.

  3. simonjohnduffy1 says:

    This is an excellent article and I agree with Steve Black that the key to good innovation within the NHS is a fixed structural framework. However reading the plans for STPs and ACOs I am reminded that these same arguments about innovation (often citing the same examples from the US) were also made at the beginning of my career in the 1990s. Looking back its hard not to be cynical.

    My optimistic assumption is that Simon Stevens et al. don’t mean to sell of the NHS and that they genuinely hope these new structural arrangements will be used to bring about positive change (call me naive). However would not be equally naive not to notice that this particular parceling up of the NHS presents chunks of the NHS as essentially comparable with US ACOs?

    Hence a US-UK trade pact could see competition rules applies and NHS ACOs purchased or replaced by US-run ACOs. Already Capita have been commissioned to run the ACO in Nottingham I believe.

    Although I began my career in the NHS I have spent most of it trying to improve social care, and latterly trying to defend the welfare state from the idiocies of Freud and IDS. One overwhelming lesson is that the Left-wing paranoia often turns out to be correct:

    – Social care has been undermined by a contracting culture, driven by Treasury (although they say EU) procurement rules.
    – The benefit system is being dismantled by people using rationales that have been paid for by US Insurance company Unum
    – Think-tanks and public policy bodies are largely now funded by private and global corporations

    Is not the basic reality that Simon Stevens is having to improvise in the space emerging between several realities:

    – Austerity continues, with its direct and indirect costs for the NHS
    – Devolution remains in play, with its evolving chaotic and unjust nature
    – Senior Tories do hope to sell-off more of the NHS to their friends (or themselves)
    – NHS loyalists are tired of the nonsense of the internal market and the tariff system is collapsing
    – NHS England’s wants to centralise power further, but without taking on direct responsibility

    But even if this is all that’s going on, and even if Simon Steven’s intentions are good, this does not mean that Left-wing paranoia is wrong. If Labour does not win the next election these arrangements will set up a sell-off.

    So – politically – I think we need to be firmly and purposefully paranoid, and use this next stage development as an opportunity to attack the Government and to increase the chances of a Labour Victory. Objective analysis and good intentions are all very well – but they will not serve to protect the NHS from its worst case scenario.

  4. This is where improvement is badly needed,
    not tomorrow but now, today
    and first port of call for this is the General Practitioner and the Clinical Commissioning Groups,
    whom should first listen to concerned parents


    Maureen Erdwin

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