Much of the reporting about the NHS is dubious to say the least. Both the government and those that oppose it are prone to making false claims and also whipping an anecdote into a major issue. Experts are no longer regarded as necessary or valuable.

As we move out of the era of markets and competition into what should be a better future we have to find better ways to communicate, to make more effective use of a wealth of actual evidence and also to challenge those peddling false news on social media – even if it means hate mail and trolling!

Context

In recent papers Steve Iliffe and I have argued that the second era, of markets and competition and of market choice, in the NHS is now over. We look forward to the third era – a better care system. In developing ideas around the third era we need to ask how to involve the public. But there we have a concern as so much reporting about the NHS is “fake”; we appear to be in a new era of information provision where experts are devalued; where evidence is replaced by anecdotes; and where clicktivists and social media reporting replaces the trade press. Cognitive dissonance is mainstream and confirmation bias reduces genuine debate.

Sadly, this is made worse by the lack of openness and transparency in the NHS (fed by lack of accountability) which then opens up the chance for alternative news and views.

So how can the public assess proposals for change – in the increasingly unlikely chance anyone asks them?

Examples of Fake News1

The first example needs no comment.

Mid Staffordshire Hospital

NHS targets may have led to 1,200 deaths’ in Mid-Staffordshire.

NHS managers were yesterday accused of putting targets and cost-cutting ahead of patients as a report into at Mid-Staffordshire Hospitals trust found up to 1,200 people may have died needlessly due to “appalling standards of care” at a single hospital. 

Telegraph 18 March 2009

The reporting around the poor care identified at Mid. Staffs was itself poor. The most authoritative comment was that “it would be unsafe to infer from the figures that there was any particular number or range of numbers of avoidable or unnecessary deaths at the Trust.” But allegations of thousands of needless deaths persisted.

(What we do know is that the data on death rates at Mid. Staffs was wrong as it was not recorded correctly.)

£10Billion?

To show how Ministers and the government can also be implicated there was the long running saga over the funding with a headline: £10 billion or £4.5 billion: what’s going on with NHS spending?

In brief there was the claim that the government is providing not just the £8 billion of extra funding that the “NHS requested”, but £10 billion of extra funding. Every analyst pointed out that the government’s £10 billion commitment isn’t all of what NHS leaders asked for, and isn’t as generous as it sounds. The false claim is still made.

(No serious analyst believes the claim that the NHS is getting the funding it reasonably needs.)

Hunt v Hawking and Weekend Effect

We then have: Jeremy Hunt accuses Stephen Hawking of ‘pernicious falsehood’ in NHS row. One aspect of the spat was the doctors urging an inquiry into Jeremy Hunt’s NHS ‘weekend effect‘ claims; claims that increased mortality at weekends is due to staffing (and related issues). The argument included a letter signed by doctors and scientists including Stephen Hawking accusing the health secretary of misrepresenting evidence – a subtle form of fake news

(There is a weekend effect and there are raised mortality rates, seen in many countries with different health systems, but there is no evidence to support this being due to staffing issues – in fact it is not yet know what causes the effect.)

HSMR Dr Foster and More Deaths

The joint venture with Dr Foster saw many years of high profile reporting around death rates and much hype over league tables and all sorts of claims about what this showed in terms of care. Some who questioned the validity of the methodology and the claims were threatened with disciplinary action! Anyway here is the current voice of reason:-

The small proportion of deaths judged to be avoidable means that any metric based on mortality is unlikely to reflect the quality of a hospital. The lack of association between the proportion of avoidable deaths and hospital-wide SMRs partly reflects methodological shortcomings in both metrics. Instead, reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.

(It’s all gone a bit quiet on the HSMR front and anyway we now have the less commercial SHMI which is better but still cannot be used objectively to point to poor care – it might but it might not.)

Mergers

After a few years away mergers are back in fashion. If you have one locally you will see press reporting of what a great idea a merger is and all the benefits that it will bring. The evidence says otherwise: –

Given the lack of evidence that mergers typically lead to more sustainable organisations, it is increasingly difficult to justify the amount of funding being dedicated to mergers rather than other potentially more effective approaches to transformation.

Where providers contemplate transactions, we need to ensure a higher standard of strategic thinking on alternative options and a realistic assessment of the costs and benefits of merger.

PFI (Into more contested space)

Nobody doubts there are serious issues with many PFIs through massively naïve contracting and accepting ludicrous business cases…..

However, on the fake news front, it has often been stated that £1 in every £10 that goes to the NHS is to pay off debts from Private Finance Initiatives (PFIs). Reality intrudes. The total annual payments to PFI providers in NHS is £2bn in round numbers; so that would be more like £1 in every £55. But the £2bn includes around £1bn which is for Facility Management services, including ongoing maintenance, and soft FM like cleaning and grounds maintenance – which is not free to provide. So, £1 in every £110. But this too ignores the possibility that there are at least some compensatory benefits (the benefits set out in the business cases made huge claims!); and actually, building new hospitals costs money however you finance the work

So the excess cost of PFIs is more likely to be around £000ms pa (less benefits), serious money but not £1 in £10 and not easy to claw back.

Cost of the Market

As Steve and I have argued the market and competition in the NHS has demonstrably failed. There are major opportunity costs in having the market ideas within the NHS but what about the real costs of tendering, invoicing and other work that comes specifically with a market? Here is a quote from a recent article:-

No-one knows the exact cost of this bureaucratic ‘marketplace’. A recent estimate by rebel Lib Dems put the figure as high as £30billion a year. Dr Jacky Davis and other doctors and campaigners including the National Health Action Party have put it at £10billion a year. The Centre of Health & the Public Interest put it at a ‘conservative’ £4.5billion a year.

The £10bn figure is a misrepresentation of a report from the Health Committee2 – when the actual cost evidence is accessed (it relates to 2003) the actual research does not identify the cost of the market – it looks at changes over time in total costs of administration and management. The £4.5bn has no source at all except the discredited £10bn – the CHPI paper does not cite evidence.

Extensive searches reveal that there has been no study into the actual cost of the market in the (English) NHS. Nobody has gone through NHS accounts and picked out the headings for “market” costs. Some studies have gone round the margins and looked at comparisons with non-market Wales and Scotland. Some have used FoI to ask Trusts and CCGs how much they spent on market activity like procurement. We do know some £000ms has been spent (totally wasted?) on consultancy related to procurement.

But, much work around tariff (HRGs), activity costing, coding, resource allocation, funding flows would be needed whatever kind of system there was in place; they don’t just come with the “market”. And actually if the £10bn was true then Wales, which would have no such costs, would have a huge costs advantage: there is no sign of this.

At best £000ms pa could over time be saved once we get rid of the market.

Privatisation

As mentioned the era of markets and privatisation in the NHS (the second era) is over and it failed to deliver. It did not fix the problems inherited from the first era or bring the benefits its proponents claimed. However rarely a day passes without someone claiming the NHS has gone or is going soon. It is being sold off, or privatised or Americanised – or a plot is being hatched.

There is a frequent mixing of various meanings of privatisation. The extreme version is of a privatised NHS which is no longer free and has moved away from the single payer NHS:-

No longer

  • Universal
  • Comprehensive
  • Free
  • Funded centrally from taxation

There is no sign of any opposition to continuing the single payer model, no matter what a few politicians are quoted as saying some years ago. All the evidence to the Lords Sustainability Committee supported this view – there was no opposition.

Privatisation in the sense of NHS services being outsourced to the private sector has increased since it was first measured consistently in 2006. It remains a threat and activists and others rightly challenge attempts to outsource core services, usually successfully. Much outsourcing has actually been ineffective – as with well evidenced scandals such as with Patient Transport Services. Various very large contracts which effectively attempted to outsource commissioning responsibilities have collapsed, but again there remains a real threat to be confronted by some poorly led CCGs.

Specific threats (such as to community services) obviously remain. But in general terms this version of privatisation is not really increasing. Payments to private (for profit) providers for health care accounts for 7.7% of the NHS budget in 16/17 the same level as in 15/16. Payments into the NHS for the treatment of private patients stands at just under 2% of income, much the same as it has always been.

The Plot and its Outcomes So Far

To complete the discourse on privatisation it is worth looking at what was claimed to be the evidence based and inevitable consequences of the 2012 Health & Social Care Act:-

  • The NHS would become just a kite mark attached to all sorts of providers
  • There would be a much reduced NHS hospital sector
  • Foundation Trusts would focus entirely on financial success
  • The majority of outpatients setting would be in privately owned cheaper local facilities
  • NHS hospitals that remained would be run by private companies
  • Specialist clinicians would be self employed and work for a mix of organisations including private
  • Many patients with long term conditions would have a fixed care budget which could be topped up
  • Insurance companies would sell products offering support for co-payments
  • Commissioners would use and become reliant on private healthcare companies.

The reality is that none of that happened, is not happening and is not planned for any future we can reasonable expect.

Conclusion

Much of the reporting about the NHS is dubious to say the least. Both the government and those that oppose it are prone to making false claims and also whipping an anecdote into a major issue. Experts are no longer regarded as necessary or valuable.

As we move out of the era of markets and competition into what should be a better future we have to find better ways to communicate, to make more effective use of a wealth of actual evidence and also to challenge those peddling false news on social media – even if it means hate mail and trolling!

1 (Reports that are either just made up or else so factually wrong as to defy any sensible impartial examination.)

2 4th Report of the Health Committee, Session 09/10 on Commissioning

Taken from the presentation to the Health Policy and Politics Network Conference – September 2017

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4 Comments

  1. Vivien Walsh says:

    We regularly hear of Richard Branson &Virgin (in particular) buying up different bits of the NHS – are you saying that’s fake news? Or the reports don’t exactly mean what they say?
    And how do you classify PFI?
    There are certainly sites on (previously?) NHS land where the private sector appears to be building health care facilities. At Manchester Royal Infirmary there is a new Eye Hospital and a new St Mary’s (Obs Gynae & related) – but the old sites appear to be being used for something else (the old St Mary’s is a building site, and I forget what the billboard said was being built, but it didn’t say NHS)
    I have had tests carried out by the private sector under the auspices of the NHS, which I understand was agreed under the Blair government – but is that not privatisation?
    I can remember being very struck by Julian Tudor Hart, until recently SHA President, saying at a SHA meeting in Manchester some years ago, that it was remarkable how efficiently a system ran when decisions were made by doctors and other health care professionals, on the basis of clinical need, and without the involvement of cost-benefit analysis or other financial considerations.
    It always seemed to me that once efficiency in financial rather than medical terms came into decision-making, the problems started. The cost of all the interim management layers must be considerable – and one of the reasons the NHS was always so much more efficient before that than the national health services in Germany, France and elsewhere. Of course under Tory governments, but under Labour too. It still is more efficient in terms of cost, but does not always produce such good outcomes any more. Unless that is fake news too.

    1. Steve Iliffe says:

      This is how fake news turns into fake history, by blurring the difference between things and simplifying a complicated public institution.

      “We regularly hear of Richard Branson &Virgin (in particular) buying up different bits of the NHS”. Contracts have been awarded (not sold) to for-profit companies like Virgin to do NHS work. Like they are to GPs, opticians, pharmacists and dentists, all subcontractors to the NHS. 90% of the NHS’ footfall occurs in the contracted out sector.

      “And how do you classify PFI?” As the most expensive mortgages ever, sought by a Labour government foolish enough to believe in ‘no more boom or bust’, but which resulted in the rapid modernisation of the NHS hospital stock. For a long time he NHS has had a very successful public-private partnership with the pharmaceutical industry to keep medication costs within limits.

      “There are certainly sites on (previously?) NHS land where the private sector appears to be building health care facilities”. Some of these are joint ventures between the private sector and the NHS. Some land may have been bought from the NHS. Why should the NHS retain land it does not need?

      “I have had tests carried out by the private sector under the auspices of the NHS, which I understand was agreed under the Blair government – but is that not privatisation?” If you receive palliative care in a hospice you will probably be in a charity-run institution sub-contracted to the NHS. Is that privatisation?

      “….how efficiently a system ran when decisions were made by doctors and other health care professionals, on the basis of clinical need, and without the involvement of cost-benefit analysis or other financial considerations”. Tudor Hart said many wise things but this is not one of them. The NHS ran well for doctors, who tend to assume that what is good for them is good for the public. An alternative view of that Golden Age is that it generated inequity, corruption and abuse, whilst being systematically inefficient.

      “It always seemed to me that once efficiency in financial rather than medical terms came into decision-making, the problems started”. They certainly did. The introduction of general management in 1983, together with the privatisation of public sector care homes (which really were sold), were the opening phase of the neoliberal turn in health and social care which we are now experiencing.

      “The cost of all the interim management layers must be considerable – and one of the reasons the NHS was always so much more efficient before that than the national health services in Germany, France and elsewhere”. When in doubt blame bureaucracy! The European sickness funds/compulsory health insurance schemes are more complex to manage than the NHS, and so more expensive; they also provide more services, so cost more. If anything the NHS is still under-managed and inefficient as a result.

      “It (the NHS) still is more efficient in terms of cost, but does not always produce such good outcomes any more”. Any more? Does that mean other countries have caught up with us in terms of cancer outcomes, say? If so we should try to learn from them. Or are we sliding backwards, in terms of clinical outcomes? It would be useful to see the evidence. The outcomes that I can see going backwards are all organisational ones, like waiting times.

      Fake history diverts our attention from the two current crises in the NHS. The first is the squeeze on the NHS budget that will – this year or the next – result in real cuts in staffing, possible cash-flow crises and service reductions. The second is the shortage of staff, with some preferring to work for agencies and others departing. More nurses are leaving the profession than are joining it. Fretting about Richard Branson won’t put either problem right.

  2. Roger says:

    “The NHS ran well for doctors, who tend to assume that what is good for them is good for the public. An alternative view of that Golden Age is that it generated inequity, corruption and abuse, whilst being systematically inefficient”.
    This is the key sentence from Steve in defense of Richard.
    Actually the NHS still works well for doctors , who are the best paid in Europe once their private earnings are taken into account.
    Doctors are relaxed about privatisation because it usually enhances their position. The more competition for their scarce skills the better.
    If you are an ancillary worker (or “business support worker”) about to lose pensions, working conditions and job security ; or a poor pensioner without public transport being asked to travel further for their medical care it’s another matter.
    The mistake Steve and Richard make is that they assume because there is a lull on the battlefield that there is no longer a war going on. Wrong.
    The historic compromise in America is that the american medical association has been allowed to restrict entry to medicine , ensure there is no price competition for clinical services , and set outrageous prices in return for complicity in a system which denies care to the poor and uninsured. That is the promise of managed care or “better care” in Richards terminology.
    Better care is a smokescreen for something more sinister.
    If its advocates instead asked for a major expansion in medical training, doctor numbers and promotion of competition in private healthcare then I would believe their good intentions.
    But trying to deny the obvious, in claiming that the government is not intent on privatisation , is not merely complacency but complicity.
    I agree with them though in promoting better reporting and more open debate. But actually there is plenty of evidence that points to the NHS not providing very good care (that was the conclusion of the Commonwealth study ” Good at most things, apart from keeping people alive”. But the solution is not to go down the American route.
    And when that proves impossible to argue the dissimulation suggesting european social insurance may offer an acceptable alternative fails to point out that it is only possible for europe to square the circle by employing a lot more doctors, paying them less and paying a lot more for healthcare generally because more is supplied.

    1. Steve Iliffe says:

      “a lull on the battlefield” is an interesting idea. Is the lull a sign that commercial attackers have underestimated the complexity of running health services, and over-reached? The handing back of contracts – like the Kent out of hours service a week or so ago – might suggest that. Is the lull due to the resilience of the NHS and it’s resistance to change? Contracting out seems to be losing favour. Or is it the lull before the storm? Dark forces are mustering just over the horizon, ready to swoop down on the NHS. It would be useful to see the evidence, but catastrophists only need evidence to fuel mood.

What do you think?

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