NHS reform myths

Richard Blogger of the torylies blog has a good site addressing some of the 'myths' around the 'reform' of the NHS, here's an excerpt from Myth 10: Private providers will just cherry-pick the easiest cases, undercutting the NHS:

The Government's Claim:

The less complex the procedure, the less someone – including in the private sector – will be paid. Unlike Labour, we will not rig the market in favour of the private sector.

The Rebuttal

 

"The less complex the procedure, the less someone – including in the private sector – will be paid"

This shows a stunning lack of understanding about how Payment by Results works. Each procedure, for example, cataract removal, is paid at the same rate (the tariff). However, not every patient is the same. There will be some cases that are more difficult than others even though they are covered by the same tariff. There is plenty of evidence where this has happened with last government's Independent Sector Treatment Centre programme (ISTC). 

...

The problem with the ISTC programme is that the provider was paid for referral, not for treatment. The government says that providers will be paid for treatment, but they do not say that once referred the provider must treat the patient, since there is no such provision in the Health Bill it means that once a private hospital receives a more complicated case they may refer the patient back to the NHS. The NHS has a responsibility to treat patients, private providers will never have this responsibility because they know that the NHS is always there for the more difficult cases.

...

This means that if the private providers are cherry picking we will not know about it because such data will be "commercially confidential". There is nothing in the Health Bill to prevent this, indeed, the Health Bill enables private providers to be even more secretive and apply "commercially confidentiality" clauses to their contracts with the NHS.

The Health Bill will not prevent private providers cherry picking because it does not mandate that once referred the provider must treat the patient. The Health Bill also strengthens the use of commercially confidentiality and so the public will not know whether the private sector are cherry-picking.

The fundamental priority of a national health service

Read this article today from a consultant working in the ill-fated Mid Staffordshire Trust:

In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell. There have been tremendous improvements in many areas such as cardiac, cancer and orthopaedic care.

However, the importance of the care of sick elderly patients who make up the bulk of our medical ‘takes’ have only rarely grabbed the headlines. Care of these patients is expensive in staff time and resources, it is often difficult and tiring and can only be delivered in a high-quality way by departments which are equipped appropriately, are well staffed by motivated individuals and led by enthusiastic consultants.

Unfortunately I fear that all these wonderful new innovations in privatised 'integrated care pathways' are going to fragment care and undermine that goal, there may be winners, but it won't be the elderly patient with pneumonia and a hip fracture in A&E.

Politicians and the NHS

Baroness Murphy blogs on the NHS 'reforms':

Given the recent Ombudsman’s report about the quality of care for older people, which everyone acknowledges is poor/ disgraceful in many NHS hospitals, and the lack of improvement we have seen with massive investment, I find the idea that the NHS does not need to change difficult to accept.  Could it be that doctors have a vested interest in maintaining the status quo?  (A doctor speaks!)

This wonderfully highlights the problems with politicians and their view of the NHS (and she's an ex-doctor). First, like so many others who utterly fail to look at the evidence, she makes unsubstantiated claims about how the investment under Labour hasn't translated to increased 'productivity nor outcomes' - this is just untrue in the latter case (and irrelevant in the former case*) - but is a standard trope trotted out to argue against increased funding of the NHS (because, you know, our health expenditure, at the mid-to-low end of the European scale, is clearly so profligate). Secondly she makes the mistake of thinking that because you think something must be done then what you're proposing to do is going to improve things - unfortunately there's just no evidence to say that the governments 'reforms' are going to do any good, and plenty of reasons to believe this thoughtless vandalism of the NHS is going to fuck it up big time, as even the most timid of GPs could tell you.

Could it be that politicians just don't know what they're talking about when it comes to the NHS?


* A large part of the increased funding for the NHS went into improving the historically low pay of employees like nurses (which by definition will adversely affect productivity) and in disastrously badly managed GP pay negotiations (which also resulted in less activity for a given amount of money, and thus decreased productivity. 

Sharing the pain

Vince Cable:

...has confirmed the 50p rate on tax will be abolished

He told BBC Radio 5 Live: "It moved up to 50p in an emergency because we had to have a sense of solidarity that everybody was bearing some of the pain, and the chancellor said in the budget that we're going to have to move away from that. I agree with him. The Liberal Democrats agree with him.

I guess solidarity* only goes so far.


* Talking of solidarity, it looks like MPs have finally agreed to take a pay freeze like the rest of the public sector - I'm sure the increase in their expenses is merely coincidental.

Sharing the risk - creaming the profits

The King's Fund demonstrate their true colours again, according to the GP magazine 'Pulse':

The King’s Fund has called for entire care pathways to be outsourced to private firms, claiming GPs do not have the time to make the required service re-design in primary care demanded by the NHS reforms.

What I don't understand is what all this talk of 'risk sharing', e.g.

‘GPs can set the standards but consortia will ultimately want to commission organisations to take on the risk.’

...a risk sharing model which would see private firms take on service re-design and practice performance management in return for receiving financial incentives

Now I understand the concept of paying someone for a service, say 'service re-design' or 'practice performance management' but what does it mean to 'share the risk'? It sounds rather asymmetrical, as if you pay a company to take on service commissioning and if it goes badly, well hard luck, you've already paid them, and if it goes well they get a nice big slice of 'performance bonus' to ice the cake - 'heads I win, tails you lose' - and that model's never gone wrong before, and certainly not in the NHS. Good job there will be no financial incentives or conflicts of interest to motivate GPs to adopt that model.

Of course I have absolutely no idea what these ‘integrated pathway hubs’ even mean:

...musculoskeletal, respiratory, and frail and elderly care the first three pathways lined up to go out to tender.

Does this mean that GPs will no longer be required to know any respiratory or musculoskeletal medicine, or to deal with older patients? The patients will refer themselves to the right 'pathway' presumably ('I've got pain in my chest, I guess that's my lungs, better go to the respiratory pathway hub').

One wonders how efficient it will seem when all the respiratory or elderly care outpatient work is taken away from the general hospital to be focused in the 'integrated pathway hub' - when suddenly the acute hospital has no money to keep a respiratory team going, no one to put in chest drains, no one to give expert opinion on difficult chest cases - instead they're having to purchase services from these private providers under their 'service level agreement'. What is the ultimate goal - A&E as a glorified NHS call centre referring you to this or that private company and 'care pathway'? Each care pathway 'integrated' with itself but absolutely no flexibility to cover the messy multiple comorbidities that cross the individual pathway boundaries and make up the real cases seen in everyday medicine. Still, at least it will save money.

Or is it that a 'care pathway' in this case is just one of those referral centres we've seen implemented in areas like musculoskeletal medicine? Staffed with clerical drones who click 'computer says no' and sends the referral back to the GP to ask a physiotherapist to waste their time looking at for six weeks before these moronic box-ticking gate keepers will approve the referral being sent back again - presumably hoping the patient has died or given up in the mean time. For those interested it looks like these care pathways will be like this sort of thing - if my experience is anything to go by they will be vague, inflexible, allow referral centre drones to bounce back anything remotely complicated (because they don't know what the words mean and thus assume it doesn't matter) and ultimately end up with enormously wasted time and duplicated effort. Vive la Revolution!

Psychiatry? Orthopaedics? Same difference

As one wag put it, psychiatry is a recruiting, not a selecting medical speciality. This year there were something like 550 applicants for 480 jobs in core psychiatry training and this was only after extending the recruitment window - locally we had exactly one applicant per job and before extending the window around one applicant for every two jobs. Although it sounds like enough people many of these applicants will be unappointable and many will have applied for psychiatry as a back-up and will get their first choice job (usually general practice, paediatrics, or core medical training) and not take up their psychiatry place. This means that lots of jobs will be filled in 'round 2' where the people who couldn't get in anywhere else and applicants from outside the EU apply (this explains why in one recent year only 6% of people taking the exam for membership of the Royal College of Psychiatrists had trained in the UK for their medical degree).

But I'm pretty sure stuff like this isn't going to help - the College published the questions to be used at interview in advance this year (although I'm informed that they didn't actually explicitly tell the candidates this) and I'm reproducing the beginning of the 'simulated patient scenario':

You are an F2 doctor on an orthopaedic ward. Jan Smith has been admitted to hospital this morning as a day case for a knee arthroscopy to be done under general anaesthetic... 

Presumably recruitment for core medical training included the scenario:

Imagine you are a consultant neurosurgeon...

Maybe this is some misguided attempt to be 'fair' to those with no clinical experience of psychiatry but I'm reliably informed that locally there are more F2 jobs in psychiatry than there are in orthopaedics. Maybe the College is afraid to even mention psychiatry in their application - perhaps they think no one applying actually has any interest in psychiatry so there would be no point starting a scenario with:

You are a CT1 doctor in psychiatry...

This is not encouraging - I'm also told the psychiatrists on the interview panels had some problems following the ensuing discussions about the management of anaesthetic risks. Do these people have any idea what they are doing?

The future of the NHS

Duck on the Badscience forums asked me to blog my concerns about the future of the NHS and how what we are about to see is wholesale privatisation.

What I was saying there is that GPs don't have the time, resources, or infrastructure to suddenly take over all the functions of PCTs next year while carrying on with their day jobs. So, naturally, they will be looking to contract out the commissioning function. But this is just one aspect of the overarching drive towards privatisation.

Something worth remembering when considering GP consortia is that these are consortia of GP practices, not individual GPs. And GP practices are no longer partnerships of equals but increasingly becoming small businesses which differ from the larger healthcare companies purely in size. The last Labour government introduced the idea that GP practices were not partnerships of GPs by removing the need for a certain number of GP partners for a given number of patients (or rather a given amount of money). Instead they were to be treated as small businesses contracted to provide GP services. This has lead to GP services being increasingly provided by salaried GPs (who are usually more recently qualified GPs) employed by the GP practices which are owned by GP partners (who are usually older GPs). Since these changes were brought in the majority of jobs available for newly qualified GPs are salaried positions and not partnerships.

So general practice has moved from being an ostensibly private but effectively collectivised system of equals (at least as far as medical staff go, the position of ancillary staff was different) to become a business like any other - the older generation of GPs have taken advantage of the new rules to become small businessmen increasingly acting as employers and screwing profit out of employees rather than acting as traditional family doctors while the newer generation of GPs become wage slaves. It won't be long before the traditional GP practice disappears (as the old partners retire and sell on their stake in the small business they own) as they are swallowed up by larger healthcare businesses - and then who is going to control the NHS budget? It won't be the workaday GPs who will just be employees of these big companies. **Poof** de facto privatisation.

The words of Liz Kendall (Labour) from the Commons debate on the upcoming NHS cluster-fuck (via Dr Grumble):

Our health and our NHS are not the same as gas, electricity or the railway. That the Secretary of State believes that they are shows how dangerously out of touch he is. What is the likely result? GPs will be forced to put local services out to tender even if they are delivering good quality care that patients choose and like; hospitals and community services will be pitted against one another when they should work together in patients’ interests; care, which as many hon. Members have said is vital as our population ages and there is an increase in long-term conditions, will become more and not less fragmented; the financial stability of local hospitals will be put at risk, and they will have no ability to manage the consequences of choice and competition in the system; and the whole system will be tied up in the costs of red tape, as GPs and hospitals employ an army of lawyers and accountants to sign contracts and fight the threat of legal challenge, huge fines and the potential of being sued. Let us also be clear that the Bill gives Monitor the same functions as the Office of Fair Trading, so it can fine organisations up to 10% of their turnover.

The more we see of the Bill, the more the truth becomes clear. The Secretary of State says that he wants clinicians to be more involved, and “no decision about me without me” for patients, but when the Royal College of General Practitioners, the Royal College of Surgeons, the Royal College of Nursing, the Royal College of Midwives, the British Medical Association or anyone else tells him that he should stop, think again and halt his reckless NHS plans, he refuses to listen. When the Alzheimer’s Society, the Stroke Association and Rethink tell him that his proposals will not give patients a stronger voice and improve public accountability, he simply tells them that they are wrong. When health experts such as the King’s Fund warn that driving competition in every part of the NHS will make it more difficult to commission the services that best serve patients’ interests, he simply puts his fingers in his ears and walks away. What makes this Secretary of State think that he is right when professional bodies and patient groups know that he is wrong?

Doctors and nurses do not support the Government’s plan, patients do not want it, some Conservative Back Benchers and members of the Cabinet do not like it, and the Liberal Democrats hate it. They had the sense last Saturday to see what the hon. Member for St Ives (Andrew George) called the potential catastrophe as far as the future of the NHS is concerned, and to ask for amendments to the Bill. I hope they have the sense to join us in the Lobby tonight.

A campaign for social science

Via Church of Rationality I came across this little proposal:

"...I would set up a campaign for social science.
This would be a little different from More or Less or Bad Science, great as they are. Very often, they deal with the abuse of statistics. I’m thinking not just of this, but of fact-free hand-waving. What my campaign would do is insist upon more scientific standards of discussion of social affairs. 

"Now, I don’t know how such a campaign would change politics. I suspect that, very often, it would reveal just how much we don’t know. But it would revolutionize the media. TV and radio would have to drop all those blowhards who just exchange anecdote and hypothesis; in proper science, no-one give a damn abot anyone's opinion - it's the evidence that matters. And it might even reverse the inequality of pay and status between columnists and reporters. "

Prescribing advice

Just discovered the 'Prescribing Advice for GPs' blog via Black Triangle, lots of useful stuff for any clinicians out there.

Placebos in medicine

Good short response on Comment is Free by Oxford Psychiatry Professor Tom Burns on the use of placebos in medicine and how the media exaggerates the beneficial effects*:

When researchers write, for example, that 20% of the placebo group recovered in a trial and 60% of the active treatment group did, they are not saying that placebos "have the same effect" in a third as many of the patients. They mean that (for the patients with this condition) 20% will recover in the natural course of events, but with the added treatment 60% will recover. It is this added 40% that matters. The placebo has had no effect on recovery.

This lead me to a good article he wrote in response to Richard Bentall's tedious criticisms of psychiatry:

Richard Bentall is right: psychological and social psychiatry research has been a Cinderella to biological and genetic explanations...He is also spot on about the exaggeration and hype of many of their "breakthroughs".

However, much of his article is so one-sided that those messages risk being lost.

 

* The seminal Cochrane review on this topic by Hróbjartsson & Gøtzsche found:

We found an effect on pain...nausea...asthma...and phobia...

There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.

'Doctor' says screw the NHS

Via the Jobbing Doctor, according to this BBC story:

"Dr David Bennett, head of the economic regulator Monitor, has told the BBC he expects to see many more private companies and charities treating NHS patients. If NHS services cannot attract patients they will be allowed to close.

"BMA chairman Hamish Meldrum said the full implications had been poorly understood."

As JD points out, 'Dr' Bennett is not a medical doctor*, he's an ex-McKinsey man, and was formerly Chief Policy Advisor to Tony Blair and head of the Number 10 Strategy Unit. Funny how this is not made clear in the article, yet Hamish Meldrum, GP and BMA chairman doesn't seem to warrant the 'doctor' label.


* I can't find out what his title derives from, e.g. a PhD.

Preventing access to psychological therapy?

Interesting article in the BMJ on the Improving Access to Psychological Therapy (IAPT) initiative started under Labour and continuing under the Tories. It remains unpopular with GPs while being heralded as an outstanding success by central government:

"The impact assessment on the expansion of the programme, signed off by Mr Burstow, estimates that the cost of providing a course of treatment is £136 for mild mental health problems and £754 for moderate or severe cases. This, the assessment says, is substantially lower than the estimated costs for talking therapies before IAPT, which are quoted as £255 and £1298.

"Quite where these figures come from is a bit of a mystery because they conflict with those collected by a team led by Professor Glenys Parry of the University of Sheffield, which evaluated the first two pilot sites for the programme, in Doncaster and Newham, comparing them with neighbouring services (Wakefield and Barnsley and City and Hackney). They found that IAPT treatments cost more, not less, than those provided in the neighbouring boroughs, and that it was not possible to say whether the extra costs were justified by better outcomes."

This accords with the experience of many GPs, mental health professionals, and patients (e.g. see the Shrink here).

Service level agreements in medicine

Apparently:

All aspects of NHS care for entire diseases are to be put out to tender under radical plans to dramatically expand the role of private companies and charities in running the health service, Pulse can reveal.

A pilot set to launch across the east of England will put entire NHS care pathways out to tender, starting with musculoskeletal medicine, respiratory care and elderly care.

As anyone who has seen their local IT services outsourced will be able to identify with, I am wondering what the response time for a chest drain will be under the 'service level agreement'?

No shit Sherlock

Saw this paper today:

Occurrence of depressive disorder was best predicted by a combination of a history of depression and subthreshold symptoms, followed by either one alone. Occurrence of anxiety disorder was best predicted by both a combination of a history of anxiety disorder and subthreshold symptoms and a combination of a history of depression and subthreshold symptoms, followed by any subthreshold symptoms or a history of any disorder alone.

Now I realise that they were trying to make the point that:

Past episodes of depressive or anxiety disorders and subthreshold symptoms have both been reported to predict the occurrence of depressive or anxiety disorders. It is unclear to what extent the two factors interact or predict these disorders independently.

But it did just make me ask whether it was really worth the effort to show that, when all is said and done, people who have had a common mental disorder in the past, and are showing symptoms of it now, are more likely to be diagnosed with it in the future.

Clinical governance

I've just started working in a new NHS Foundation Trust. Last night I was on-call. During my on-call I got summoned to a ward and told by the nurses to do something - something both illegal and likely to have me up in front of the GMC - 'not bloody likely' I said, 'but it's trust policy they whined'. Eventually they called in the on-call consultant, who wouldn't do it either.

'Silly nurses' I thought, 'policy indeed!' Now, officially, I'm supposed to have read all 30 of the clinical policies (and the other non-clinical ones too), I've never had the time set aside to do this but the trust have told me to do it so that's their arse covered. They're each 20+ pages long and written in a dreary bureaucratic speak that makes it impossible to easily extract the approximately one line that is actually relevant to clinical practice.

Having a few minutes of downtime I thought I'd check the relevant policy, and sure enough, there it was, an explicit instruction that in these circumstances a doctor should do something both illegal and likely to get them struck off. I looked at who wrote the policy, a nurse and an admin person (sorry, 'organisational risk lead'), no doctors seem to have been involved.

So, feeling like a good little boy, I contacted the 'Risk & Clinical Governance Department' to point out this gross oversight - 'oh yeah, someone mentioned something similar in 2008 but the policy isn't up for review until 2012 so we'll take a look at it again then'. Fantastic.

NHS Whistleblowers

People often ask me why I spend so much time bitching about how craply run the NHS is in my area rather than submitting incident forms at work and tipping off the local press. The answer is that I want to continue to work in the NHS, and to continue to work as a doctor. The NHS hierarchy, whether that's local management or the people at GMC towers, do no tolerate dissent as seen in this via the Jobbing Doctor:

Dr Raj Mattu, a consultant cardiologist in Coventry, has finally been dismissed by his Hospital. Dr Mattu made the mistake of criticising the conditions in which patients were being treated in his hospital department.