Saturday, 9 April 2011

NHS reform: from liberating, to modernising, to pausing - but has anyone ever been listening?

Relax, I'm not going to even attempt to assess the proposed NHS reforms in anything like full. If you're looking for a much more learned analysis, then I would recommend the following Twitter luminaries:

@HPIAndyCowper - Editor of Health Policy Insight
@ProfAlanMaynard - Professor of Health Economics, University of York
@jappleby123 - Chief Economist at the King's Fund
@martinmckee - Professor of European Public Health, London School of Hygiene and Tropical Medicine

What I am going to try to do is look at whether genuine efforts have been made to listen and address legitimate concerns that have been raised since the Con-Dem Government came to power on 12 May 2010 and the proposed NHS reforms were first pursued with gusto. I’m also passionate about the abuse of ‘facts’ to further political agendas, so that might also get a mention or two (if it’s a straight choice, for me, you can keep your dodgy expenses, but don’t try to get away with your dodgy facts – and definitely don’t trot them out over and over again once they’ve been outed as dodgy!).

The now infamous White Paper 'Equity and excellence: Liberating the NHS' was published by the Department of Health on 12 July 2010 (just two months after the Coalition took power - whatever your political hue, that's a very quick turnaround time to propose such major changes to such a major institution).

On the same day, Secretary of State for Health Andrew Lansley made a statement to Parliament concerning the White Paper. The statement lists challenges facing the NHS, including an increasing and ageing population, advances in medical technology and rising expectations.

On the very next day (13 July 2010), Sir David Nicholson, Chief Executive of the NHS, wrote a letter to all NHS Chief Executives and Chairs entitled ‘Liberating the NHS - Managing the transition’. This is a very significant letter. Depending on your point of view, it could represent good boy scout style planning (dib, dib, dob, dob, be prepared), or it could totally undermine a three month consultation period by telling all senior NHS staff the day after the consultation is launched that they better get on and deliver the key reforms, as time is of the essence, there's no alternative and there's no point in waiting.

The consultation period concerning the White Paper ran from 12 July to 5 October 2010, with a commitment made to publish all responses received in full. All of these groups responded.

On 15 December 2010, the Department of Health published its response to the consultation. It states that "substantial feedback" was received that "reaffirms the strong commitment to the reforms", with the document including various snippets from various responses.

Since January, I have been pursuing publication of the individual responses to the consultation. It was a brave and bold commitment to make by the Government, something that should be applauded. However, for the applause to start, the commitment must be honoured. I am yet to receive either a confirmation of when the responses will be published, or an explanation as to why the responses now won't be published. Cherry-picking certain responses to be included as evidence of support is very different to committing to publishing all responses received, unedited and unsanitised. In my humble opinion, anyway.

Fast forward to 6 April 2011, and we have this - Government launches NHS listening exerciseI have no idea what makes this pause a natural pause (seems like a supremely unnatural, exceptional pause to me), but leaving that aside, we have the Prime Minister David Cameron, the Deputy Prime Minister Nick Clegg, and the Secretary of State for Health Andrew Lansley all declaring their love for the NHS. 

We've also got Lansley saying that 90% of local authorities have signed up to play their part in improving services for patients (the only surprise here is surely why it isn't 100%, given the incredibly directive letter from the head of the NHS, David Nicholson, back in July 2010... or am I being unfair and cynical? The best analogy I've heard about this is that just because the lifeboats on the Titanic were used doesn't mean that the passengers approved of the ship going down).

To complement the launch of the ‘natural’ pause / ‘listening’ exercise, we were blessed with a leafletThe first interesting thing about this leaflet is that it's not produced by the Department of Health, but by the Prime Minister's Office (make of that what you will).

The next interesting thing about this leaflet is that almost the first words in it are "We love the NHS" in big, bold letters. What the founders of this website make of the appropriation of that emotive phrase, I can only guess at.

The leaflet then goes on to explain that the population is ageing (hang on, didn't Lansley explain that back in July last year when the White Paper was launched?). It has a brilliant summary to ram home the point:

"For the first time ever there are more pensioners in this country than there are children under 16. Clearly this is something to be welcomed..."

Really? Doesn't that depend on whether you prefer old people or children? And wouldn't lots of people actually have a neutral view of whether they'd prefer there to be more old people or children in England? It also has the much loved by some “No change is not an option” claim.

The leaflet then explains that advances in medical technology are making some treatments increasingly expensive (hang on, didn’t Lansley explain that as well back in July last year when the White Paper was launched?).

The leaflet then moves to what should be incredibly safe territory, but manages to make it potentially the most controversial ground. It starts off with the assertion that we want to have the best health service in the world. Well, ok, so far, so good (but seriously, which country wouldn’t want to have the best health service in the world?!? Obvious. Stating. The. Bleeding). We then have three figures that are presented as “facts”. This is absolutely critical, as the leaflet states:

These facts alone compel us to modernise and improve our NHS

Wow – sit up straight, concentrate. You’re about to see three facts that on their own justify the NHS reforms. Drum roll, please.

‘Fact’ one: if our NHS was world class, every year we would save an extra 750 lives from heart disease

No source is provided for this ‘fact’, which is a shocking omission. I therefore have been deprived the primary source with which to review and comment on this ‘fact’. I therefore do not view it as a ‘fact’. If you want me to engage with you, then engage properly with me. Don’t claim things if you can’t back them up. Mouth. Trousers.

‘Fact’ two: if our NHS was world class, every year we would save an extra 2,000 lives from respiratory disease

Different disease, different number of lives, but same fundamental problem and shameful omission. No primary source. I therefore do not view it as a ‘fact’. Money. Pudding.

Bad start (to put it mildly) – two out of three ‘facts’ down, one to go.

‘Fact’ three: if our NHS was world class, every year we would save an extra 5,000 lives from cancer

Different disease, different number of lives, and by jove, we have a source! The source is Abdel-Rahman et al, BJC Supplement, December 2009.

Before we look at the source, take a quick look at David Cameron’s speech on 6 April 2011, at the launch of the ‘listening’ exercise.

Hmmm, he’s steered clear of the heart disease figure completely (interesting? Possibly, possibly not). And he describes the other two figures as estimates. No wait, he’s calling them ‘facts’. No wait, he’s calling them both!

But if our NHS was performing at truly world-class levels, we could save literally hundreds more lives every week. It's estimated we would save an extra 5000 lives from cancer every year. An extra 2000 lives from respiratory disease every year. These facts alone compel us to modernise and improve our NHS

Am I alone in seeing a fundamental difference between estimates and facts? With apologies for the undergraduate style of referring to dictionary definitions, but it feels just about justifiable in this instance.

- something that actually exists; reality; truth
- something known to exist or to have happened
- a truth known by actual experience or observation; something known to be true

- to form an approximate judgment or opinion regarding the worth, amount, size, weight, etc., of; calculate approximately
- to form an opinion of; judge
- to make an estimate;
- an approximate judgment or calculation, as of the value, amount, time, size, or weight of something

A difference? You decide.

Anyway, where were we… oh yes, ‘fact’ three and Abdel-Rahman et al. Having a source in the leaflet allows us to look at the source for ourselves. And me including the source in this blog allows you to look at it for yourselves, and not just take my view on it, or the excerpt that I choose to quote (a certain national journalist who chose to block me on Twitter might want to take note… not that I’m bitter or bear a grudge or anything).

What’s that you ask? Which excerpt would I personally choose to quote? Well, this one, as it goes:

We set out to estimate how many cancer deaths would have been avoided within 5 years of diagnosis if survival among patients diagnosed in Great Britain (England, Scotland and Wales) during 1985–1989, 1990–1994 and 1995–1999 had been equivalent either to the mean survival or to the highest survival seen in other European countries. Cancer survival has been improving in most European countries, so comparison with a shifting baseline is appropriate. Trends in avoidable mortality can be seen as an overall comparative measure of progress in cancer control between Britain and the rest of Europe

Actually, there’s more I would choose to quote, so I will (my dull blog, my dull rules):

For several cancers, survival in Britain was slightly higher than the mean survival in Europe

Avoidable premature mortality among cancer patients diagnosed in Britain during 1985–1999 has represented 6–7% of cancer-related mortality compared with the mean survival in Europe. Compared with the highest levels of survival in Europe, the reduction from 12.2% to 10.6% of cancer-related mortality reflects small but steady progress over the period 1985–2003

So, in summary, we’re making steady progress on cancer survival rates, and the study doesn’t look at any data beyond the year 2003. Hmmm, well, it’s 2011 now. The latest cohort of patients looked at in the study were diagnosed with cancer between 1995-1999.

Since then, we’ve had the NHS Cancer Plan, published on 27 September 2000. It includes the following:

Despite the best efforts of the NHS staff and cancer patients across the country, decades of under-investment alongside outdated practices mean that survival rates for many of the major cancers lag behind the rest of Europe

Well that sounds like it roughly tallies with what Abdel-Rahman et al estimated in their study. Lest we forget, their study came out in 2009. That’s one of the problems with healthcare. It’s complicated, and it takes a long time to review and study very complicated areas, like cancer survival rates.

The NHS Cancer Plan goes on:

The Cancer Plan is a practical document for the NHS and its partners, setting out the actions and milestones that will deliver the fastest improvement in cancer services anywhere in Europe over the next five years. By 2010, our five year survival rates for cancer will compare with the best in Europe

What, what?!? You mean the idea of looking at outcome measures, like survival rates, didn’t start with the new Coalition Government? Well I’ll be. And hang on a second, I’ve got a crazy idea… if Abdel-Rahman et all were able to provide interesting estimates about cancer survival rates in 2009 based on a cohort of patients between 1995-1999, maybe, just maybe we need to wait a while longer to know whether the NHS Cancer Plan has delivered what it set out to deliver.

Instead, what we get is a 2011 Government leaflet telling us that the NHS reforms must happen based on an historic estimate dressed up as a current and ongoing fact. Annoyed? Irritated? Disappointed? Me too!

I’m almost done (I’ve got some Jehovah’s Witnesses to bother), but just a couple more snippets from the 2000 NHS Cancer Plan:

The Plan will be supported by new funding, rising to an extra £570 million a year for cancer services by 2003/04. By 2006 there will be approaching 1,000 extra cancer specialists, more radiographers, more nurses, and targeted action to respond to shortages of other staff who contribute to cancer diagnosis and treatment. In partnership with voluntary organisations, with the New Opportunities Fund, and others, we shall extend the range and accessibility of cancer services right across the country. We cannot make all the changes overnight. But as the Plan is rolled out and milestones are reached, people will begin to see the improvement that will mean we no longer lag behind Europe, and in time will compare with the best in Europe

Now, honestly, hand on heart, politics aside, I really like the above paragraph. Why? Well, it’s easily understandable, it’s compelling, and above all, it’s realistic.

It’s basically saying, yeah, we know we’re not doing so well right now, not as well as we’d like, and certainly not as well as the best. So we’re going to splash some cash (quite a lot of cash!), we’re going to hire some extra staff (quite a lot of extra staff!), we’re going to work with others, including volunteers (extra, extra, read all about it – Big Society spotted 10 years earlier than thought!), and we’re not promising immediate improvements, but we’re working to a longer term plan.

Common sense and realism, innit. I can buy into that. Now what would be a fitting reward for such common sense and realism? Well, what wouldn’t be fair is if in the year 2011, one year after the deadline for the NHS Cancer Plan, we have a Government leaflet telling us that the NHS reforms absolutely have to happen because of our poor performance on cancer.

Even worse, the ‘fact’ in the leaflet pretty much pre-dates the NHS Cancer Plan being introduced.

Apologies, as I’ve droned on a bit about this one, and I could do a bit more, but I won’t (phew).

The leaflet then explains that we’ve now got more doctors (doctor graphic = white figure, with stethoscope) and fewer managers (manager graphic = black figure, with tie).

I could bang on about this as well, but I will leave it to the magnificent @RealDMitchell
and his astoundingly good article on this general topic.

Oh, just one point (sorry – indulge me). Yes, the leaflet does indeed more frequently refer to managers as bureaucrats (boo, hiss! They’re behind you, in front of you, beside you, getting in the way and being annoying).

What else is in the leaflet… well, in terms of fetching infographics, there’s one more doozie for me:

95 per cent of people want more choice over their healthcare

Not exactly groundbreaking stuff (who are the 5% that don’t want more choice?!? – I could have every sports channel known to mankind, and my wife would claim I already do, but if someone asked me if I wanted more choice of sport to watch, I’d still say yes), but the source is the really interesting part. It’s a figure from the 25th British Social Attitudes Survey.

This is a survey that has been running for more than two decades, providing a fantastic comparative source of exactly what it says on the tin – British social attitudes. It includes a range of questions about the NHS and healthcare.

The reason why it’s so interesting is that the Government leaflet has chosen to quote the figure from the survey just weeks after the Department of Health withdrew funding for said survey. Little bit weird? Little bit shifty? Little bit dodgy? The survey is good enough to provide a source for why the NHS reforms must happen, but not good enough to be funded, despite such funding having been in place for more than 25 years.

Thankfully the King’s Fund are going to step in to help save some of the questions in the survey.

Check out the stats and graph from the latest (27th) survey, and make your own mind up about whether there may be more to it than just a minor cost saving as to why the Government no longer wants to fund the survey (hint: that worm is on a steep upward trajectory over the last three years. If it was a cricket run chase, you'd think someone like Boom Boom Afridi or Bash Bash Sehwag was having a grand old time - are they about to get clean bowled?). "I can't get no satisfaction" doesn't seem to be the theme song of the NHS in recent years - don't take my word for it, have a look at this.

Right, enough is surely enough. This was supposed to be a short, concise, focused entry. It’s got away from me, and I sincerely thank anyone who has made it this far.

My closing comments would be that I am incredibly unimpressed with what has happened over the last few months. We’ve had a public consultation that was looking like being open and transparent, but ended up being almost immediately undermined by behind the scenes directives, and a failure to publish what key groups thought about the proposed reforms. And we’ve now got a public listening exercise that still has the potential to be meaningful, but is already in danger of being undermined by behind the scenes directives… yes, David Nicholson’s at it again... a leaflet that some feel is nothing more than crude propaganda… and an ongoing failure to actually listen. 

Listening does not mean talking more slowly. Listening does not mean using smaller words or bigger font. Listening does not mean converting a parliamentary statement from July 2010 into a glossy leaflet, resplendent with infographics, in April 2011. And listening absolutely does not mean pausing and then continuing regardless.

Oh, and if I'm wrong (it happens..... a lot), then tell me how you are listening. Show me what you are doing in response to what you're hearing. Because I'm hearing a lot, and it's not what I'd call universally supportive and positive. This fantastic piece from Paul Corrigan's invariably excellent blog is inspired - basically casting Larry Labour (who can be over controlling and bossy, and likes a bit of Tina Targets action on the side) as the NHS' childhood sweetheart, and Tony Tory as the NHS' childhood bully, now saying that he's seen the error of his ways, has totally changed, and has fallen in love with the NHS. But what is the basis of this new found love? Conceptual only? And if Tony Tory loves the NHS so much, why is he wanting her to change so much?

As for the two pronged approach of vilifying bureaucrats and relying upon the frequent use of dodgy facts, I can only make a very simple plea. Stop doing it. Now.

The former is completely unfair to the thousands of committed individuals who work incredibly hard, no matter what the Government of the day is, and despite the axe of redundancy or the spectre of job insecurity hanging over or around them. And the latter is an affront to our intelligence and a very dubious way to conduct any kind of business, let alone business that affects every single person living in England.

Goodnight meaningful political engagement and appropriate use of evidence to support claims, wherever you are

Wordle: Liberating the NHS


  1. excellent article
    I agree with almost all your points
    the worry is that we are now entering a phase that appears undemocratic - listening again but with no clear mandate as to whether this listening undermines all the comments and formal consultation that has preceded it.
    The RCGP will be making its views known

  2. Excellent. And thanks for pointing out the timing, absence of sources .... Amazing that they don't think they're bureaucrats themselves.


  3. Actually for anyone paying attention, it was quite clear before the election what was going to happen. (Read my blog from last January.) The problem is that no one was paying attention. The newspapers were distracting us with trivial things like MPs expenses (FFS that's only £14m, under Lansley's plans we will see the misuse of billions) or "electoral reform" (FFS Lansley wants to take almost *all* accountability out of the NHS, the government will *no longer* be responsible for ensuring that there is universal comprehensive healthcare).

    Lansley and Cameron knew that these plans would hit the buffers at some point (my prediction was November 2011, when the money runs out, but it has happened earlier than I thought). This is why they started the irreversible changes on the first day. Without Parliamentary approval they have abolished PCTs - they cannot be re-created.

    Some of us who have been trying to get the NHS on the agenda for two years, and now, finally, it is there. The problem is that Lansley and Cameron have got their way. It will be too expensive to go back to a system where GPs only make clinical decisions (PCTs making the financial decisions) rather than the new policy where GPs will have to break even first, and treat you second. We are now in the situation of working out how we get the best of this nasty policy.

    (Oh and BTW Lansley does not "know the NHS better than anyone" as seems to be the popular opinion. Look at his policy on consortia, where he has no clue at all about how they should be organised, how big they should be or what legal standing they should have. These are vital details and if you get them wrong the consortia will fail. Lansley could not care less.)

  4. Enjoyable read, good spot on pamphlet's lack of references.

    And if that first comment is from Clare Gerada as it appears, you've got some good readers!

  5. Good factual blog.

    Whether David Cameron will actually listen or this will suffer the same fate as consultation, time will tell.
    Assuming that the reforms are going ahead either way, what’s your opinion on the best way forward?

  6. Hi Anon (12 April 2011 07:38)

    To be honest, I'm not going to pretend to know the best way forward. As I said, I'm not an expert and this is a massive set of reforms, with huge implications.

    What I do want however is a Government that fulfills its commitments, or explains to me why when it doesn't.

    I want a Government that doesn't peddle dodgy stats to try to justify what would otherwise be ideologically motivated reforms (if you've got firm, reliable evidence in favour of the reforms, then show me, and I'm much more likely to back you).

    I want a Government that doesn't rely on the absurd claim that "No change is not an option" - doing nothing is, always has been, and always will be an option! It may not be a good or appealing option, but make no mistake, it is an option.

    Check out pages 3 and 4 of the Department of Health's Impact Assessment:

    Only one option considered! No date for review. And a load of risks identified.

    And when you've got a successful rap about the NHS White Paper and the Secretary of State for Health sneering at The Lancet, something is definitely not right.

    Finally, here's a couple more interesting reads: