Quite like heaven?

James Gubb, 29 November 2007

In an important new report for Civitas, Nick Seddon argues compellingly that it is out of respect for the founding principles of the NHS – to provide universal and comprehensive health care – not to mention better care, that it must embrace fundamental, market-based, reform.
Described in a foreword by Mr Bernard Ribeiro, CBE, President of the Royal College of Surgeons of England, as ‘an excellent analysis’, Seddon picks apart the recent NHS reforms and shows:

• Consistent with the Sir Derek Wanless’ report for the King’s Fund, the quality of service in the NHS has not increased at the same rate as the billions of extra expenditure it has received. (pp. 41-77)
• Unexplained and unacceptable variations in performance persist. While in a small number of hospitals, such as UCLH, patients are waiting just 3 days to receive a CT scan, in others, such as Norfolk and Norwich University Hospital NHS Trust, they are waiting as much as 141 days. (p.83)
• The service is not comprehensive, with the gap between supply and demand growing day by day. The NHS has a history of rationing, through waiting lists, dilution of service and denial of treatment, but this has become more, not less, acute as medical technology has advanced. The BMA recently declared ‘in the future the NHS will not be able to provide all services’. (pp.88-104)
• The ‘sharp elbows’ of the middle classes have enabled them to better work a system that is complex and where patients are under-powered. As a result they get better access to care, whereas the poor, mentally ill and ethnic minorities suffer. Patients in deprived areas, despite being in more need of hip replacements or CABG, are much less likely to get them than those in higher-socioeconomic groups. (pp.80-88)
• Inefficiency remains rife. Inflation is chronic, there is too much waste and innovation is stymied – the UK clearly lags behind other countries in the use of new technology in the health sector. (pp.130-144).
• But most worrying of all, the medical profession is alienated and dispirited. Fiona Godlee, editor of the BMJ, wrote in 2006 that ‘the spirit of medical professionalism is quietly dying’. (pp.144-150)
As Seddon shows, much of the reasoning for this can be found in the structure of the NHS and the half-hearted attempts by the government to introduce market-based reform:
• Payment-by-Results itself is an ingenious attempt to make the NHS function as if it were a market, but it is not payment by results at all, but payment by activity. There is no account of health outcomes. Moreover, with price negotiation ruled out, it assumes the government can accurately ‘guess’ the cost of every procedure, which risks leaving many becoming unprofitable. (pp.122-126)
• What market-based incentives that have ben introduced by Payment-by-Results and strengthened commissioning have been mangled by constant ‘re-dis-organisation’, excessive bureaucracy and a target culture. (pp.126-130)
• Commissioners have been protectionist rather and progressive; at the latest count just 43% of patients even recalled being offered a choice of hospital. Patient choice has been put on the back-burner, secondary to meeting targets. (pp.110-113)
• There is still only limited plurality of provision. Foundation Trusts offer many opportunities, but are being stymied by the system they are working in and the independent sector is still only carrying out a fraction of NHS procedures. (pp. 113-122)
• Unsurprisingly, the focus of the NHS remains on Whitehall, not the patient.
A new generation that feels no historical allegiance to the NHS is asking if this is really the best we can do. In a foreword to the report Bernard Ribeiro, writes:
‘Generation Y, born between 1978 and 1995, is a new generation, brought up desiring instant gratification in the form of iPods, laptops and Blackberries…they will not tolerate an NHS that does not deliver and they lack the social cohesion and responsibility of a wartime generation brought up on rationing, which inspired and built the modern NHS… the long-awaited debate on the future of the NHS has only just begun’. (pp.ix-x)
The causal nexus of the NHS’ problems, argues Seddon, is that the government remains well and truly in control of the purse strings and refuses to embrace competition in health care. (pp.105-112)
Nowhere in Europe does such a high proportion of health spending come through the state, which is the root cause of the constant meddling with incentives and the root cause of why patients remain disempowered: (ch.5)
• Evidence from abroad, particularly countries such as Switzerland and the Netherlands, indicates that it is possible to deliver universal and comprehensive healthcare, equitably and to higher standards than in the NHS.
• The Dutch, in particular have succeeded in setting up a system that has the potential to harness the benefits of real competition and real choice, through insurance arrangements, while maintaining health care for public benefit through tax credits and a Health Insurance Fund.
• In both systems the government is neither the provider, nor main funder, of health care, but regulator. Political interference is at a premium compared to the NHS.
• The ability of the patient to choose between insurers, insurance packages and hospitals ensures the system is patient-focused. Patients are a lot more cost-conscious and, if they don’t like the health care they receive, they can vote with their feet and go elsewhere.
• The power of exit for providers is real and acts as a powerful incentive for them to drive up standards. (ch.5)
Of course, we must not replicate mistakes made elsewhere – health insurance should be compulsory, not linked to employment and, above all, competition must be focused on the consumer and on patient value (i.e. health outcomes), not activity (ch.6). But key sources show when properly used real choice and real competition will result in better, more efficient, health care for all.
As Seddon concludes: ‘…the NHS does not have the wherewithal to deliver the founding aspirations of making all necessary health care available at high quality to everyone, irrespective of ability to pay. Our system is full of dynamic and committed individuals. Will we stay in the past or find a way to the future?’
The report received widespread media coverage:
BBC Online Guardian – Seddon Guardian Telegraph – Leader Telegraph Daily Mail Daily Express Press Association
To order a copy of the book, please visit the Civitas Online Bookshop or Amazon-UK.