Health Policy InsightEditorial Monday 10 October 2011: Bonfires
A well-built bonfire is an elegant way of minimising waste.
The smell of burning autumn leaves is also a delight.
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This afternoon, my bonfire started with months' worth of personal information, much of which was personalised marketing in the form of junk mail. You know this stuff: heavy, shiny card where they don't just put your name and address details in one easy-to-detatch place, but all over it to wow you with this persoanlised touch - so you'll think their brand is your friend, and spend, spend, spend ...
This stuff smells noxious when you burn it. Its gaudy colours and glossy texture would be a long time rotting, if you were the type to put it in the ground.
Tomorrow, the House Of Lords will face a similar unwanted mountain of paper when they begin their debate of the Health And Social Care Bill. They will do so to the background of a few interesting arguments.
The TINA defence (There Is No Alternative)
One of these is that the Bill must go forward because of the risks to the NHS of continued uncertainty, given the need to save £4 billion a year for this and the next three financial years while maintaining services that is The Nicholson Challenge.
I can see why people are using this line, but it's unwise.
In the first place, if the Bill is seriously deficient (as around, oh, such trivia as training and workforce planning, or dealing with failure), then getting on and doing it faster is definitely not the answer.
It makes as much sense as suggesting that "no change is not an option", which - whoops - Sue Slipman of the Foundation Trust Network has done. It's a significant false dichotomy. That way lies the Yes, Minister politician's syllogism: 'Something must be done. This is something. Therefore this must be done'.
Wooly thinking may be comforting when worn next to the skin, but it's not how we ought to be planning to spend £110 billion a year and organise our healthcare.
The false duality that those who oppose the Health Bill oppose change reveals the intellectual poverty of those who use it.
The Nicholson Challenge is a big challenge - and probably impossible, unless a major top-down redisorganisation were to focus on closing the unsafe or uneconomic capacity and putting into place things we know we need like step-down care and community reablement - or helping people to die at home where they want to, rather than in hospital with vexatious levels of intervention.
'We will stop the top-down reorganisations of the NHS that have got in the way of patient care ... We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services' - Coalition Agreement
Well, despite being explicitly promised no top-down reorganisation of the NHS in manifestos and the Coalition Agreement, we have had our top-down reorganisation. PCTs and now SHAs are clustered.
And the Bill isn't even law yet.
PCTs, which as HSJ pointed out were where what knowledge and skills the NHS had about how to achieve cost-control and rationing could be found, remain - yet are in many cases ghost organisations.
Many former PCT managers and commissioning staff have long since jumped ship, annoyed by constant criticism from Coalition ministers and the PM about "bureaucrats" and "bureaucracy".
There is much talk about the need for greater clarity on how Monitor will work, and the boundaries between competition ands preventing anti-competitive behaviour. This area is critical to these reforms' chances of succeeding on their own terms ... and it remains as clear as mud.
Enterprises and undertakings
There are real concerns over what will happen to the status of NHS organisations as 'undertakings' under European law - which has always applied.
This article provides a comprehensive-looking summary from a pro-comepetitive perspective; this offers an informed and somewhat sceptical view of the infamous 38 Degrees legal advice. And this 2011 presentation by a competition lawyer from Browne Jacobson and the NHS Confederation European Office defines the issues helpfully.
Evidence and competition
Another argument is that the evidence base for the Health Bill reforms is scant. Professor Alysson Pollock (so spectacularly vindicated on PFI) and colleagues, writing in The Lancet, resume attention on the actual findings of the Zack Cooper and Carol Propper competition research, and their interpretability.
Meanwhile, Richard Cookson and colleagues from the University Of York Centre For Health Economics have studied small area administrative data, and concluded that evidence 2001-8 shows that equity was not harmed by the period's "accelerated expenditure growth and pro-competition reform".
Something for both the left and right, then.
Interestingly, the authors conclude that their findings "suggest that socio-economic inequity in utilisation of health care in the English NHS may reflect slow changing demand factors relating to patient care-seeking behaviour, rather than supply factors that respond to short term changes in NHS spending growth and reform".
Meanwhile, Gwyn Bevan and Matthew Skellern argue in the BMJ that postoperative mortality is a bad proxy, and it is too early to tell yet whether comptition-orineted reforms have been effective in improving performance.
Bonfires and ashes
A bonfire is a response to a gardener's need to get rid of waste. You have to build it right, and pick your moment. Too big a bonfire and you'll burn the hell out of your grass roots, scorching the earth.
We are just a few weeks from Bonfire Night, which commemorates a famous attempt at Parliamentary sabotage on a grand scale.
Tomorrow and on Wednesday, we shall see what kinds of gardeners the Lords are.