Fresh from his appearance on BBC1 two weeks ago, Dr Phil Hammond argues that the benefit of NHS reform is still no clearer to being understood, and that a change in direction is needed. It might just win over Andrew Lansley’s critics, too.
BBC1’s Question Time is not the place for nuanced debate. The producers encourage you to be adversarial, to make three “broad brush” points in under a minute and assume that those watching have no knowledge of the issues in depth.
They also wind up the studio audience, telling them it is their show, and they even do a dry run show with volunteers on the panel so everyone can practise booing and interjection.
My debut appearance was billed as Private Eye’s medical correspondent up against the health secretary. Ha Ha versus La La. Ian Hislop’s advice was simple: “Don’t get angry. Otherwise you’ll look mad.”
Alas I found it impossible to debate with Andrew Lansley without getting angry. Politicians cannot acknowledge uncertainty and doubt. Mr Lansley is publicly certain that the NHS will improve with the competition of the free market, that clinical commissioning groups will have the expertise and resources to deliver the toughest multibillion pound challenge the NHS has ever known and that neither competition law nor chief executive Sir David Nicholson will stand in their way. I have big doubts about all of these.
NHS reforms are like overhyped wonder drugs. They are never as useful as they make out and there are often unpleasant side effects. There is no reason why the National Institute for Health and Clinical Excellence should not provide independent analysis on which strategies are most likely to work and give value for money.
Before we spend another small fortune on structural reorganisation, redundancy and rehiring, shouldn’t someone independent tell us if this represents a good use of precious resources?
Health services not only need to be evidence based but also reflect, or win over, the culture of the country. English patients and NHS staff brought up on the idea of a universal, equitable, free-at-the-front-door public service are always going to be spooked by talk of competition, markets and health as a commodity. The NHS may be too wedded to provision of care in hospitals, but hospital staff have no vision of the reforms other than sit tight, cut costs and hope you don’t lose your job.
If Mr Lansley realises his days are numbered, he might be brave enough to make the public case for whole-scale hospital closures and reinvestment in community services to keep patients out of hospital. Having opposed such closures in opposition, he would get a lot of stick but a surprising amount of support from those with a good grasp of health economics.
Commissioning in a market system requires huge expertise and the kind of sophisticated and competent regulation that the NHS has never had. And until we have robust comparative outcomes for different treatments other than adult cardiac surgery, we don’t know the quality of what we’re buying.
Twenty per cent of patients take up 80 per cent of the budget so it makes sense to lavish care and attention on them in the community to prevent them needing hospital admission. Clinical commissioning groups are making good progress with this, and emergency admissions are down.
Primary, secondary and social care are working together to design better care for complex patients, splitting the savings and reinvesting some into service improvement. Crucial to this are visionary, expert managers in a primary care trust cluster doing all the tough contractual stuff.
The NHS also needs to rediscover its humanity, both in the way we treat patients and each other. The mental health of the workforce is crucial for good patient care, which is why rapid reform and job insecurity can be so harmful. We need to stop bullying each other, accept that error and harm will occur in such a complex system and start measuring it to minimise it.
We need absolute transparency in the way we measure clinical outcomes and manage complaints. And we need to know exactly where the money ends up in the new system to expose waste and profiteering.
Humanity, integration, transparency. Three words of wisdom versus 358 pages of “wonk.” HIT me, Mr Lansley.