'Without evidence, the rhetorical reforms are irrelevant at best'

After the Blair-Brown bonanza of increased NHS funding, adjusting to the harsh realities of austerity is challenging. The government espouses some real funding growth for the next four years but in reality, and particularly because of inflation, real funding levels are being eroded.

In this situation the focus has to be on “balancing the books” and demonstrating that the Lansley reforms will assist rather than undermine efforts to avoid bankruptcy. The proposals are reminiscent of the Milburn-Blair reforms over a decade ago.

The rhetoric is similar with claims that primary care will be the engine for increased productivity and better quality care that meets patients’ needs.

There is talk of around 300 GP consortia. The proposed reforms will mean that risk management will be difficult and transaction costs will be high. Are we incapable of learning from experience? Remember how Alan Milburn’s 500 PCGs were translated into some 300 primary care trusts, and then into the “failed” 151 PCTs now being scrapped? What goes around comes around.

The principal concern in the last decade and now is the ability of primary care to be the basis of commissioning. Are we building castles on sand again?

Primary care is a “black box”: we do not really know how good it is as there is little comparative data and few national evidence-based standards of process and outcomes. For instance we have no national data on GP consultation rates, that is we do not know what GPs do, let alone whether it is efficient.

This compares unfavourably with data about consultant activity in hospitals. For these practitioners we have annual data since 1989 (hospital episode statistics) which enables managers and analysts to identify outliers. There are signs that HES data is at last being better exploited.

Where similar data for GPs exist there is evidence of considerable variations in activity. Of course, to vary is normal. The management issue is whether these differences are defensible in relation to the evidence base and the best interests of the patient and the taxpayers. Sadly we do not know the answer to this query as for 60 years we have trusted GPs to do a “good job” rather than require them to demonstrate value for money.

Should we be concerned about the 10 – or is it 20? – per cent of GPs who are not well engaged in providing good clinical care and conserving NHS resources? Such important questions can only be answered by acquiring and using comparative data about processes and outcomes.

Part of the Lansley message is that the reforms will produce more local and appropriate decisions about care. Why will it? The word “choice” has to be considered carefully. If you have a heart attack or are in a car accident and are unconscious, choice is irrelevant. You need high quality care quickly.

Where might “choice” be helpful for patients and their agents the GPs? An obvious answer to this question is where there is evidence of high quality, low cost care. But where is that evidence? Mr Lansley seems to think GPs have that knowledge at their fingertips.

Such faith would be nice if it could be evidenced. There is still an absence of national audits of hospital consultant specialties. Gradually coverage of clinical audits is increasing as practitioners join, often at a snail’s pace. There should be compulsion to audit as part of revalidation. This data should be available for GPs and patients. Without such data, GP advice is based on rumour and hearsay.

A nice example of such auditing is the work of the Association of Cardiothoracic Surgeons of Britain and Ireland. This audit is comprehensive and provides the surgeons with data showing their comparative performance. The incentive effects of this transparency are obvious, as are the benefits to GPs and patients: they can access real data rather than opinion.

Why is it that successive governments have failed to ensure such audits take place? Without them, how can GPs, let alone patients, make choices that enable them to access high quality care? Until such audits provide valid information to GPs and their patients, “choice” is little more than vacuous rhetoric.

The government’s proposed reforms are based on beliefs about how the NHS works. This faith based approach is consuming large amounts of resources and managerial effort which could be better used improving NHS productivity as real funding is eroded. It reflects the basic cowardice of politicians to deal with fundamental rather than illusory policy challenges.