Monday, February 20, 2012

There's no public or professional support for the NHS privatisation reforms - and the LSE Study's indicators can't measure quality of patient care

David Cameron’s planned NHS reforms are opposed by more than twice as many people as support them. A YouGov poll this month found 48% oppose them and only 14% support them (1). That’s up from 41% opposing them and 20% supporting them in a June 2011 YouGov poll, showing that as people hear more about the ‘reforms’ they like them less and less (2).   The rest are don’t knows, probably because they don’t understand the reforms, which is no surprise because even Professors of Healthcare funding say they don’t understand how they’re meant to work in practice.

The British Medical Journal reports that ‘Despite 25 years of experience researching health systems, including writing over 30 books and 500 academic papers, Professor Martin McKee from the London School of Hygiene and Tropical Medicine says he still can’t understand the government’s plan for the NHS.

In a Personal View published on today, he writes: “I have tried very hard, as have some of my cleverer colleagues, but no matter how hard we try, we always end up concluding that the bill means something quite different from what the secretary of state says it does.”’ (3)

Mark Britnell, a former adviser to David Cameron, is now head of the Healthcare division of accountancy firm KPMG told a conference of private healthcare companies that the NHS would be shown “no mercy” in the reforms leading to “big opportunities” for private healthcare firms (4). No wonder Andrew Lansley and David Cameron don’t want people to be clear about what their ‘reforms’ would involve.

Cameron later claimed to have no idea who Britnell was and to have never met him, despite Britnell being the head of the NHS body covering Cameron’s constituency and NHS Oxford documents showing Britnell and Cameron had definitely had at least one meeting. The Financial Times reported that Britnell certainly was in meetings with Paul Bate, Cameron’s special adviser on healthcare, so either way clearly has some input into and understanding of the government’s healthcare plans (5). (The fact that Britnell was a senior NHS official under Labour might ring alarm bells about the right wing of the Labour party too).

The “quite different thing” which the bill will actually involve if it’s passed is likely step by step privatisation, as with the Royal Mail, with the planned end game being to set the NHS impossible tasks to compete with private firms who are cherry picking the profitable business and leaving the expensive work to the public sector, which is then judge to have failed and so to require privatisation (and when I say ‘work’ I mean ‘patient care’ as we ‘dinosaurs’ who don’t see ensuring everyone can afford healthcare as just an impediment to profits for private firms)

he June 2011 poll also showed 71% opposed privatisation of the NHS with only 7% supporting it (6).  So if more understood the reforms include private companies running NHS hospitals, even more would oppose them.

Private healthcare firms like Care UK are reported to have donated money to Health Secretary Andrew Lansley’s office and Paul Ruddock, who, according the the Conservative Home website, donated over £480,000 to the Conservative Party , is one of the major shareholders of Circle Healthcare, the first private company to be given a contract to run an NHS hospital.

The reforms are also opposed entirely by 75% of GPs and 65% of all NHS employees polled ; and many more want them changed. If passed they would result in much of already overworked doctors and nurses’ time being spent on management rather than patient care (7) – (8).

Many studies show increased competition leads to increased death rates among heart attack patients, an internationally accepted measure of patient care (9) – (11).

Some others claim evidence that competition improves patient care – but the indicators they use as supposed measures of ‘efficiency’ , ‘productivity’ and ‘quality of care’ can’t show anything of the kind. For instance the recent London School of Economics study, which supposedly found competition improved care, used how long patients stayed in hospital before and after hip operations as it’s only indicators. Yet shorter stays may mean less preparation for the operation and less post-operative care – i.e poorer care. You might as well try and measure temperature by using the average height of lamp posts as try to measure quality of patient care by how long they were in hospital before and after hip operations (12) – (13).

Professor Steve Field, the GP heading the government’s listening exercise says the plans would destroy key NHS services and that what is needed is not more competition but more co-operation between different hospitals and practices (14).

Cameron and Lansley’s plan would not save the NHS – it would destroy it. It has no support, either among the majority of the electorate or among the majority of healthcare professionals – and there is no evidence that competition improves healthcare provision – only dodgy studies drawing conclusions that can’t follow from the indicators they use.

(1) = YouGov / Sunday Times Survey Results 9th - 10th February 2012 ,  and

(2) = YouGov/ Politics Home 07 Jun 2011 ‘The Politics of NHS Reform Special Report’  page 3,

(3) = British Medical Journal 17 Jan 2012 ‘Does anyone understand the government’s NHS reforms, asks senior professor’,

(4) Observer / 14 May 2011 ‘David Cameron's adviser says health reform is a chance to make big profits’,

(5) = Financial Times 03 May 2011 ‘Meeting prompts talk of sidelining Lansley’,

(6) = YouGov/ Politics Home 07 Jun 2011 ‘The Politics of NHS Reform Special Report’  page 9,

(7) = Channel 4 News 28 Jan 2012 ‘’Don’t derail NHS reforms’ senior GPs warn’, , ‘ And a Yougov poll in the Sunday Times also shows that 65 per cent of NHS workers want the bill withdrawn, 66 per cent believe it will make the NHS worse, and 84 per cent are concerned about the role of the private sector, Clare Gerada, chair of the Royal College of General Practitioners, pointed out, however, that last time they had surveyed their members, 2,600 had responded and 90 per cent had had serious concerns about the NHS reforms. Dr Gerada said that 56 heads of clinical commissioning groups was small in light of the increasing opposition.’

(8) = 12 Jan 2012 ‘Three-quarters of GPs want health and social care bill withdrawn, poll reveals’,

(9) = Karl Propper, Simon Burgess & Katherine Green (2002)‘Does competition between hospitals improve the Quality of Care : Hospital Death Rates and the NHS Internal Market’, ; ‘We find the impact of competition is to reduce quality. Hospitals located in more competitive areas have higher death rates, controlling for hospital characteristics, actual and potential patient characteristics. The estimated effect of competition is small, but is

robust to different measures of competition and hospital volume. We also find evidence that AMI death rates in small local areas that are served by many hospitals are higher (again conditioning on population characteristics) for all but the wards that are located in the most competitive areas. Whilst the estimated impact of competition on quality is small, what it is not is positive. and

(10) = Karl Propper, Simon Burgess & Denise Gossage (2003) ‘Competition and Quality: Evidence from the NHS Internal Market 1991-1999 , ‘Payer-driven competition has been widely advocated as a means of increasing efficiency in health care markets. The 1990s reforms to the UK health service followed this path. We examine whether competition led to better outcomes for patients, as measured by death rates after treatment following heart attacks. We exploit differences in competition over time and space to identify the impact of competition. Using data on mortality as a measure of hospital quality and exploiting the policy change during the 1990s, we find that the relationship between competition and quality of care appears to be negative.’ ,

(11) = Stephen M. Shortell, Ph.D., and Edward F.X. Hughes, M.D., M.P.H. (1988) ‘The Effects of Regulation, Competition, and Ownership on Mortality Rates among Hospital Inpatients’ in New England Journal of Medicine 1988; vol 318: pages1100-1107April 28, 1988 ; ‘ We found significant associations between higher mortality rates among inpatients and the stringency of state programs to review hospital rates (P≤0.05), the stringency of certificate-of-need legislation (P≤0.01), and the intensity of competition in the marketplace, as measured by enrollment in health maintenance organizations’

(12) = 20 Feb 2012 ‘NHS reform: competition improves hospitals, report finds’, ; ‘Prof Zack Cooper, who led the study team, said …"We found two core findings. Clearly competition between NHS hospitals improves productivity, quality and efficiency. But when they opened up competition to private sector in 2008 it didn't improve results," said Cooper.

 (13) = Zack Cooper, Stephen Gibbons, Simon Jones and Alistair McGuire (2012) ‘Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service’, Center for Economic Performance, London School of Economics , CEP Discussion Paper No 1125, February 2012  ‘The underlying logic for this measure is that if hospitals can maintain quality and deliver care within a shorter period of time, this is evidence of improvements in efficiency. However, rather than improving their efficiency, hospitals could shorten their overall LOS by skimping on quality and discharging patients ‘sicker and quicker’. Likewise, because overall LOS is heavily dependent on patient 3 characteristics (which directly influence recovery time), hospitals could also appear to shorten their LOS by avoiding high risk patients and focusing their care on patients who are likely less costly to treat or alternatively discharging patients before it is clinically appropriate ……….To address these issues and differentiate between genuine productive efficiency gains and quality skimping, we disaggregate LOS into its two key component parts: 1) the time from the patient’s admission until surgery; and 2) the time from the patient’s surgery until discharge.’ (How can this ‘disaggregation” possibly “addresses these issues’?)

(14) = 13 May ‘Andrew Lansley's NHS reforms are unworkable, says review chief’, ; ‘In an interview with the Guardian, Field says Lansley's plan to make the NHS regulator Monitor's primary duty to enforce competition between healthcare providers should be scrapped. Instead it should be obliged to do the opposite, by promoting co-operation and collaboration and the integration of health services…."If you had a free market, that would destroy essential services in very big hospitals but also might destroy the services that need to be provided in small hospitals," says Field.’

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