Citizen Coders

This article is interesting:

Speaking to Government Computing, [Tim] Kelsey [Director of information at NHS Commissioning Board] said: "We want to help people to innovate and make best use of the data that is running through the veins of the health service, taking a leaf out of the very accessible and brilliant campaign launched by Code for America."

As a software developer and someone who has spent 20 years writing books, magazine articles and training courses (and spoken at conferences and given hands-on courses) on how to programme, I have some interest in this area. I am a C++/C# programmer and before the .NET framework was released I developed Windows applications using the Windows SDK (which is a library that gives you access to just about every feature of Windows). At conferences there would always be a discussion, either officially (as a panel discussion as part of the conference), or unofficially (in the conference hotel bars), of which was better: VB (Visual Basic) or C++. Clearly C++ is better, but I was always willing to take part in a good natured discussion with VB developers to prove them wrong.

There was always one point that I would concede: VB3 was the reason why Windows 3.1 became popular. VB3 was a drag and drop environment where basic components of a program (visual controls like buttons and list boxes, or functional collections of code like timers or database access) were packaged as visual objects that you could drag from the toolbox of controls and drop on the window (or Form) that you were developing. You then wrote a small amount of code to connect the objects together: handle the user clicking on the button to read data from the database and put it in the list box. In C++ I would have tens or hundreds times more code to write to do the same thing because the Windows SDK gives fine grain access to functionality. This makes SDK development very flexible, but you had to write a lot of code.

When VB3 was released it became very easy to write software for Windows, and almost overnight huge numbers of applications appeared as shareware or freeware. Business were also keen to use VB since it was easy to teach developers and it took much less time to develop a VB application than a C++ application. At that time (93/94) I taught both VB3 and C++ courses. The VB3 courses were three days to learn both the language and the objects that you could use. The C++ courses were two five day courses: one course to learn the language and the other to learn the library (Windows SDK or a C++ library called MFC). The cost per day was also cheaper: the company I worked for charged two thirds the C++ daily rate for me to teach a VB3 course. Consequently, for every C++ course I taught I taught five VB3 courses.

VB3 meant that there was a huge number of applications and this meant that somewhere, if you could find it, was one that did exactly what you wanted. The problem was that, as a hobbyist language, the quality of most applications was poor. They were bug ridden and the user interfaces were not designed with (dare I say it) any taste. Since it was so easy to make a form background shocking pink and all the text italic putrescent green, people did.

VB3 applications only ran on Windows so people bought Windows computers and, for the fairly reasonable cost of the VB development environment, they could be creating applications within days. Or, if they did not want to develop code themselves, people could find somewhere on bulletin boards or in the classified ads of computer magazines, a VB3 application that would do what they wanted. The popularity of Windows 3.1 came from VB3.

Tim Kelsey's idea is similar, he plans "to launch a 'mass training programme' in basic data coding across health and social care with the aim of creating thousands of applications to open access to NHS data". He does not say what language or framework will be used, nor how the "mass training programme" would be carried out (hint: I can recommend an excellent developer to author and delivery the training). However, I am somewhat cautious. Developing useful apps comes in two parts: having the idea and developing the code. As a developer I am skilled at the latter. The thousands of "doctor, manager or patients" that Kelsey identifies, are skilled at the former.

I am always in favour of training people new skills (hint: and looking for a job right now!) but it has to be done in an economic way. If a surgeon had an idea of a robotic surgical instrument would he go back to university and take an electronics degree so that he could design the device himself? No, the surgeon would find someone who could design the device and explain the idea to the engineer. The important point is to get the new, innovative ideas to the people who have the skills to implement them. The implication that you can teach anyone to programme an innovative idea is also rather demeaning to skilled developers: it implies that there is no skill in development. However, as with VB3 applications, it will fairly rapidly become apparent that there is a lot of skill in developing and this will show in the quality of the applications created. I suspect that the idea to train thousands of people in "basic programming" will result in thousands of very basic, buggy applications and the challenge would be to trawl through them all to find the one that does something innovative and is reliable.

A more powerful idea would be to get the ideas people to connect with the coding people. Create a virtual "dating agency", a website where a "doctor, manager or patients" can post their ideas and developers can take up those ideas and produce a working application. I would go one step further. I think such a website should also include a toolkit that developers would have to use. Such a toolkit would ensure that all the applications had the same look and feel and would be compliant with standards of reliability and accessibility. This would ensure that all patients (regardless of their disability or their mother tongue) could use any application created with the toolkit.

And just in case I've been too subtle: I am available at reasonable rates to help design such a programme.

Rat-arsed

Joe Farrington-Douglas tweeted last week an article on Lib Dem Voice posted at the time that Norman Lamb  took over the Lib Dem health brief. Lamb wrote a paper about his thoughts and followed up with interviews with newspapers. In particular Lamb said:

"If you get rat-arsed on a Friday night and get taken to A&E where you are foul and abusive to staff, is it right for the taxpayers to fund your life-saving treatment?"

The implication being that it isn't and we shouldn't and hence there should be a charge for A&E in these circumstances. The Guardian said:

He called for wide public debate on whether the community should pay for the excesses of the individual. There was a strong case for charging drunks for stomach pumps or treatment of injuries, and pubs and clubs should also be made to contribute if their complicity could be proven.

This is not only wrong, but it is very unliberal. Lamb was suggesting that we create a concept of deserving patient and undeserving patient. Under Lamb's plan the undeserving patient has to pay for their treatment. Where does it stop? Do we charge smokers for their treatment? Do we charge drunk drivers for the injuries they receive, or the injuries they cause?

What happens if someone is foul and abusive but sober? Is Lamb concerned with people's behaviour, or their condition? If a person does something illegal (they are foul and abusive to A&E staff) then the legal system can be used: they will be punished for their behaviour. But what if they are drunk but polite, do those drunks get a discount, or get the treatment free? Who decides what is foul or abusive, will there be national standards or will some areas be allowed to be more sensitive? What if the patient has mental health issues which is the cause of the abusive behaviour and is unrelated to the alcohol they consumed?

The whole idea was poorly thought out.

It didn't matter that this policy was unworkable because Lamb wanted to get a different message out to the public. The message came straight out of the Lib Dem's Orange Book. Lamb wants to deliberately break the cherished free-at-the-point-of-delivery principle of the NHS. Once you start charging for treatment, regardless of the reason, that principle has been broken and charges will spread throughout the NHS. Imposing charges will encourage the development of an insurance market. Insurance companies will produce products so that you pay a small premium every month (say, for the cost of 5 pints) and the insurance company will pay your A&E bill if you get injured when rat-arsed. Of course, this may backfire. Just as some people are rather "clumsy" with a paint pot "accidentally" knocking it over the carpet that they want replaced, or like some people foolishly put all their valuable electronic items in one bag which they lose "by accident" so that they are replaced with the latest models. Just as there are always people who will abuse insurance, there will be people whose behaviour will be worse if they have "A&E drunk coverage" because they know that whatever they do, whatever injuries they get, they will be covered. Indeed, since they have paid for the insurance they may well want to get their money's worth.

Such ill-thought-out policies are fine for a spokesperson for a party that will never be elected, but these were the policies of Norman Lamb, who was just appointed Minister of State in the Department of Health. It is a cause for concern for health policies in the future.

Independent

What is the point of being "independent" on a committee? Surely it is so that you can use your abilities, expertise and knowledge to form your opinions, rather than to simply parrot the opinions of the people who have appointed you?

The Future Forum is described as "independent". It isn't. It is appointed. Nick Timmins "Never Again" says

[Prof Steve Field said that Sir David] Nicholson told him "that the chancellor, the prime minister and the deputy prime minister had met and decided that because of the reaction in Sheffield and the noise in the system, they wanted to get a better understanding of what the problems were. He told me my name had been discussed about potentially chairing this Future Forum and that they were going to make a decision, but if I was asked by the minister would I do it?" He [Prof Field] said yes and was told to expect a call from Number 10, while the department worked hard on assembling names for four working groups

The Department of Health "worked hard on assembling the names" of the four working groups of the Future Forum meaning that they appointed the forum. Timmins goes on:

Finally on a train back to his home in Birmingham a call came through from Simon Burns, on behalf of Cameron and Lansley, formally asking him [Field] to chair the new Forum.

Hence Field was asked by Burns on behalf of Cameron and Lansley to be the Chair of the Future Forum.

The Future Forum (FF) is a committee appointed by the Department of Health. Even if the FF was not told what to think (and I have doubts about that) it is clear that the composition of the forum is important and if the department chose people that agree with the thinking behind the bill they would provide a report that agreed with that thinking. It is a classic move that could have been a plot line of Yes Minister: need an "independent" report that agrees with you? so appoint a committee of people who agree with you to write it and tell them they are "independent". The FF report only made cosmetic changes to the Bill.

Now we are told that Prof Field has been appointed to the National Commissioning Board as Deputy National Medical Director. But he is still the Chair of the "independent" Future Forum. How can the FF be independent when the Chair is Deputy National Medical Director?

What about NICE (the National Institute for Health and Clinical Excellence)? Its website says:

We provide independent, authoritative and evidence-based guidance on the most effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation.

NICE evaluates drugs and treatments, it uses evidence from peer reviewed papers to determine how effective the drug or treatment is. It is vital to the finances of the NHS that the service uses only those drugs that have been shown to be effective. The problem is that drug companies hate NICE. They hate NICE because the drug companies spend large amounts of money to create public demand for ineffective drugs which are then rejected by NICE.

It is vital that the experts who make the decisions on behalf of NICE are independent, they have a very difficult and important job to do. But now that independence is under threat, the following article is from Pulse:

Pulse has learnt that the Department of Health is set to table secondary legislation under the Health and Social Care Act so that the health secretary will personally approve all appointments to the panel of experts that consider appeals from drugs companies against NICE appraisals of drugs. The chair of the appraisal appeal panel will also have to be 'someone from outside NICE'.

Apparently, the Association of the British Pharmaceutical Industry wrote to Lansley and told him "Policy is made a long way from political accountability and the NICE Executive appears to have no remit or desire to challenge the decisions of independent academics." They were complaining that decisions were being made by independent academics! In the future the appeal panel members will have to be approved by the Secretary of State for Health (the completely, and totally incorruptible Jeremy Hunt someone who would never be influenced by large multinational companies).

If the 18th Century British politicians were anything like the current government it is no wonder that they fought a revolution to gain their independence.

QIPP

QIPP goes by various names, "the Nicholson Challenge" and "efficiency savings" being the most common. The former was a phrase coined by Stephen Dorrell, the Chair of the Commons Health Select Committee and includes the name of the man who will be responsible for the programme: Sir David Nicholson, former member of the Communist Party and Chief Executive of the NHS and soon-to-be Chief Executive of the NHS Commissioning Board.

QIPP stands for Quality, Innovation, Productivity and Prevention. As a patient my priorities are Q-P₂-I-P₁ (that is, productivity last), with the Q and P₂ (prevention) almost equal priority. However, the government's obsession with QIPP is on P₁, productivity. This is because it is ingrained in Tory DNA that the NHS wastes money and is a waste of money. The Conservative zeal for QIPP is the last chance for the NHS to make amends for its waste. The idea behind QIPP is that the NHS must improve productivity through innovation and prevention while keeping quality high. There are some enlightened people in the NHS who point out that improving quality will, in the long term, reduce costs, but improving quality often requires investment and this is not a short term "efficiency saving" which is the government's obsession.

QIPP is steeped in mystery. The NHS has always been concerned with productivity, this is not surprising because, as a taxpayer funded system, the service is always under pressure from the Treasury to reduce its costs so that the taxpayer pays less. The most recent source of QIPP comes from the McKinsey slidedeck provided for the Department of Health in February 2009 and published in May 2010. The main points of the summary are here:

Notice that the "efficiency savings" are £13-20bn over 3-5 years. In March 2010 the Department of Health described QIPP as being "£15-£20bn [savings by] 2013/14", which is a 3 year efficiency drive if you assume that QIPP would start in April 2010. The 2010 Conservative majority government morphed QIPP into £20bn "efficiency savings" over the period 2011/12 to 2014/15. QIPP is expected to extend beyond 2015 and may last until 2017 or even 2020. It is not worth spending much time reading the McKinsey report because it is just a series of graphs and assertions with no cited evidence.

The interesting figure is that £20bn is the funding gap between what most economists say the NHS will need and the flat funding (in real terms) that the government allocated in the October 2010 Spending Review. That is, if NHS funding increased at the rate that is needed to take into account demographic change and healthcare inflation, the service would need £20bn more (real terms) in 2015 than it does now, but the Spending Review has allocated the NHS the same amount of money (real terms) as now. There is a lot of evidence that the NHS budget drives QIPP rather than the results of QIPP determining the NHS budget.

An example of the funding gap can be seen from the slidedeck McKinsey produced for NHS organisations in London (released to Health Service Journal via a Freedom of Information request). This graph shows the funding gap between flat funding and the amount of money needed to meet healthcare activity (ie the treatments needed by the population) for London. This gap is similar when extrapolated for the rest of the country.

The government eulogises over QIPP, and their favourite phrase is "We are delivering efficiency savings in order to reinvest every penny of that for the benefit of patients." This implies that when an efficiency is identified it results in a pile of cash which is then spent on something else, that we need. This is not the case. The "efficiency savings" is the grey area in the graph above: the area between the money that is available (the lower black line) and the money needed (the upper black line). It is money that does not exist. QIPP is ghost money.

It is a large amount of ghost money, too. The Year/The Quarter, which is the annual report of the NHS says that QIPP delivered £5.8bn of ghost money last financial year, 2011/12 (which, interestingly, it describes as "the first year of QIPP"). However, this document does not say that this money will be "invested" anywhere, because, of course, it does not exist: it is money that the NHS would have spent if it had not done the same work "more efficiently" than in the previous year.

So, are there any examples of QIPP? Yes, lots. The NHS Evidence website has a subsite devoted to QIPP. For example, Wrightington, Wigan and Leigh NHS Foundation Trust provided details of a project to reduce patient falls in hospital. In 2008 the trust had a high number of patient falls, 7 for each 1000 bed days, which is in the middle of the national variation between 3 and 12 falls per 1000 bed days. Patient falls are upsetting for the patient and they are dangerous, but are preventable. Falls are also costly because they lead to further treatment and longer stays in hospital. The National Patient Safety Agency estimates that falls cost NHS trusts in England £15m a year (or £92,000 for an 800 bed hospital). The costs of the project were estimated to be £15,000 startup costs and £5,000 maintenance costs per year. You can immediately see that if the project reduces the number of falls there will be an increase in Q and P2 (prevention) of QIPP and if the number of falls prevents more than £5,000 of extra treatment and bed-days then there will be a rise in the P₁ of QIPP (rise in productivity through reduced costs). The project involved training staff, providing equipment (bed rails and non-slip shoes) and additional risk assessment to determine which patients were susceptible to falls. The actual results are that there was a 34% reduction in the number of falls over the whole trust in 9 months. The target was to reduce the number of falls by 50% and it was estimated that this would save £120,000, so a 34% reduction would save around £80,000.

This example is quite easy to understand, and reducing the number of falls is the right thing to do, even if it didn't save any money. However, hospitals don't have a separate "falls fund" from which they can draw money if someone needs treatment due to a fall and if the "falls fund" has money left over at the end of the year, an ability to spend it. Instead, the PCT will pay for the extra treatment: the saving is in less PCT spend. The hospital does not benefit from this QIPP saving because the saving is money they will not see. So it is disingenuous for the government to say that this money is "reinvested for the benefit of patients", it isn't. The £80,000 "saved" will contribute to the £5.8bn quoted by the Department of Health. Yet this is ghost money that does not exist.

QIPP is worth doing for the Q and for the P₂: better quality care and prevention of illness. But some of the case studies on the NHS evidence site appear to take the  idea too far that QIPP is about productivity. For example, the first recommended example on the site involves the Royal Cornwall Hospital Trust providing intravenous iron to patients in their homes and community hospitals rather than in hospital. This is likely to provide better patient experience and hence increase the Q in QIPP, but the case study focuses too hard on productivity, to the point of producing what appears to be nonsense figures.

The example says that many patients have to travel up to an hour to get to hospital and that some patients needed hospital transport which was an additional cost to the treatment. The case study calculates the "savings" between treating patients at home or in a community hospital, compared to receiving the treatment in hospital. The calculations are (to say the least) a little dodgy. The case study says that the cost of the treatment in hospital is £113 per treatment (excluding the cost of the drugs) and one third of patients will need NHS funded transport at an average figure of £20 per treatment. They say that there are 163 patients receiving the treatment in a community hospital and 17 in their homes, so 180 people in total were not having the treatment in hospital. Each patient will have 6 treatments every year so that means that there were 1080 treatments not being carried out in hospital. Using the figures of cost per treatment and cost of travel they calculated that if those patients had the treatment in hospital it would cost £129,520 (1080 x £113 + 1080/3 x £20) [the QIPP document has a typo and gives a figure £1,000 less]. The issue is: is it cheaper to treat the patients in the community? To do this they should provide the cost of treating the patients in the community hospitals or in their homes. The QIPP document says:

"The cost calculation assumes a reduction in the cost of hospital appointments to the PCT, but does not appear to include any increase in costs at the community hospitals. The costs are absorbed into the daily costs of the community hospitals. The cost of consumables and healthcare professional time is met by the PCT. On this assumption the scheme generates savings of £29,000 per 100,000 population."

The population of Cornwall PCT is 450,000, so the QIPP saving is obtained by dividing £129k by 4.5.

It is naive to say that community hospitals will do the work for free, and really is not a sound basis for estimating "efficiencies". There will be a cost in providing the treatment in a community hospital or at the patients home, not least the cost of a district nurse travelling to the patients home and spending time that could have been spent on another patient. The treatment in the community may well be better for patients, who will have to travel less far, but there is no evidence presented to show this.

So this "evidence" says that £29,000 can be saved per 100,000 population, but there really is no evidence to support this. Presumably when a trust says "x% of our patients have their intravenous iron in a community hospital" this is entered into a spreadsheet that converts the number of patients into a "saving" based on this "evidence" and the "saving" is added to the grand total that, at the end of the year, appears as £5.8 billion. The question is: how much of the £5.8 billion is based on similarly dodgy evidence?

There is some doubt whether QIPP savings are savings at all since there are some quite unusual calculation methods. But even if the calculation was sound, the QIPP savings are not real money that can be spent because it is money that was never available to spend. QIPP is the grey area of the graph that does not exist.

Cutting Bureaucracy

Remember that we were promised before the last election that a Conservative government would bring in the post-bureaucratic age? Well, there is little evidence that is what we have got, and there is a lot of evidence that we are going in the opposite direction: getting more bureaucratic.

For example, the botched NHS reforms have created two new levels of bureaucracy. It is interesting that at the time that the government were trying to push through the hideous monster of a bill that was the Health and Social Care Bill their main justification was that it would cut bureaucracy, yet their favourite management consultancy firm was saying the opposite.

Health Service Journal have published the results of a Freedom of Information request on the communications between Matthew Kershaw (Department of Health Director of Provider Delivery) and the main private providers (pdf). If you set aside that the emails read like a bunch of giggly teenagers trying to set up a blind date for a love-lorn friend ("this is fun!!!", "brilliant - it works!"), there are more serious concerns.

The document includes a slide deck from an event that McKinsey provided for stakeholders in London (the GLA, councils and NHS organisations). In this deck is a slide that compares the NHS before the Bill with the NHS after the Bill:

As you can see, McKinsey were saying in March 2011 that the new NHS would have a "More complex partnership as GP commissioning consortia [CCGs] and clusters [Local Area Teams, part of the National Commissioning Board] replace 31 PCTs". If McKinsey could see that the Bill would complicate the NHS, and make it more bureaucratic, why were ministers claiming that the Bill would make it less bureaucratic? So much for the post-bureaucratic age.