"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Friday, 16 July 2010

NHS White Paper Part 3

Improving healthcare outcomes
Before I start I should point you to the three blog posts I wrote about the Conservative policy documents on outcomes.

Health Outcomes: Part 1
Health Outcomes: Part 2
Health outcomes: Part 3

Reading through this section in the white paper I was struck by how different it was to the other sections. For a start there is less of the rabid, right-wing free market approach, it talks about an integrated services as opposed to the fragmented "health market" that the other sections promote (and by necessity mean competition rather than integration). I was also rather struck by the fact that the section has a lot of emphasis on targets standards. If I didn't know that this was from Lansley's Department of Health as part of a Cameron government I would think that it was from Alan Milburn's Department of Health as part of a Blair government. There is a striking contradiction between Cameron and Lansley's tedious mantra about abolishing "top-down targets" and the hugely bureaucratic tick-box culture that "standards" will produce. But I will let you make up your mind as you read the section.

Improving health outcomes

Anyone in healthcare who does not want to improve health outcomes should be taken out and tarred and feathered. I can happily say that because there is no one in the NHS that does not want to improve health outcomes. (The same cannot be said about private healthcare – their only goal is increasing profits. So I would be happy to provide the barrel of tar and the pillow of feathers for anyone willing to start the job on the chief executive of their local private hospital.) So let's have a look at some of the more interesting parts of this section.

"the Government will now establish improvement in quality and healthcare outcomes as the primary purpose of all NHS-funded care ... this primary purpose will be enshrined in statute, the NHS Constitution, and model contracts for services" (3.1)

I have no complaint here. All healthcare providers must put quality first. I am a little worried that the law will only cover "NHS-funded care". I take a relaxed attitude to people choosing to buy private treatment, on the proviso that the provision of this healthcare does not adversely affect the provision of NHS healthcare. If such people want to spend their money on private health, then they should be allowed to spend it how they wish. So why exclude them from a law guaranteeing quality care? Does Lansley want private hospitals to provide poor quality care? Clearly he thinks that the only way to ensure quality in the NHS is to legislate, so by excluding private hospitals he is saying that he is happy for them to provide poor care. People buying private healthcare are citizens too and they should also be protected by the law. Or am I missing something here?

"In future, performance will be driven by patient choice and commissioning; as a result, there will be no excuse or hiding place for deteriorating standards and our proposals will drive improving standards." (3.2)

This is extremely worrying. Other commentators have said how these plans will turn public healthcare into a system similar to electricity provision, that is, the consumer (patient) has to constantly check and double check that their provider is providing the highest quality service because no one else will. This is not how things should be. Patients are often in discomfort or pain and simply want to be treated. They are not in a frame of mind to check quality metrics. That role should be taken by regulators. Healthcare providers should be constantly monitored and if there is the slightest deviation from best quality the provider should be told to improve.

Research has shown that patient choice has limited effect in improving quality. The Kings Fund say:

"Data from choices made in hypothetical and real situations showed that patients valued aspects of quality when choosing a hospital. However in practice, most patients chose to be treated by their local provider and few consulted published performance information on quality to help them choose, instead relying on past experience and their GP's advice. While the threat of patients choosing a different hospital led some providers to focus more on reputation, there was little evidence of direct competition for patients' custom and choice has not so far acted as a lever to improve quality."

Since 2006 NHS patients in England have had a choice of four or five providers for their treatment. Since four years of evidence shows that choice does not improve quality, why is the government so keen? Ideology?

The NHS outcomes framework

This is where the paper starts to sound very Blairite.

"The Secretary of State, through the Public Health Service, will set local authorities national objectives for improving population health outcomes. It will be for local authorities to determine how best to secure those objectives, including by commissioning services from providers of NHS care." (3.5)

This section refers to public health and social care. It is interesting that there are national targets objectives which "will provide for clear and unambiguous accountability". However, like all other cases when Conservatives talk about accountability they fail to mention how the accountability is implemented. You do not get accountability simply by mentioning it, you get it by identifying transgressions and penalties.

"A new NHS Outcomes Framework will provide direction for the NHS. It will include a focused set of national outcome goals determined by the Secretary of State, against which the NHS Commissioning Board will be held to account, alongside overall improvements in the NHS. In turn, the NHS Outcomes Framework will be translated into a commissioning outcomes framework for GP consortia, to create powerful incentives for effective commissioning." (3.6, 3.7)

You can just feel the bureaucracy oozing out of these words: lots of frameworks, lots of quangos to implement them.

"It is essential for patient outcomes that health and social care services are better integrated at all levels of the system. We will be consulting widely on options to ensure health and social care works seamlessly together to enable this." (3.11)

This is talking about an integrated system. By definition a system where there are many providers is fragmented, so where will this seamless integration come from? Are these just platitudes or is there a civil servant trying to getting something workable out of Lansley's ideological diktats?

Developing and implementing quality standards

The section gets even more bureaucratic.

"Progress on outcomes will be supported by quality standards. These will be developed for the NHS Commissioning Board by NICE, who will develop authoritative standards setting out each part of the patient pathway, and indicators for each step. NICE will rapidly expand its existing work programme to create a comprehensive library of standards for all the main pathways of care. ... Within the next five years, NICE expects to produce 150 standards." (3.12)

NICE will develop 150 targets quality standards which will cover every patient pathway (ie all stages of treatment). As you'll see these quality standards are supposed to be performance markers. One hundred and fifty is a lot of standards. This is about three times more than all the current targets and ten times more than the targets that are currently used for performance benchmarking of hospitals (the targets that really count, and the ones that the Conservatives hate). We were promised a "post-bureaucratic age", so where did that go?

Oh dear, it gets worse:

"Each standard is a set of 5-10 specific, concise quality statements and associated measures. These measures act as markers of high quality, cost-effective patient care. They are about excellence, derived from the best available evidence and are produced collaboratively with the NHS and social care professionals, along with their partners, service users and carers." (3.13)

That's right, for each of the 150 targets quality standards there will be 5-10 tick box quality statements. Therefore, there will be 750-1500 of these mini-targets (or targettinies as Roy Lilley from nhsmanagers.net calls them). Wow, what a lot of bureaucracy! I am sure that the NHS will have to employ thousands more administrators to make sure that all of that box ticking is done, right? Wrong! Lansley expects there to be a 30% saving in administration costs and 45% savings in management costs. Since salaries are the biggest cost then we can interpret this as a 30% cut in administrators and 45% cut in managers. All of this additional bureaucracy must be done with 30% fewer admin staff and 45% fewer managers. Is that possible?

However, a target is only a target if there is a performance sting in the tail. In the current target system hospitals are performance tested against a couple of handfuls of key targets. If the hospital is not performance tested against a target then it becomes an aspiration of the management rather than a necessity. The 18-week referral to treatment target is part of the NHS constitution (therefore it is a right) but since Lansley has said that hospitals will not be performance tested against this target it means that hospitals will be less focussed to make sure the target is met.

So what about Lansley's new targets quality standards?

"Commissioners will draw from the NICE library of standards as they commission care. GP consortia and providers will agree local priorities for implementation each year, taking account of the NHS Outcomes Framework. NICE quality standards will be reflected in commissioning contracts and financial incentives. Together with essential regulatory standards, these will provide the national consistency that patients expect from their National Health Service." (3.15)

Yup, that's right, hospitals will be performance tested against the new targets quality standards. Rather than a couple of handfuls of targets there will be 150 of them.

Incentives for quality improvement

Erm, perhaps the incentive is to make people feel better and live longer? What other incentives does a healthcare professional need?

"In future, the structure of payment systems will be the responsibility of the NHS Commissioning Board, and the economic regulator will be responsible for pricing. ... Payments and the 'currencies' they are based on will be structured in the way that is most relevant to the service being provided, and will be conditional on achieving quality goals." (3.17)

The curious part of this statement is the word 'currencies'. Will there be different 'currencies' for different providers? Is this how Lansley will provide a hidden subsidy so that private providers can "match" the NHS on cost? I wonder if Lansley will intend to pay providers the same national tariff, but that the figure will be in pounds sterling (£) for NHS providers and Lansley pounds (L) for private providers where the exchange rate is L1 = £2. This will mean that the national tariff for cataract surgery will be £750 or L750, and will nicely allow private providers to "compete" with the NHS. Stranger things have happened.

The statement also says that quality targets goals will have to be achieved before there will be payment, so yet again, these "goals" are not much different from the targets they are replacing.

"The Department will also refine the basis of current tariffs. We will rapidly accelerate the development of best-practice tariffs, introducing an increasing number each year, so that providers are paid according to the costs of excellent care, rather than average price." (3.19)

I have written about the national tariff before. The original intention was for the national tariff to be the average cost of a procedure for all English NHS hospitals. A hospital is paid this average, regardless of their actual costs, and if the hospital manages to do the work cheaper than the average then they will generate a surplus that can be invested in other services (or pay for services that generate a deficit). The idea is to provide an incentive for hospitals to improve efficiency.

Since hospitals are paid per procedure, it means that the more procedures they perform the more money they will be paid, and if a hospital has a service that makes a surplus on the national tariff then there is an incentive to treat more patients. The main problem with this system is that the money to pay for treatments is limited by how much money the local Primary Care Trust (PCT) is allocated. This leads to a bizarre situation where hospitals over-perform. Yes, they are criticised for being too efficient and doing too much work! The white paper gives no solution to this problem because there will still be a limit on the money available to pay for treatments, the only difference is that the money will be held by GP commissioning consortia rather than PCTs.

In the final Operating Framework produced by the New Labour government they included a directive that some tariffs will be based on best practice rather than the average across England. This limited number of best practice tariffs put a lot of strain on NHS hospital managers since they did not have to be as good as their peers, they had to be as good as the very best. The pre-austerity Labour government also froze the tariffs so that hospitals will be paid the same money this year as last year for the same treatment regardless of inflation. The Conservative government have not unfrozen the tariff, therefore Cameron has broken his election pledge to provide "real term" increases in NHS funding.

In the white paper the Conservative government says that they will extend the idea of best-practice tariffs by producing "an increasing number each year". This means that there is a danger of hospitals going into deficit since only the very best hospitals are as efficient as the very best, and not everyone can be the very best. This stretch target will be the most difficult to achieve. (And remember section 1.22 which says that there will be no bail-outs?)


This section heralds a new target culture. Rather than a couple of handfuls of performance targets there will now be 150 "quality standards" and each one will have 5-10 tick-box "quality statements". The administration of a thousand such statements will be a nightmare with fewer staff. Furthermore, hospitals will be put under financial pressure by only being paid the costs of the very cheapest while under the threat of bankruptcy because the government refuses to "bail-out" hospitals.

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