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

Sunday, 11 September 2011

Simon Jenkins is wrong about everything

There is a general aphorism that "Simon Jenkins is wrong about everything". On Friday he was a guest on BBC Radio 4 Any Questions. When the inevitable NHS reforms question came up he gave a characteristically ill informed answer (43m 45s). He said:

The NHS has been re-organised countless times in the last 20 years and every time  it has proved unsatisfactory. ... the reason is that when it has been re-organised it has been re-centralised.
Well, yes, there have been countless re-organisations, but he has not been paying attention if he thinks each organisation has been centralising. The creation of SHAs and PCTs localised decision making. The original twenty SHAs were devolved responsibilities from the Department of Health and similarly the 300 original PCTs received some responsibilities that had been central. The new Bill does the opposite, it takes the work of the current ten SHAs and centralises it into the four regional arms of the National Commissioning Board and these regional arms will take a quarter of the commissioning that is currently done by PCTs. The current Bill is a centralising bill.

Jenkins continues:

the health systems that appear to work are where the government pays but does not organise, ... for instance Denmark. There the counties run the hospitals ... in effect the counties run the health service.
He is five years out of date and even five years ago he was wrong. Denmark used to have 14 counties and with a population of 5.5m that means an average of 400k per county. The median size of PCTs in the UK is 290K, so our system is more localised than the Danish county system. However, in 2007 the system was re-organised replacing the 14 counties with five regions and so each region covers about a million people. Compare that with the 290k that our PCTs, before the reforms, cover. I suspect that Jenkins was getting confused between Danish counties and English counties, so to give the comparison: our PCTs are more or less a third the size of an English county (there are 150 PCTs and 50 counties or metropolitan areas). Under Lansley's plans public health (vaccination, action against smoking, obesity, teen pregnancy etc, will be carried out by English counties, this is yet another centralisation).

As a consequence of Lansley's disastrous mishandling of the system, the PCTs are coalescing into "clusters" each of which is roughly the size of the Danish regions (about a million people). So for a brief time we will look something like the Danish system, that is until the 300 or so Clinical Commissioning Groups take over. International studies show that smaller commissioning groups are financially unsustainable and are unable to commission effectively. Civitas, for example, present evidence that commissioning groups should cover populations no less than 300k (close to the size of PCTs); the BMA give a higher figure of 500k for the smallest size of an effective commissioning group.

However, it is interesting to compare the Danish system with the NHS. There is a fabulous facility called the European Health Observatory provided by WHO and the following uses facts from their health system profile of the Danish system.

Denmark is much smaller than England at 5.5m (about the population of Scotland which would have been a better comparison for Jenkins to make). OECD says that the Danes pay about a third more than us for their healthcare (UK: 9.8% GDP, $3287; Denmark: 11.5% GDP, $4348). EHO say that most of this money is "earmarked proportional taxation" at the national level which is then redistributed to the five regions via block grants based on social and demographic indicators. This is very similar to England where parliament (the Chancellor) determines how much the NHS will get and the money is then distributed to PCTs using block grants based on population size, demographics and deprivation levels (the contribution for deprivation levels is being cut by the current government).

In 2007 there was a reform that changed control from the 14 counties to five regions. So that means the control of local healthcare is for a body that covers about 1 million people.
Median population covered by a PCT is 164K, so about half a Danish county or one eighth a Danish region. Hence PCTs provide a more localised service. Would it make any difference if local healthcare in England was coordinated through county bodies rather than PCTs? 

In Denmark, GPs are private practice (not employed by the state) paid by capitation (a fixed amount per registered patient) and fee-for-service (for example, paid a fee per vaccination) - much like UK. Regions control the number and location of GPs. In England this work - the commissioning of GPs - is carried out by PCTs, but under Lansley's reform it will be centralised and carried out by the new quango the National Commissioning Board through its "regional arms" (four of them, covering between 10m and 15m people). In Denmark, GP's fees and working conditions are negotiated centrally - just like us. Access to primary care is free-at-the-point-of-use, just like the NHS. There is an option (about 2% of patients) to use any private GPs for an extra payment and such patients do not need to get a GP referral to see a specialist (much like private healthcare in the UK). Private healthcare in Denmark is not regulated.

Danish hospitals are owned and run by the regions, in England we moved to a system where the government owned NHS hospitals became NHS trusts, and in the late 90s NHS trusts became accountable to the local Strategic Health Authority. There were twenty SHAs, each covering about 2.5m people (compare this to Denmark where each region covers about 1.4m). SHAs were re-organised in 2006, so there are now ten (covering about 5m each). However, about half of hospitals are Foundation Trusts which means that they are autonomous and are not accountable to the SHA: the SHA does not "run" them. So compare the Danish centralised system where a central organisation (region) runs the hospitals to Foundation Trusts where they run themselves. (Again, Jenkins is wrong.)

There was a reform in Denmark 1993 to allow patients to be treated anywhere in the country (5-10% of patients take this option). The NHS had a similar reform in 2006, initially to cover specific private facilities (Independent Sector Treatment Centres) but tightened when Andy Burnham became the Secretary of State (to make the NHS the "preferred provider"). In Denmark private hospitals are less than 1% of provision. The Danes have co-payments for dentistry, physiotherapy, spectacles and pharmaceuticals. In the UK we call these "NHS charges", so in other words, the Danish system is very similar to the NHS.

One of the most significant thing about the Danish system is that there was very little change until 1970 when there were reforms to create the current system. There were some changes in 1993 to give patient choice (not significant, and largely used by the affluent and better educated, ie not equitable) and then again in 2007 when the system was re-organised from county based (14) to region based (5).

Frankly Simon Jenkins did not know what he was talking about. The Danish system has more similarities to the system we had in the 1980s before the Internal Market was introduced than to what the current government is proposing. The aphorism "Simon Jenkins is wrong about everything" is yet again upheld.

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