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THE BRITISH HEALTH DEBATE
The Telegraph, India
February 19, 2013 Tuesday
- There is no competition in the health system in Britain
WRITING ON THE WALL -ASHOK V. DESAI
In India, a darzi means a tailor, and so probably does it in Armenia.
But Lord Darzi is one of Britain's most distinguished and influential
surgeons. He was born in Iraq, whence he went to Dublin to study
medicine in Trinity College. In 1991, he became consultant surgeon in
Middlesex Hospital at the age of 31; in 1996, he became professor in
Imperial College, London. He specialized in minimal invasive surgery,
also known as keyhole surgery.
In 2006, NHS London, the local health authority, asked Darzi to tell
it how to improve its working. He showed that people in East London,
which has always been poor, live 7 years less, and have much fewer
doctors per head. Originally, Britain nationalized doctors and
expected them to provide primary healthcare. But in London, they were
ever more concentrated in hospitals, so people were going to hospitals
for minor problems. Darzi suggested something intermediate between
doctors and hospitals called polyclinics: they would have doctors and
investigation facilities, but would not be hospitals. Some of them
would be urgent care centres, where people could go in accidents or
emergencies. Minor operations could be done there without keeping
patients overnight.
His report to London NHS was relevant and practical; it drew national
attention. In 2007, Gordon Brown, the prime minister, appointed Darzi
parliamentary undersecretary of state for health. Two weeks later he
was raised to Lord Darzi of Denham, which presumably saved him the
hassle of being elected to parliament. He was asked to make a review
of the NHS. This time he adopted a different strategy; he asked
clinicians all over the country to give their views. Some 2,000
contributed. The resulting report was not nearly as good as his own
for London; there was much vague idealizing in it. But it had a
central message: that what mattered in healthcare was quality, and
that together with their annual financial accounts, healthcare
providers should publish quality accounts. It envisaged a
decentralized system. There would be local primary care trusts; they
would represent patients. There would be regional strategic health
authorities: they would manage the healthcare providers. The PCTs
would buy medical services from the SHAs.
Quality was to be measured in terms of three parameters: patient
safety, patient experience, and effectiveness of care. In other words,
it was not enough that the patient should get good treatment; he had
to feel that he had been treated with compassion, dignity and respect.
Seven steps were worked out to raise quality: being clear about what
was to be measured, measuring it, publishing data on quality,
rewarding quality improvement, raising standards, safeguarding
quality, and innovation. There would be no national enforcement of
quality; each individual PCT would be required to aim at higher
quality. But PCTs' performance parameters would be published so that
anyone could judge and compare them.
Meanwhile, the department of health also carried out an enormous
opinion survey in 2006. It eventually covered 42,866 people. It found
that while people were generally satisfied with the NHS, they wished
that their doctors would give them more time, that various services
would be coordinated and available together, that they provided the
latest treatment, that treatment was available more quickly and
readily for minor problems, and that the standards of treatment were
the same across the country.
After the survey, the health department published a white paper, Our
Health, Our Care, Our Say, which basically said that the government
would do what the survey told it that people wanted: it would invest
more in preventive services, give more support to emotional and mental
well-being, listen more to people, and make sure they could go to a
doctor of their choice close to them.
All these intentions were brought to an abrupt end when the Labour
government was voted out of power in 2010. The Conservative government
brought out its own white paper in 2010. Reflecting its own
predilections, it said that it would cut the administrative costs of
NHS by 45 per cent and save 20 billion pounds by 2014. But for the
rest, it repeated many of the assurances given by the previous Labour
government, for instance that patients would get information and have
a voice in the treatment they received, would have a choice of
doctors, and would be able to rate hospitals, that clinics and
hospitals would have to meet national quality standards, and would be
paid on performance.
But it has not been able to implement its election promises. Britain
has two institutions that are supposed to act as representatives of
patients: primary care trusts, which are essentially district-level
public bodies, and consortia of doctors, who register patients and
arrange treatment which they cannot themselves provide, for example in
hospitals. The Conservatives wanted to abolish PCTs and leave patient
servicing entirely to doctors; but they have not done so.
The Labour government had created a monitor to supervise major
hospitals; but they largely ran themselves, and the monitor did not
have much to do. The Conservatives had planned to turn it into an
overall regulator for the NHS, and tell it to promote competition; but
they have done nothing. They also wanted to transfer the overseeing of
the NHS from the minister of health to the regulator. But their
Liberal Democrat allies did not like that, so the minister continues
to be in charge as he has been for over 60 years.
Thus, all British governments in the past decade and a half have come
in with plans for radical restructuring of the National Health
Service; but hitherto, they have achieved little. Competition is an
ideal that appeals to non-socialists; but it is difficult to create
competition in a monopolistic situation, especially where those who
work for the monopoly are comfortable with it. Further, competition
can make a difference only if there is surplus capacity; only then do
buyers have a choice of sellers. There is no competition in the
British health system. Every patient is attached to a general
practitioner, as the British call their doctors. Patients can access
hospital and other facilities only through their GP; and there is no
surplus of GPs. And then, patients do not pay for medical services;
the government does on their behalf. It has made noises from time to
time that it would give them control over their medical expenditure;
but it has not been able to work out how to do so.
Tony Blair had one idea: he made Lord Darzi deputy minister of health.
If he had lasted, and left it to Darzi, quite possibly he might have
found a workable solution. But Blair lost the election and went on to
comfortable international assignments; I guess Lord Darzi went back to
keyhole surgery. The British are generally good at government; but
even they have been defeated by the NHS. They are handicapped by the
fact that the British people are by and large quite satisfied with
their NHS. They would like to see shorter waiting periods. That
requires surplus capacity, which would be costly. The Conservative
government wants to cut costs, which would cause shortages. The two
are unlikely to agree.
The Telegraph, India
February 19, 2013 Tuesday
- There is no competition in the health system in Britain
WRITING ON THE WALL -ASHOK V. DESAI
In India, a darzi means a tailor, and so probably does it in Armenia.
But Lord Darzi is one of Britain's most distinguished and influential
surgeons. He was born in Iraq, whence he went to Dublin to study
medicine in Trinity College. In 1991, he became consultant surgeon in
Middlesex Hospital at the age of 31; in 1996, he became professor in
Imperial College, London. He specialized in minimal invasive surgery,
also known as keyhole surgery.
In 2006, NHS London, the local health authority, asked Darzi to tell
it how to improve its working. He showed that people in East London,
which has always been poor, live 7 years less, and have much fewer
doctors per head. Originally, Britain nationalized doctors and
expected them to provide primary healthcare. But in London, they were
ever more concentrated in hospitals, so people were going to hospitals
for minor problems. Darzi suggested something intermediate between
doctors and hospitals called polyclinics: they would have doctors and
investigation facilities, but would not be hospitals. Some of them
would be urgent care centres, where people could go in accidents or
emergencies. Minor operations could be done there without keeping
patients overnight.
His report to London NHS was relevant and practical; it drew national
attention. In 2007, Gordon Brown, the prime minister, appointed Darzi
parliamentary undersecretary of state for health. Two weeks later he
was raised to Lord Darzi of Denham, which presumably saved him the
hassle of being elected to parliament. He was asked to make a review
of the NHS. This time he adopted a different strategy; he asked
clinicians all over the country to give their views. Some 2,000
contributed. The resulting report was not nearly as good as his own
for London; there was much vague idealizing in it. But it had a
central message: that what mattered in healthcare was quality, and
that together with their annual financial accounts, healthcare
providers should publish quality accounts. It envisaged a
decentralized system. There would be local primary care trusts; they
would represent patients. There would be regional strategic health
authorities: they would manage the healthcare providers. The PCTs
would buy medical services from the SHAs.
Quality was to be measured in terms of three parameters: patient
safety, patient experience, and effectiveness of care. In other words,
it was not enough that the patient should get good treatment; he had
to feel that he had been treated with compassion, dignity and respect.
Seven steps were worked out to raise quality: being clear about what
was to be measured, measuring it, publishing data on quality,
rewarding quality improvement, raising standards, safeguarding
quality, and innovation. There would be no national enforcement of
quality; each individual PCT would be required to aim at higher
quality. But PCTs' performance parameters would be published so that
anyone could judge and compare them.
Meanwhile, the department of health also carried out an enormous
opinion survey in 2006. It eventually covered 42,866 people. It found
that while people were generally satisfied with the NHS, they wished
that their doctors would give them more time, that various services
would be coordinated and available together, that they provided the
latest treatment, that treatment was available more quickly and
readily for minor problems, and that the standards of treatment were
the same across the country.
After the survey, the health department published a white paper, Our
Health, Our Care, Our Say, which basically said that the government
would do what the survey told it that people wanted: it would invest
more in preventive services, give more support to emotional and mental
well-being, listen more to people, and make sure they could go to a
doctor of their choice close to them.
All these intentions were brought to an abrupt end when the Labour
government was voted out of power in 2010. The Conservative government
brought out its own white paper in 2010. Reflecting its own
predilections, it said that it would cut the administrative costs of
NHS by 45 per cent and save 20 billion pounds by 2014. But for the
rest, it repeated many of the assurances given by the previous Labour
government, for instance that patients would get information and have
a voice in the treatment they received, would have a choice of
doctors, and would be able to rate hospitals, that clinics and
hospitals would have to meet national quality standards, and would be
paid on performance.
But it has not been able to implement its election promises. Britain
has two institutions that are supposed to act as representatives of
patients: primary care trusts, which are essentially district-level
public bodies, and consortia of doctors, who register patients and
arrange treatment which they cannot themselves provide, for example in
hospitals. The Conservatives wanted to abolish PCTs and leave patient
servicing entirely to doctors; but they have not done so.
The Labour government had created a monitor to supervise major
hospitals; but they largely ran themselves, and the monitor did not
have much to do. The Conservatives had planned to turn it into an
overall regulator for the NHS, and tell it to promote competition; but
they have done nothing. They also wanted to transfer the overseeing of
the NHS from the minister of health to the regulator. But their
Liberal Democrat allies did not like that, so the minister continues
to be in charge as he has been for over 60 years.
Thus, all British governments in the past decade and a half have come
in with plans for radical restructuring of the National Health
Service; but hitherto, they have achieved little. Competition is an
ideal that appeals to non-socialists; but it is difficult to create
competition in a monopolistic situation, especially where those who
work for the monopoly are comfortable with it. Further, competition
can make a difference only if there is surplus capacity; only then do
buyers have a choice of sellers. There is no competition in the
British health system. Every patient is attached to a general
practitioner, as the British call their doctors. Patients can access
hospital and other facilities only through their GP; and there is no
surplus of GPs. And then, patients do not pay for medical services;
the government does on their behalf. It has made noises from time to
time that it would give them control over their medical expenditure;
but it has not been able to work out how to do so.
Tony Blair had one idea: he made Lord Darzi deputy minister of health.
If he had lasted, and left it to Darzi, quite possibly he might have
found a workable solution. But Blair lost the election and went on to
comfortable international assignments; I guess Lord Darzi went back to
keyhole surgery. The British are generally good at government; but
even they have been defeated by the NHS. They are handicapped by the
fact that the British people are by and large quite satisfied with
their NHS. They would like to see shorter waiting periods. That
requires surplus capacity, which would be costly. The Conservative
government wants to cut costs, which would cause shortages. The two
are unlikely to agree.