Tuesday, 23 April 2013

An Elevator Pitch (or Lift Pitch) on NHS Reforms


The Health and Social Care (HSC) Act was passed in March 2012 and came into effect on April 1st 2013. GP led CCGs (Clinical Commissioning Groups) became responsible for the NHS budget and are now compelled to use competition as a means of improving NHS services. To most of us this seems like a good thing at first glance. Many of us are unaware of what this really means. To help public awareness, here is my ‘Elevator Pitch’ on NHS reforms. An Elevator Pitch is a summary of a concept or argument, short enough to be delivered between floors in an elevator. In the UK, we might call this a Lift Pitch.

The NHS is one of the most efficient healthcare systems in the world. It provides universal, comprehensive healthcare to EVERYONE. Healthcare is free at the point of delivery. We do not run the risk of personal bankruptcy when we fall ill. NHS hospitals are run on a non-profit basis where savings are reinvested in healthcare. Clinical outcomes are excellent. The US spends 2.4 times more on health per person than the UK, yet Britons live longer than Americans. Despite these achievements, the NHS has come under significant attack in the media. Budget cuts at a time when the NHS is at its most efficient have led to staffing shortages and ultimately problems outlined in the Francis Report.

The HSC Act 2012 removes the Secretary of State’s legal obligation to provide or secure healthcare for everyone. The NHS is also now subject to EU Competition law. Section 75 (being debated in the House of Lords today) compels CCGs to invite bids for all health services from ALL willing providers. This leads to a free market based system where expensive tendering processes will consume much of the CCG budgets and time. In the US, administration costs account for 20% of healthcare expenses, three times higher than in the UK.

Healthcare providers will compete against each other for the contracts. This may improve some services. However, barriers between primary care and hospitals will move us away from integration and data sharing. There is a risk that profit making organisations will cherry pick lucrative contracts, leaving difficult and expensive services to non-profit organisations. The irony is that a last minute amendment to the HSC Act makes this even more likely. The amendment declares that the only services NOT subject to competition law are those which can ONLY be provided by a current provider (most likely to be complex, expensive services).

As NHS budgets become tighter and healthcare becomes more expensive (largely as a result of spiraling administrative costs), the NHS is likely to change from a mostly single payer (government funded) system to a US style multiple payer healthcare system, what Don Berwick refers to as a ‘zoo of payment streams’. We only have to look to the US to see how our healthcare system might look in a few years.

Vinod Achan

For my blog on Don Berwick, see here.

Thursday, 4 April 2013

Nostalgia and the NHS

On BBC Radio 3 last night, Samira Ahmed hosted a debate on whether nostalgia was obscuring clear debate about changes in the NHS? GP and blogger Dr Jonathan Tomlinson argued on  behalf of the NHS. Journalist Ian Birrell argued against.

Ian Birrell painted a view of the NHS that many of us within it would not recognise. One of elderly patients dying in squalid conditions, doctors stifling change, doctors encouraging long waiting lists and disapproving of patient choice. Of course there are isolated examples of these, many of which are put under the microscope by the media. But these descriptions are not typical of the NHS.

Many of us within the NHS would love to and do engage in discussions about how service delivery can be improved. The NHS is constantly evolving and improving. Waiting lists have been driven down considerably. Care is becoming increasingly patient centred. We put the patient at the centre of everything that we do. Or we try to. And we deliver results. Cardiovascular mortality is falling faster than in any other OECD country, for example.

Compassionate care for patients with complex needs, especially the elderly and disabled, is precisely what the NHS strives for as it delivers universal comprehensive healthcare. Hospitals talk to each other and to GPs as a national network of organisations, mostly working together. We believe that healthcare is a basic human right. There are occasions when we fail, but those are the exceptions. As Don Berwick said, we leave no one out.

Healthy debate is essential to progress. What is hampering good debate and progress is the continuous cycle of redisorganisation costing billions of pounds. Teams of excellent administrators within PCTs, responsible for many of the recent service improvements, have been disbanded with a huge drain of talent. Instability leads to poor morale which, in combination with staff shortages, leads to poor care. The current reforms will lead to increasing competition and fragmentation amongst healthcare providers and spiralling administration costs. How we reverse some of these changes, and avoid a US style healthcare system driven by market forces and profit, will be the next big challenge that faces the NHS.

I invite both Samira and Ian to spend a day with me at the NHS frontline to see how things are being done well in the NHS.

Jonathan Tomlinson's response to this debate can be read here.

Tuesday, 2 April 2013

We Leave No One Out: Professor Donald Berwick

Professor Donald Berwick is a Professor of Paediatrics at the Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health, and CEO of the Institute for Healthcare Improvement. In July 2010, Professor Berwick was appointed by President Obama as head of Medicare and Medicaid but resigned at the height of the Obama healthcare reforms debate when it became clear that Republicans would block his appointment. Last week David Cameron appointed him to turn the NHS into the safest healthcare system in the world (in the wake of the Francis report). In his first interview as Cameron’s ‘Health Tsar’ with a newspaper, the Telegraph ran the title: “My Cure for the Sick NHS” (1).
Many of us will therefore be relieved to know that Professor Berwick is in fact a great supporter of the NHS. In the US, he has been denigrated by the Republican press for praising the NHS and wanting to move the US away from its traditional fee-for-service medicine. In a keynote lecture at the NHS Live Conference (July 2008) celebrating the 60th birthday of the NHS, the following were just a few examples of his praise (2):
1.     “The NHS is one of the most astounding human endeavours of modern times” 
2.     “The UK promises to make healthcare a human right. The US does not promise healthcare as a human right and people ask, “How can healthcare be a human right? We can’t afford it.” As a result, almost 50 million Americans, one in seven, do not have health insurance. Here (in the UK), we make it harder for ourselves, because we don’t make that excuse. We cap our healthcare budget, and we make the political and eco­nomic choices we need to make to keep affordability within reach. And, we leave no one out.” 
3.     “In the US, we can hold no one accountable for our problems. Here, in England, account­ability for the NHS is clear.” 
4.     “In the US, we fund healthcare through hundreds of insur­ance companies, a zoo of pay­ment streams. Administrative costs approach 20% of US total healthcare bill, at least three times as much as in England.” 
For a video excerpt, see here.

Professor Donald Berwick is a friend of the NHS. By appointing him, David Cameron may in fact help steer the NHS out of the choppy waters we find ourselves in. Professor Berwick, we welcome you to the UK and look forward to your support and guidance in making the NHS even safer.