Response to NHS England Mandate Consultation 2016-17
The government very quietly launched a consultation on the future of the NHS in October 2015, entitled "Setting the mandate to NHS England for 2016 to 2017". It asked five questions on the proposed objectives for the NHS for the next 5 years. Here are my answers.
I have decided to publish them here both as a permanent record of my response, and as an explicit waiver of my right of anonymity in the survey.
If you want to get involved with the consultation, it's at www.gov.uk/government/consultations/setting-the-mandate-to-nhs-england-for-2016-to-2017 and is live until 23 November 2015, so you don't have much time.
Here's my response to the survey, shorn of all formatting:
1. Do you agree with our aims for the mandate to NHS England?
2. Is there anything else we should be considering in producing the mandate to NHS England?
There should be a commitment to a fully accountable, fully funded, publicly owned NHS.
3. What views do you have on our overarching objective of improving outcomes and reducing health inequalities, including by using new measures of comparative quality for local CCG populations to complement the national outcomes measures in the NHS Outcomes Framework?
3.2 – This must include the same duty of transparency for privatized healthcare providers as already exists for NHS providers. Commercial confidentiality must not be used as an excuse for non-cooperation when providing essential public services. 3.3 – Equality of outcome across CCGs is a laudable goal. Fragmentation of the health service into pseudo-independent local health services will not achieve this and should be resisted. 3.4 – Scorecard systems can be a blunt instrument. Any such system must be developed with the full involvement of NHS staff, and must be set up to avoid perverse scoring incentives (e.g. getting worse outcome measures by taking on a higher proportion of more difficult cases). 3.6 – The NHS constitution includes patient choice. Care must be taken that an illusion of choice is not provided at the expense of real excellence. It must also be clear that patient choice is within the bounds of acceptable, rigorous, evidence-based medical practice.
4. What views do you have on our priorities for the health and care system?
The duty of care of the government to provide healthcare should be restored. The very wording of the consultation, using phrases like “We expect NHS England to...” sets up an unhealthy distance between the government and the responsibility for delivery of services. Health and care systems must be joined-up, but not necessarily integrated. Integration of paid-for services and services which are free at point of use must be monitored especially carefully as it allows for “charge creep” where previously free services are bundled with paid-for services and then charged as a whole. Similarly, the principle of free treatment based on need is also subject to charge creep when particular sets of people are singled out for charging. (This is also counterproductive as cheap, early, elective interventions are delayed in favour of expensive, late, emergency interventions.) Delivery of healthcare should be done effectively, equally, safely and efficiently. Recent changes to the healthcare system have the potential to compromise one or more of these principles. Recent budget cuts (presented as “efficiency savings”) compromise all of these principles. If the government continues with the planned £22bn of cuts to the primary care budget over the next 5 years, the NHS will not be efficient, fair, equal, safe or efficient. In addition, each of the principles has specific problems: Effectively – Cuts to social care spending mean that there will be fewer care home places for people to be discharged to, resulting in more delayed discharge and fewer available beds for new admissions. A joined-up strategy with proper funding is absolutely required. Effectively – A naive interpretation of the phrase “patient choice” is being used as a loophole to introduce unproven (or disproven) medical interventions into NHS hospitals, compromising the effective treatment of patients and wasting money. For example, Hazel Russo of the Complementary and Natural Healthcare Council, speaking at the CAMExpo 2015 conference, said that Personal Health Budgets provide an opportunity for complementary healthcare providers to influence patient spending, naming the “energy field” practice of Reiki as a specific example. Effectively – Health legislation should be drafted and considered from an evidence-based perspective. Appropriate weight should be placed on the opinions of those in the field. As a specific example, the Medical Innovation Bill (the “Saatchi Bill”) has yet to produce any evidence that legal problems affect medical innovation, and is widely denounced as either useless or dangerous by a large proportion of the medical profession. Despite this lack of evidence for the problem it seeks to address, let alone the efficacy of its proposed solution, it seems to be progressing. Equally – Splitting the NHS into independent local health services will only increase the “postcode lottery” effect. Smaller areas will have less buying power and will therefore likely pay more for the same services than their larger neighbours. Safely – The introduction of the so-called “7-day NHS” coupled to cuts in funding will necessarily spread staff more thinly. I believe that this will result in longer hours, or fewer staff on duty at any one time. Stress levels will cause staff to leave and be replaced with cheaper, less experienced staff. Neither of these will have good outcomes to patient safety. Safely – The provision of privatized services introduces extra barriers to transparency, hindering effective comparison between NHS and private services. Private providers also do not seem to provide the same level of emergency provision as NHS providers. Efficiently – Fragmentation of services will reduce the bargaining power of the NHS as a large buyer of drugs and other services. Privatization of services will result in expensive bidding processes and more expensive provision of care. PFI has led to punitive levels of debt. The internal market requires even NHS services to compete against each other rather than cooperating. The government should commit to a 100% publicly-owned health service based on cooperation rather than competition, with proper transparency and accountability. Innovation - Innovation in healthcare can be encouraged by requiring all NHS providers (including all private providers) to sign up to the All Trials database. Under this system, all clinical trials are registered before they are conducted, so that they are fully transparent and negative results cannot easily be hidden. Politicians found to be distorting evidence on healthcare matters should be heavily disciplined. A well-reported but untrue statement can cost lives.
5. What views do you have on how we set objectives for NHS England to reflect their contribution to achieving our priorities?
Objectives set by the government should be designed and judged from an evidence-based perspective. Data on the performance of changes must be available publicly and transparently. (And if it is not possible to record data in a way that can be retrieved in a cost-effective and timely manner, then how can it be used to judge the effectiveness of a change?) Every change introduced should be provided with SMART objectives, and there must be a rollback plan in place for use if the objectives are not met. Even a failed trial can be useful. As a concrete example, the trial of 7 day GP opening in Yorkshire was found not to be either cost effective or popular. As it objectives were not met, it should be withdrawn. This is a useful data point and should be taken into account in wider policy. Objectives must be set after consultation with experts in the appropriate fields.