Many have spoken out in opposition to the bill. Some have spoken out in support. As health economists most of us have done little of either. I recently wrote to health economists asking them to answer a simple question:
“With regard to the future of the Health and Social Care Bill 2011, what do you believe to be the best course of action and why?”
Here are the responses*.
Christopher McCabe, Professor of Health Economics, University of Alberta
I believe that the most appropriate action with regard to the Health and Social Care Bill would be to stop its current procession through Parliament.
The bill’s immediate impact will be to fragment care, when all the evidence points to co-ordinated care being both more effective and more efficient. In addition, the bill allows both primary care and hospitals to develop their private sector practice without regard to the impact on the health of those who cannot afford private health care.
The democratic accountability for the expenditure of over £100 billon will be significantly diluted through the changes to the responsibilities of the Secretary of State, whilst the ability of the public to hold third and private sector providers to account through freedom of information will be substantially reduced.
The costs of implementing the reforms are likely to be equal to the cost savings that have been cited as a justification for them and there is no evidence to support the government’s proposition that the new structures will improve the quality of care.
The bill is now too complex to amend with a view to overcoming these substantial problems. Therefore it should be abandoned.
Cam Donaldson, Yunus Chair in Social Business & Health, Glasgow Caledonian University
My feelings on this are many and complex, but here are some ‘starters for ten’:
- Those who say there was no mandate for such reforms must have missed Tory policy documents in the run up to the last General Election.
- Those who complained during the ‘pause’ have made things worse, as it is now no longer clear who holds the purse strings. Not a good situation in the midst of a health care credit crunch.
- The previous system was unsustainable due to its emphasis on the most expensive part of the health care system (the ‘black hole’ of the acute sector). The creation of Foundation Trusts and associated incentives (such as PbR and the need to pay off PFI-funded projects) had created too much power on the supply side, backed by encouragement of funds to flow in that direction.
- That’s why I like a model based on GP fundholding. PCTs could not stop flows of funds into the acute sector, and, by my experience, even ‘cosied up’ to FTs under the previous arrangements. The evidence is not great, I admit, but what there is showed that fundholding has potential to create countervailing power on the demand side of this imbalanced market – a market that became even more imbalanced than it had been under Thatcher or Ken Clarke. These guys (GP practices and consortia) might be smaller than PCTs, but the countervailing power might come from something to do with their professional status.
- I agree with people’s worries about the explicit push to more commercial interests becoming involved. This is the bit I’d want junked, revised or whatever.
- Is going back an option? Given my third bullet point above, I’d say not. So, when people slag off the Bill, I’d like to know what THEIR alternative is. That’s what’s frustrating about Twitter!!!
Stephen Wright, Executive Director, European Centre for Health Assets and Architecture
The Health Bill raises a number of questions:
- The compatibility of integration of care with competitive provision
- GP conflicts of interest as providers and commissioners (let alone as rationers)
- Whether the NHS will be converted into an insurer rather than a provider, by stealth
- Centralising administration (Commissioning Board) – in the name of localisation
- Whether administration costs will rise with the partial privatisation
- Reorganising a system while simultaneously expecting it to achieve unprecedented economies
- The legitimacy of reorganising the architecture of care provision before the Bill has even been enacted
- Whether the proposed failure regime can achieve its goals (to bring in commercial capital)
- The lack of clarity of the mechanisms for planning long-term investment in assets
- The inadequate nature of the tariff (PbR) and associated payments streams, including Market Forces Factor and Service Increment for Teaching and Research, both of which need serious reform.
These questions of health economics principles (principal-agent; the health production function; factor pricing; capital investment decision-making; etc.) are so profound that the Bill is destined to create system failure.
David Cohen, Professor of Health Economics, University of Glamorgan
I am very much against the bill for 3 principle reasons:
- There are many criteria on which inescapable resource allocation decisions can be made – one being efficiency (maximise health gain from available resource). In recent years, largely due to the influence of NICE, the efficiency/cost-effectiveness criterion has played a much larger role in these decisions thus reducing the role of other less defensible criteria such as the political power of consultants or the ability to gain public sympathy by shroud waving. These 2 – as well as prioritisation according to drug company influence – are certain to increase if the bill is passed.
- There is no evidence that increased competition by private providers will improve efficiency.
- “Evidence” used to defend greater use of market principles in the NHS on the basis of what patients want is dubious. Who would say no if asked “are you in favour of more choice?”. I can see no evidence that ‘more choice’ is a burning issue for patients. Free market health care has advantages including consumer choice. Socialised health care has advantages including greater equity. Attempting to get both from the same health care system won’t work.
Peter West, Health Economist
The key point is that changes should be piloted for some time, in say one geographical area and across a range of institutions and services. PCTs were, let’s be frank, not very effective purchasers because purchasing is difficult and they never had the skills and resources. Will something clinically led be better? Very hard to say. Indeed, it is hard to know if it really will be clinically led.Will competition damage networking and the moving of the patient to the best place rather than the place that wants to keep the most income from that patient? Possibly. But in practice NHS hospitals already compete and, in addition, once a patient has received their initial urgent care, hospitals develop strong ownership. Competition is always weakened in the NHS anyway because the obvious place for assessment is local OPD and once assessed as needing continuing care, the patient has a relationship with a doctor and hospital and is likely to continue their care there unless some problem came up in the assessment phase.For those less familiar with the NHS, some examples of competition and collaboration. I do not pretend that similar stuff could be found everywhere but I think issues like these are widespread:
I have worked in a merged teaching hospital where rivalry between the two sites was fierce, dating back to a historic schism around 200 years ago. The new combined medical director regularly received hate mail from some colleagues on his former site. Could market competition be any stronger? I have also heard of hospitals holding on to patients after the King’s Cross fire instead of sending them to a Burns Unit, because the receiving hospital in Central London wanted to build up its plastics service. And it had of course already stabilised the patients and started their care. Similarly, I have seen local doctors in a far flung part of the NHS raising money for cancer equipment so that they could have a go locally at treatments which are acknowledged to be best carried out in a major cancer centre. So collaboration is far from perfect, but it could still get worse with more competition.Of course it will frustrate some that we cannot move directly to a new system but without evidence, collected with significant research resources, we would be lurching in the dark yet again!
Gillian Mann, Health Economist, Liverpool School of Tropical Medicine
I believe the primary function of a public health service should be to provide universal coverage of appropriate promotive, preventive, curative, and rehabilitative services at an affordable cost. These should be delivered equitably such that those with the greatest need should have the greatest utilisation. I believe that the most efficient means of ensuring equitable cost-effective services is to have treatment and care guidelines written from a strong evidence base taking into account the views of medical professionals, patients and other stakeholders. In a publicly funded system this must be based on cost-effectiveness, so that the maximum health benefit is gained from the public purse.
I do not believe that putting increasing decision making power in to the hands of GPs can achieve this. They do not, and should not, have the time nor the resources to weigh up all new evidence across a range of care needs.
I believe the argument for patient choice is misguided; effective choice relies on evidence, not media reports. As a patient, I expect medical professionals to make evidence-based decisions – an individual cannot. Patient choice will lead to inequitable service provision, since the most informed patients, who are more able to negotiate with their GPs, are unlikely to be those with greatest need, who in all societies tend to be poorer with access to fewer resources.
As both a patient and an economist I believe the proposals are regressive; I would not like to see them implemented.
Let us know what you think in the comments below, and be sure to vote in the poll.
*if you missed the deadline for submissions, but believe your views to be of interest to readers, you can contribute by clicking here.
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For those who are opposed to the bill and in London on March 7th this rally may be of interest: http://www.goingtowork.org.uk/rally-to-save-our-nhs/
[…] There has been considerable resistance to the proposed changes from professional and public sector groups. The Keep Our NHS Public campaign (a public organisation); the British Medical Association (representing doctors), Royal College of Nursing ,Royal College of GPs and a collective of public health specialists, among others, have written very considered and constructive, yet in places quite damning responses. Some summaries of professionals’ and academics’ responses to the Bill are available here and here. […]
Great to see such a range of informed views, succinctly put. The Secretary of State is still reiterating his assertion that the current system is too ‘bureaucratic,’ which a) implies that managers, commissioners etc. have no expertise at all in health, and b) is disingenuous given the layers of organisation that seem to be being designed for the ‘reformed’ system. By the looks of things, CCGs are going to be fairly large organisations (and cover large populations) – difficult to see how they will function without ‘bureaucracy’ (and who do we want to manage that – GPs?). While ‘clinically led’ commissioning decisions may be broadly better than what we currently have (‘bureaucracy led’ ones..?), it does not seem that credible to insist that this means that ‘my’ GP will be making those decisions based on what s/he thinks best for ‘me’, which is implied in the rhetoric.
Good point, Kate.
This is all speculation, but let’s say that right now, generally, there is an under-supply of clinicians (see waiting times) but not of managers and commissioners. If this is the case then increasing demand for GP time while decreasing that for managers is surely a very bad idea. Allowing clinicians to provide more services privately will exacerbate this by reducing supply of services to the NHS by more than it will reduce demand.
Clinician-led commissioning sounds nice, but if we need more clinicians as it is, do we really want them spending their time commissioning? I think not.
Predictably, I agree with much of what is said above. I personally would like to see the Bill buried, primarily because it has seen so much opposition from the people that are expected to enact it.
I have no strong opposition to GP commissioning, though I am strongly opposed to almost every other aspect of the Bill, as discussed by the authors above. As an academic I find the Bill’s lack of empiricism most concerning, and for me this issue highlights the motivation of this bill as 100% political.
I trust those who argue that reform is necessary, but that is no reason to continue flogging this dead horse of a bill. We need to start afresh.