Current Tory health plans are backward-looking and reactionary

DavidDP

"But this would require taking on the NHS establishment"

No, this would require taking on the electorate. Which is fine, but it makes getting elected very difficult. In which case you won';t be able to carry out any reform anyway.

Still, I'll make an appointment with you next time I'm ill. Can't trust the professionals after all.

anonymous despairing conservative

It is impossible to have a rational debate about the NHS. It has assumed the mantle of state religeon and is sacrosanct.

In office, Thatcher never touched it and increased spending in real terms every year. Major had a go with GP fund-holding, but backed down from making that universal. That led to "them and us" claims from the left and Dobson dismantled it. Milburn went back to fund-holding, just at PCT level. Brownian influence has slowed the moves to bring alternate providers in.

Lansley has been captured by the health lobby and has gone native. Cameron, understandably, can't see past the treatment his son got - which was fantastic as all NHS care in those circumstances is. It is just the routine stuff they mess up!

With Lansley in charge, nothing will change and things may actually get worse. A gift for Labour!

Tiberius

As I'm sure you're well aware, Fraser, it will get better after the first term.

Kittler

All the "pen pushers and administrators". Sack the lot of course and get clinical staff to do their own filing and typing. They could also organise the purchase of all the requisites for their departments, do a bit of store keeping and if they still have some spare time what about looking after the payroll or little bit of maintenance work.

Fergus Pickering

You see, Fraser, the problem with being a consumer of the Health Service is that when you want to consume it you are ill. All these free choices! But you don't want a free choice. You want someone to hold your hand and make you better. When I'm offered an operation I can have any one of six at any one of six hospitals. But I don't want any of that. I want someone to hold my hand and. Most long term consumers of the Health Service are old, many half gaga and frankly I don't feel so well myself. All these comprisons wit the Red Army are not to the point. Even if you could sack lots of unproductive pen pushers there would still be a million people doing Health things, as I am sure there are in France, Germany, Italy etc etc. Here's a rahter out-of-date anecdote for you. A friend of mine got lung cancer. Well she smoked forty a day. The NHS pretty well told her there was nothing else they could do for her. So she went to Italy and the nice Italian Health chaps took a lot of her money and she died in six months. Most health care ends in failure wherever you are. The only people whose opinions are worth much about it are the sick. And the sick are sick, often too sick to have much of an opinion about anything. All hospitals are vile. They are full of sick and dying people, what would you suppose they would be like? Is the French Health Service really as wonderful as they say it is? Well, French bureaucracy in general is ghastly, unfeeling etc etc. Does it change when you get tothe Health end of things? What about poor people? How do they deal with them?

Ben

You need to calm down a bit on this Fraser. I'm an NHS consultant surgeon - no private practice etc, I am a supporter of the NHS, but I know there's a lot wrong with it. Consider this: if your mother/father needed a hip replacement, and it was quicker to get it from a treatment centre, by 4 weeks say, but there was a 5% chance of a serious complication, rather than 3% in the NHS, what would you recommend? Low probability but high impact complications are the result of lower clinical standards in the competitive sector. There is good evidence for this claim. The perceived "need" for alterative health care suppliers, like ISTCs has been generated by arbitrary waiting times targets, which have now gone way beyond what patients require in most cases, and are really just a means for political points scoring. Milburn was a dreadful Health Minister in many ways, and styling him as a lost leader of reform is amusingly bizarre. Health care should be about minimising risk within reasonable time limits, not about driving down waiting times at all costs. There are many many other aspects of this debate, but you need to look beyond your usually admirable economics viewpoint sometimes. No doubt we could usefully lose a lot of nonclinical staff, but no party is actually proposing that. In fact Milburn presided over their expansion. Rawnsley looks like a caretaker, not the man to change things for the better. Dave will know that. For elective (nonemergency) care I would summarise: relax the targets a bit, they are expensive and there's no money, as we all know; annualise the consultant's contracts and use operating facilities more flexibly; smarten up the procurement process for implants, supplies etc, it is inefficient and wasteful; make redundant about 25% of nonclinical admin staff immediately - ask the doctors who to keep; remember that elective services are only the priority if you have already got the emergencies right (they are the political Cinderella).

Really though, Milburn, what were you thinking?

Verity

Fergus Pickering, the reason the health services in France and Singapore are so efficient is, the money follows the patient. If you need a test, or an x-ray, whatever, your doctor hands you a prescription, and off you go with it. You will choose a lab or an x-ray or ultra sound establishment that your friends have recommended as being friendly, efficient and clean. The staff act like private enterprise people, because that's what they are. The government pays for all these tests. If they get a name for being surly, or not keeping appointments on time, customers will go elsewhere and they will go out of business.

I had an ultra sound, and the courtesy and friendliness were amazing, especially as this was in France, where they don't notice that their supermarket trolley has jammed you into a freezer compartment and that walking on the pavement four abreast means people coming in the opposite direction get pushed, unnoticed, into the gutter.

They only get paid for services they render, and they can only render services if they make it easy and convenient for the customer.

Also, when they've explained your results to you, they hand them to you. You get to keep the ultrasound or whatever, and you decide whether to return to the doctor that prescribed it or go to another doctor.

Like everything the French do, it's very efficient.

I recommended, although it has been posted up as I write, that we adopt the Singapore system and get a Singaporean to run it for five years, but this would apply equally to the French. They are both superb managers.

Robert

My own quite extensive experience of the NHS is that once you are in the system with some identifiable problem, you might (possibly) do very well; however, you are quite likely to be dead before you can get to that point. And that is the point: it is rationed by mortality.

Olaf Rye

You miss the point, Kittler: no one is suggesting abolishing all administrative support, but instead want to see less than a one to one ratio of bureaucrats to medics in the service. Surely, if the military can do with one officer for every thirty men, the NHS could manage one administrator for every twenty doctors or nurses. It is a wasteful system as it is, meaning that we could easily reduce staff, save money, and have a more efficient medical service.

Simon

Glad you've found a resting place at the NoTW.

Ben

One more point Fraser: who sorts out the complications and cock ups of the private clinics, overseas providers and ISTC's? Who deals with the very many slightly less healthy patients that these risk averse providers refuse to take on? The NHS of course.

The mixed healthcare economy is a firefighting measure at present, because of waiting list guarantees. A genuinely competitive model would require ground up restructuring, where these clinically weak alternative providers can supply a clinically equivalent service. Right now they can't, and they know it. It's too expensive and too complex for them to organise.

Mark M

Quite right about payment v provider. The NHS should only be a way to pay for healthcare. Patient choice is absolutely crucial if we want to get the best out of our healthcare system and this does not happen at the moment.

If I'm not happy with what's on offer at my local supermarket, I try out another chain. If I'm not happy with my state healthcare, I have to lump it, get in line and wait.

There has to be a better way, and surely we have enough intelligent people in this country to make it work.

Dirty Euro

Patient choice is a another term for making rich people get better services than poor people. All that education passport means is rich people will use that to cut their prices at Eton.
It is a reactionary policy not a policy of choice. If you have more money you will get more choice. End of story.

TomTom

I am not a Consumer of health care but a Recipient of health care. I cannot possibly evaluate treatments, drugs, hospitals, medical teams, nursing care unless I want to give up my day job and become a professional.

I want better information, well-trained doctors, well-equipped hospitals, and my every need catered for...pity that you Fraser drew the short straw when you were ill as I had tailored the whole system to my personal needs and convenience

Will J

"The patient should become the consumer, as is the case in the healthcare system of every developed country."

Yes, and the way most of them do that is not by the state funding healthcare through PCTs and private companies providing hospitals (which is what this article seems to imply), but through a carefully regulated compulsory insurance scheme and local government as the main hospital provider. Insofar as this works it does so not only because insurance schemes give patients freedom to choose their preferred place of treatment, but also crucially because they ensure in one way or another that some of the cost of care is borne by the patient personally, so that with the freedom comes the all important incentive to be responsible in balancing quality (and necessity) with cost. Until the British system introduces this incentive to buyers to keep costs down it is impossible for it to become an efficient market, however many private companies provide hospitals.

This is such a basic economic point about the structure of the system that it should be obvious to anybody who's ever studied economics. And yet here we are in the seventh decade of the NHS and still no one is proposing reforms which address this fundamental structural flaw. What makes this even more incredible is that we're surrounded by countries who understand this point perfectly, so that whatever other flaws their healthcare systems have they don't suffer from the kind of chronic bureaucratic bloatedness that only a system which fails to grasp Economics 101 could labour under. Come on guys, brush up on the theory, take a look at how everyone else does it, and get a grip!

Fergus Pickering

Verity, I presume these doctors etc are not in Paris. Nobody is Paris is polite to anyone else ever. It is true that things get better as you head South. But then I imagine the South of France is your natural home. Singapore? Never been there. Never will. When I had the only operation I have ever had in my life the NHS staff and doctors (doctors all brown) were very polite and efficient. But then in East Kent everybody is polite and efficient AND we have nice Grammar Schools and a jolly good cricket team. East Kent must be bigger than Singapore. Home Rule for East Kent.

David Bouvier

Ben - Browne, Jameison, et al "Case-mix & patients' reports of outcome in Independent Sector Treatment Centres: Comparison with NHS providers" published in BMC Health Services Research in 2008 gives ISTCs a pretty much clean bill of health.

Is there comparable research you which to quote against this? What evidence did you have in mind. It also mentions that the case-mix for which they adjusted arises from the NHS's contractual arrangements not the ISTCs 'cheating' in some way.

Not that the ISTC model is a particularly good example of actual competition or anything.

Ben

To David Bouvier - the British Orthopaedic Association has a substantial report - which is continuing to be added to - regarding substandard orthopaedic care in ISTC'S. Most patients fare well anyway, but the important detail is in areas like reoperation rates after initial surgery, where apparently small differences (my 5% v 3%) matter hugely to patients, but not to government or management. I believe that this has been presented to the DoH, who will not of course be interested. Longer term results are of course yet to be available for procedures like joint replacement, but if your new hip only lasts 8 years, rather than 20, you might wonder if you'd been sold short at the beginning. There is no doubt at all that ISTC's, and the private providers who are feeding on the NHS waiting lists are cherry-picking straightforward cases, which should improve their outcomes, you might think. It also tilts the residual NHS casemix to more risky and complicated procedures thereby slightly increasing their number of adverse events.

Ian C

One fight at a time. One that is popular and can be won. Education was Blair's mantra and he ducked it because he was powerless to do the right things against the socialist Labour education establishment. This is now so unpopular that it is defeatable in a short timescale and must be reformed early to show electoral (not to mention educational) gain by the time of the 2014/15 election.

The NHS is a second term issue. It is expensive and incoherent politically what Cameron is saying. But as a piece of political strategy it is essential to make it an issue for later while Tory competence credentials are established.

guy

It is so easy it actually hurts. There are only two principles that matter in the NHS, it should be high quality and it should be free. That’s it! Attempting to nuance this message has resulted in the cadaverous stranglehold that so bedevils an organisation that is stuffed with high quality individuals just waiting to be set free. The government should confine itself to setting (and inspecting) the standards and range of services it expects an organisation calling itself NHS to achieve; better surely than the current private provider cherry picker approach. . All that the government has to do then is pay, a simple per unit of healthcare price; call it a passport if you like. How the provider spends the cash to achieve the quality, quantity and range of services required is up to them; no grand plans, no world class commissioning, definitely no PCTs. Politicians will become unpopular for sure, because some hospitals and GP surgeries will close, and the massive forces of conservatism will vocally hate them, nobody likes change. But it is a tough job, and surely they didn’t go into it to be popular! It is that simple, not wielding the axe, but cutting the chains!