The DeAbolition of the National Health Service

The NHSBill is now irrevocably destined for enactment. Now, the only hope is repeal. #StopTheBill becomes #repealHASCA.

This process has been a shocking display of how not to run government. Coalition was supposed to bring us consensus; instead it has brought us a foul fudge.  There are lessons to be drawn about democracy.

Our much-lamented health service certainly needed reform. On that, almost everyone agreed. The impending demographic shifts in the population mean it had to change. But HASCA12 is the wrong change, mostly because of the way it came around. It is driven by the ideological obsessions of Andrew Lansley himself.  He believes that there should be a market in the provision of health services, and that competition will drive down the price while driving up the quality.  Whatever the merits of the case, in a democracy, you shouldn’t just impose your ideology. Even if you are elected, it is tyrannical to do so, and it is a weakness of our Parliamentary democracy that there are few controls against this tyranny, within the lifetime of a Parliament. Actually, we hoped that coalition might act as some form of control, and the fact that it didn’t suggests that British politics is more rotten than we thought.

If you plan major reform of any part of the public realm,   you should make your case before an election, so that you have a mandate. The shape  of the reform should be in your manifesto. Then, you could realistically say that you have democratic legitimacy. On the other hand, if your campaigning should suggest, for example, that you do not intend any major top-down reforms, and then – contrary to your campaign statements – you impose reforms against the will of the majority affected, it is acting tyrannically.

That this Bill was first approved by Cabinet, without vociferous LibDem complaints, was a bad sign. The LibDems in Cabinet only started to get concerned when the public started to complain. Their first, and only, success, was to win last year’s pause.

No doubt Andrew Lansley is so convinced of the rightness of his position, that he believes that it would be wrong to consider  the views of practitioners whose vested interests would inevitably set them against reform.   He would, of course, be the first to point out that many practitioners, including the BMA, were indisposed to the creation of the NHS in 1948. But revolutionary thought it was, the NHS was a continuation of a much older tradition of medical treatment driven by motives other than money.  Barts, for example, had provided treatment free at the point of use since its foundation in 1123. The quality of its care advanced dramatically between 1123 and 1948, driven by the tradition of charity and  the competition of scholarship . Its ethos, with that of many other constituents,  became part of the wider principles of the NHS to serve the nation as a whole. It is one that the nation’s GPs now adopt wholeheartedly, despite the reservations that their forbears had in 1948.

These latest marketisation reforms, which are much more radical than the  ”internal market” imposed under the Tories’ previous regime,  infer an equally old ethos – that of commerce. Medicine will become a trade, as it is in the United States, and being traded, we are asked to believe that the forces of the market will bring down the price and improve the quality – despite the impressive history of advance from competitive scholarship.

Yet I do not think that the problem is medicine, and its non-commercial exceptionalism.  Rather, it is public procurement.  It is very unlikely that your GP, under the new system, l – when you need a hip replacing or a course of chemotherapy –  will lookout for the best provider on that day. Rather, he will send you to the wholesale provider of orthopaedic surgery or oncology that his Clinical Commissioning Group selected at the last round of contracts. Now that wholesale provider – say, Virgin Orthopaedics, or Serco Cancer Care, will have bid low to get the contract. To make its margins, it will cut out the fripperies and will try to charge you for as much extra as it lawfully can, and if not you, the commissioning group. Pay extra for the latest chemo?   Grieving relatives are always good for a whip-round. Watch out for claims that the orthopaedics contract  only included one session of post-op physio per patient – and upselling to Virgin Active.

It’s these contracts that are the problem.  Negotiating, drafting, enforcing and mediating them is fertile ground for parasitic professionals who will command high fees and suck money away from frontline care. These professionals, and the institutions who employ them, are largely responsible for the additional costs of the US healthcare system. They are different in every sector, and jurisdiction, and they are a significant part of the economy.  In this country, mostly they are Tory.  They are part of the web of corruption in which Lansley and over 100 Tory peers who supported the Bill are implicated.

So how should the Secretary of State for Health have set about addressing the reform that the NHS needed?

Government in a democracy is essentially about consensus, but consensus-building is an art to which today’s partisan politics does not lend itself. It needs active, multilateral engagement; it did not just need a “pause”.  It means approaching the problem with strongly-engaged opinions and yet being ready to change them.  To build consensus in the face of the health sector’s myriad slightly differing vested interests – from patients’ groups to Royal Colleges, not to mention the hospital trusts and the pharmaceutical industry – is a job that could have taken a political genius the lifetime of a parliament.  Every vocal representative would use every opportunity to grandstand at meetings and in phoneins and talkshows: tyranny must seem a much simpler option. Yet there are many strategies that can be adopted to build consensus: for example, conducting meetings under the Chatham House Rule helps to temper grandstanding.

There is, fundamentally, a difference between tyranny and leadership. What Andrew Lansley has shown has been tyranny; because had he shown leadership, the troops would be following.

Instead, they are mutinying, and mutiny is the only sane response to tyranny.

 

The NHS and patient data

David Cameron is sweetening the controversial announcement that he’s planning to talk to pharmacos about data mining the NHS’s clinical data with a promise of faster access to newer treatments….

But (and for someone who’s as strong on personal privacy as I am on corporate transparency, this is perhaps counterintuitive) – I think he’s on to something.

The NHS’s collection of patient data is  a fantastic resource that’s just not exploited. Partly it’s because it’s mostly in trolley-loads of folders with paper notes and printouts of various incompatible scan machines, partly because the question of patient confidentiality – and supposed need for individual consent – has always stopped it being exploited.  But if it were mined effectively, doctors could get a lot better at prescribing.  There has to be lots of evidence that bulk statistical searches of the data would show up – evidence of drug interactions, positive and negative, that we don’t know about, clues to preventing and curing all sorts of disease. It’s frankly irresponsible not to try to release this data to medical research.

Of course, patient confidentiality must be respected. But  orderlies  telling the paparazzi that a Z-list star’s in A&E are a much more serious threat, and much harder to manage.

Properly anonymised, this resource should be made available, not just to pharmacos, but to anyone who’s interested.

 

 

Transparency in publishing

It may seem strange, when the financial world at which my ire is mostly targeted is collapsing all around us, to look elsewhere. But I was inspired to do so by Saturday’s Bad Science column in the Guardian.

Approval for medicines depends on publication of research in peer-reviewed journals – of which there are thousands – amongst other things. A key element of the research is the clinical trial, which tests whether a new drug works, or has significant side effects.  There’s a symbiotic relationship between the pharmaceutical companies producing the new drugs, the hospitals where the clinical trials are carried out, the clinicians who monitor them (and whose name tends to go on the published paper, which has an impact on their career prospects) and the publishers of the journals.  Ben Goldacre, who writes the Bad Science column, has previously pointed out that statistically, a negative result in a clinical trial (one showing that the drug didn’t work) is just as valid as a positive result, yet it’s much less likely to get published.  Peer-reviewed “scholarly” publishing is a profitable industry going through a transformation, yet it plays a crucial role in the medicines approval process.

The medicines regulators are really the right people to control the problem that Ben points out. It is, in fact, relatively simple to do so: first, clinical trials must be registered and published before they take place, and secondly, the results of all clinical trials must be published at their conclusion. It doesn’t matter whether or not they’re published in a peer-reviewed journal or not – of course, it would be better if everything was peer-reviewed – but it does matter that they are published, as in made available for the public (and regulators) to read. Unfortunately, in science, “published” has come to mean “accepted for publication in a peer-reviewed journal” – and science as a whole depends on this for determining promotion, funding and a whole lot more under the general heading of kudos.

The technology for this is even simpler than accounting. It is now commonplace to deposit so-called pre-prints of journal articles in pre-print repositories, so others working in the field can read them before the publishers get round to organising the peer review. It is normal in high-energy physics; it is less normal in biomedicine, because the pharmacos control it. The regulators can and should insist on it now.