One big contradiction

James Gubb, 10 January 2008

Reading John Carvel’s interview with Alan Johnson in Society Guardian this week, one could be forgiven for supporting this government on the NHS. He does seem, at least on the superficial level, to get it. It’s funny how every recent Secretary of State for Health has gone into the job with a very ‘nicey-nicey’ approach to the NHS and then, six months to a year or so down the line, realise it’s not going to reform itself and that Blair didn’t introduce competition just for kicks.

No, it was because he increasingly came to see monopoly as the source of the NHS’ problems; that there were no in-built drivers for the NHS to become more efficient. NHS organisations had no incentive to treat more patients because they wouldn’t get paid more; new providers with new ideas and new ways of working couldn’t get into the system because they weren’t allowed to; patients had no choice and were stuck with who they got, even if standards of care were poor. The whole system was, and by and large still is, risk-averse and inclined towards an inefficient status quo. This is not an attack on the doctors, the nurses, the admin staff, the managers, nor even NHS organisations, but the system they’re working in. People respond to the incentives; and the systemic incentives are all wrong.
Mr Johnson increasingly seems to concur. Carvel writes: ‘On the defining issue of competition, there is not a shred of difference between him and Hewitt…far from abandoning use of the private sector, he says he is extending it into primary care’. But then it seems he’s fallen into the trap – just with the cuts to the independent sector treatment centre (ISTC) programme – of believing that somehow the private sector has its definition as competition and you can turn competition on and off when you feel like it. It doesn’t and you can’t. Ultimately, private sector organisations will become just as sleepy if they get just a few loaded contracts from the NHS and have no other providers, or system, in sight that challenges them to constantly improve. This is not an argument for the private sector. This is an argument for competition. It is competition, not the ‘private sector’ per se, that will drive improvement; in a competitive system NHS organisations may, just as much as the private sector, adapt, revolutionise patient care and thrive. UCLH and the Heart of England Foundation Trusts are cases in point.
But then there are signs that Mr Johnson may even be getting this: ‘If you had a very unpopular hospital with high levels of healthcare-acquired infections that people don’t want to use because they want to go elsewhere, then that [closure] is the logical consequence’. He goes on…’but we are in the business of building new hospitals and making the service more responsive to patients’ needs. Competition leads to improvement, not [just] closures’. Bravo. It’s getting the best possible standards of care for the patient that we should be concerned about. If my local hospital closed because it was hopelessly inefficient and rife with C-difficile, others could open in its place and I could choose to be treated elsewhere I’d be more than happy about it.
So why’s it not all rosy; why aren’t we seeing this? Because while Johnson and co. may at least now get the logic of competition – and have even put frameworks, in electives, in place for it to work – what they seem to think is that it then doesn’t matter if they proceed to bludgeon the service with targets, priorities and central diktat at the same time. It does. Hugely.
The Health Service Journal, not exactly a libertarian publication, leads on the NHS Operating Framework for 2009/09 with ‘keep your eyes on the Kremlin, comrades’ and a dome-embellished picture of Richmond House to the left. While Mr Johnson insists the era of targets is over, it’s still very much ‘look out and up’ according to PCT Network director, David Stout. Targets, it seems, have just been replaced with instructions which are, let’s be honest, little more than targets with a different name.
And there’s plenty of them; over 60 new ones in this document alone, many of which have other instructions within them – the national ‘must-dos’, the national ‘priorities’ and then, of course, the 20 or so pre-existing national targets. All this runs to some 15 pages alone; reading, in the words of Nigel Edwards, policy director of the NHS Confederation, like ‘a large shopping list’. And then there’s the new measures that have come along with Gordon Brown’s pledge this week to ‘renew’ the NHS yet again: a national screening programme to spot the early signs of heart problems, stroke, diabetes and kidney disease; extended screening for breast and colon cancer; the deep cleans for hospitals et cetera.
One wonders what room is left for anyone in this politically-dominated system to do anything apart from follow whatever instruction next comes from Whitehall. Instead of using some of the competitive mechanisms already in place to drive performance and ensure a relentless focus on the patient, the vast majority just want to meet the targets and not rock the boat. And who suffers? The patient who receives inadequate care. The doctor who just wants to be able to treat the patient, not fill out pointless forms. And the manger who just wants to align incentives with what’s best for the patient, not ‘the Kremlin’.
The irony is that Labour have made the ideological jump in accepting there are real benefits from competition in public services, but can’t seem to do what should be a lot easier: keep their hands off. This country has benefitted hugely from liberalising telecoms, financial services and airlines; how about the same in health care?