Keep Politicians out of the NHS

In the run-up to the election, politicians are trying to out-bribe us with our own money to pay for escalating NHS expectations. Democracy has a dark side. Doctors are telling politicians to: “stop messing with NHS to win votes.” (The Times, 17th February, p.15).

Demand will always outstrip capacity for a free good such as health. The questions are simply two: how much money should be allocated to the NHS and how should those resources be best managed to maximise welfare?  The former question is essentially political but the latter should not be. The budget should be set annually and not agonised over every day.

As every government IT project demonstrates, government does not do management well. One can blame either politicians or civil servants but it is the combination that is fatal. Apparently the present Secretary of State for Health assembles his entire team every Monday morning to micro-manage NHS issues in Darlington, Taunton or wherever. Or rather to attempt to micro-manage. This may improve media coverage but it builds confusion and disheartenment throughout the NHS.

All the best-run large businesses know that those at the top should lead, not manage. The first level of management should be empowered to deal with the micro-stuff and thereafter the next level of management should deal with matters the lower level cannot sensibly address. Because the NHS is so very large, that lesson is the more important.

How can politicians be removed from NHS management? Simple. We have a relatively new, well experienced, NHS England Chief Executive. He seems excellent and a great improvement on his predecessor. NHS England and the other national NHSs should be converted into public corporations, like the BBC, i.e. a stand alone operations funded and responsible to government but managed, day to day, independently. Whether to close, say, a cottage hospital would be a matter for NHS England. Politicians will still, rightly, lobby but they should not be making the decision.

Our political leaders should lead, not second guess local NHS doctors and managers. In addition to setting the budget, politicians should agree the budget and the strategy, i.e. what, overall, we should expect for our money. Then they should get out of the operating theatre.

Rules and recipes are different things Mr. Burnham

We tend to think that there must be some special dictionary out there, one hidden from us mere mortals, that allows politicians to say whatever they damn well please and yet not use the words that we all do. Almost as if there’s some other foreign language they use to speak to us mere voters.

Take this from Andy Burnham for example:

As Burnham correctly said last week: “For change to work in a market context, all players need to be following the same rules.”

This is in the course of The Observer managing to get absolutely everything about obesity, sugar and fatty lardbuckets entirely wrong. We all consume fewer calories than our grandparents did, sugar is not addictive (we consume less of it than in the past) said fatty lardbuckets do not cost the NHS money (dying young saves the NHS money) and so on and so on throughout the entire litany. And, of course, they’re entirely wrong in the basic theory of what they are talking about for the role of government is not to tell us how to live our lives but to enable us to live our lives as we would wish.

But specifically what Burnham is talking about there is that manufacturers should be forced, whether by taxation or by regulation, to put less sugar, less salt, in our food. And no doubt to throw some organic lentils in there at some point as well.

Which is where that special dictionary comes in of course. Because that’s not “rules” that’s “recipes”.

Is it too much to hope that one who would rule the country actually speaks the language of it? Sure, Willie the Conq and George I didn’t do so well on this basis but aren’t we supposed to have moved on?

Hinchingbrooke Hospital isn’t an example of bad privatisation; just an example of bad business

The first private healthcare provider to take over an NHS hospital just over three years ago is pulling out of its contract today, claiming it is “‘no longer sustainable under current terms’ because of rising demand and falling funding.”

You can picture the foam forming around the mouths of hungry public-sector supporters and Burnhamites; in this ultimate battle to keep UK healthcare not only free at the point of use, but in public sector control, they’ve been craving a golden piece of evidence against the private-sector.

But Circle’s contract termination isn’t quite that.

Circle’s involvement with Hinchingbrooke Hospital is far from a traditional private sector model. Hinchingbrooke did not become a private hospital, but rather a privately managed hospital, that was still under the jurisdiction of NHS bureaucracy and, more importantly, dependent on public funds for its operations. Furthermore, there was nothing particularly competitive about the market, and while Circle did have an incentive to make some profit if it made a surplus, not much of its own money was at risk.

Circle’s contract with the government dictated that the hospital would be supported with public funds, give or take up to £5m worth of payments from Circle if public funds weren’t sufficient to provide necessary support for Hinchingbrooke.

Within a few years of taking over Hinchingbrooke Hospital, Circle Holdings took a failing hospital that “consistently ranked near the bottom of the 46 trusts for waiting times” – and that would have been shut down if it hadn’t been sold – and turned it into “one of the highest (ranked hospitals) for patient happiness”. Circle also corrected waiting time failures, leading the hospital to “(top) the list for short waiting times, seeing 98.2 per cent of patients within the required window”.

From ASI Fellow, Tim Evans:

Circle massively improved this hospital and the government should now do two things –
1. Recognise what a good job they have done and re-negotiate the contract to keep them on board – barring another company taking it over.
2. The government should announce that is wants more – not less – private and employee ownership of hospitals, clinics and other care facilities.

It is definitely the case that Circle brought to the table a much better management system and improved healthcare significantly for the hospital’s patients. But these triumphs for both the hospital and its patients didn’t necessarily reflect a sensible business strategy. In fact, choosing to muddy the waters between public and private care under NHS supervision was a risky decision indeed.

From the ASI’s Dr Eamonn Butler:

I was very surprised that any private firm took on an NHS hospital. I spoke to private providers throughout the 90s and they all rejected the idea. An existing hospital comes with current buildings, equipment, procedures, personnel and above all culture. In schools a new head teacher can turn around a school, though there will be a lot of redundancies and redeployments along the way. In the NHS that is even more unthinkable, given the strength of the employee unions, including the doctors’ trade unions, and the ease with which any changes can be dramatised as ‘cuts’.

“Hinchingbrooke’s funding has been cut 10.1pc this financial year”, and having already spent £4.84m of the required £5m of its own funds, Circle claims it can no longer run the hospital in a successful, effective way.

More from Eamonn:

What we need is more private, voluntary or charitable groups providing healthcare services on their own terms, in facilities that they themselves create and with staff that they pick by hand because of their skill, dedication and commitment to the enterprise.

Circle’s improvements to Hinchingbrooke Hospital should not go overlooked, and the Circle experiment should not be dubbed an example of private healthcare gone awry. Real privatisation puts the risk and responsibility on healthcare providers and those who hold equity – ideally including doctors, nurses, and hospital staff members – and then allows for public choice to dictate the winners and losers in the field. It’s not backed up or heavily regulated by public funds.

If Circle’s experiment has shown us anything, it’s that private healthcare providers need more stake and control in their endeavours to produce good results.

More from Tim:

We have to move to 100% independent provision of hospitals through genuine ownership and property – not time bound and counterproductive government contracts.

In reality, Circle’s flirtation with public healthcare was not an experiment in the privatisation of the NHS, but rather an experiment to determine if public funds and oversight were compatible with private sector management. And in the case of healthcare, it looks to be a bust.

The latest argument for paid kidney donation

Apparently people receiving kidney transplants sometimes have to put up with pretty much any old dog end:

Almost 300 patients have been given kidneys previously turned down by other hospitals, with the majority not having been informed.

One in 11 kidneys transplanted from dead donors recently were used after at least three other units rejected them, official figures showed.

Doctors said a shortage of donors meant there was a need to use lower-quality “second-hand organs”. Critically ill patients are being forced to choose whether to hold out for a better organ that might never come.

Recipients were, however, not told that the organs had been turned down elsewhere. Patient leaders are calling for improvements to be made to enable patients to make informed choices. Patients are told what is wrong with the organs, but surgeons said it was irrelevant how many others had rejected them.

Kidneys have been offered on a “fast track” scheme after they had been rejected by five hospitals if the donor was brain dead, or three if the donor died after cardiac arrest since 2012.

This is not, to put it mildly, optimal. However, it is a useful illustration of the basic point about kidney transplantation. Which is that, very simply, not enough people die healthy enough to provide the kidneys needed for those who will die without a transplant. This is true whether we use an opt in system, an opt out one, even if we nationalised the cadavers of everyone in the country. We have to supplement that cadaveric supply with live donations.

At which point we’ll make our now ritual point. There’s only one country in the world with no shortage of kidneys for transplant. There’s also only one country that allows direct compensation of live donors (under quite strict government and ethical control, of course). Iran is the only place that manages both. given that this does in fact work, does save lives, it’s really something we ought to be doing ourselves. And, given that a transplant is vastly cheaper over time than continued dialysis it would save the NHS substantial sums if we did just bung a live donor £25k or so.

There really are some things that are just too important not to have markets in them.

This is not the right time for another pay claim by NHS unions

On Monday, NHS unions plan stoppages ‘short of strike action’. It may not feel like it if your hospital treatment has been cancelled or you are lying in a ward with fewer nurses to look after you.

The stoppages come after strikes back in October failed to move the government to raise its pay offer for NHS staff. A pay review body recommended a 1% increase for all NHS staff, but the government argues that this is unaffordable and unfair. After all, the 3% ‘increment’ rise puts more money into the hands of higher-paid NHS workers than lower-paid ones.And some 55% of NHS staff already get an annual 3% rise: so the government is saying that any extra cash for wages should go to the workers who do not get this. So it is proposing a 1% rise for the others, but not an extra 1% on top of the existing 3% increments.

Extending the 1% rise to all NHS workers, says the government, will cost around £300 million. Some 75% of hospitals’ budgets is staff costs, so the extra cost that the union proposals would impose on them would mean cutbacks in staff – some 4,000 nurses lost this year, and another 10,000 next year. That could leave hospitals unsafe, risking another Mid-Staffordshire disaster.

Many members of the public would say that NHS staff should count themselves lucky. Average pay in the UK grew just 0.1% last year, and many businesses are hanging on by the skin of their teeth. But NHS pay has been rising since 2012. More than 5,000 nurses were recruited last year, and more midwives too. Public sector pay is generally higher than private sector pay for the same job, even before you count the more secure and higher public sector pensions. Lower paid workers, including those in the NHS, have been helped by the rise in the tax threshold to £10,000. Moreover, the £133 billion NHS budget – some 18% of public spending or over £2,000 per man, woman and child – is ring-fenced, so there is no chance of it falling – unlike the fortunes of most high-street businesses.

And if you want to know how bad things can really get, look at Portugal, which slashed its health budget 17%. Our public finances are not quite in that much of a mess, but things are still tight. The UK has economic growth of 3% but it is still fragile, and there are lots of things that could still spell disaster – a potential crisis in the eurozone, ebola, tension with Russia, you name it. The British government is 1.45trillion in debt, and adding to that debt by another £100 billion a year, despite creaming off 40% of the national income in taxes.

This just is not the right time for another pay claim. And certainly not for another Winter of Discontent (with images of ambulance crews dropping ‘non-emergency’ cases off in the snow to find their way home). The mind shivers. It is clear the government cannot budge, so why don’t we all go back to work and try to get Britain out of this mess?