Photo: Turtles are Slow Moving Targets by Epicletic from Flickr

Under the terms of the 2012 Health and Social Care Act, the ‘new’ NHS is to be based on four ‘new’ measures of ‘quality’, ‘safety’ and ‘value for money’. These measures are i. current best international standards of evidence, ii. current best clinical outcome measures, iii. current best patient outcome measures and iv. current best patient experience measures. All of this data, so we are told, will be routinely collected (in what amounts to an information revolution) from health professionals’ daily undertakings.

All of this information will be fed into a framework that will collate amd interpret the data – a Quality and Outcomes Framework or a Commissioning Outcomes Framework or an NHS Outcomes Framework. The Quality and Outcomes Framework already operates at the level of the individual GP practice, and will continue to do so. The Commissioning Outcomes Framework will relate to the oversight and governance of any and all providers in terms of the local Clinical Commissioning Groups. The NHS Outcomes Framework measures will then exert a degree of oversight and governance over the national level healthcare priorities. All of these measures will directly impact upon the levels of remuneration that respective local, regional and national commissioners and providers can expect to command.  What I want to draw attention to is the shift in the locus (or loci) of control inherent in these new measures. DeVries and colleagues discuss the fallacy of objectivity inherent in Evidence-Based Medicine. The supposition that objective science, based on clinical outcomes measures and the best international research, is beyond the realm of political influence or even control is not sustainable once it is subjected to proper scrutiny.

I want to consider the role of these ‘new’ forms of evidence in terms of the re-structuring of the NHS. The primary issue is the need for government to develop innovative ways to deal with ‘any qualified providers’. The rules of engagement have to be such as to expand the reach of statutory governance without extending the reach of statutory responsibility. The (not so) implicit intent of the Health and Social Care Act is to reduce the statutory obligation of government in health and social care provision, by increasing the roles and obligations of a panoply of providers across the statutory sector, the third sector and the private sector.  Contemporarily, governance arrangements have been based on a central principle of central government control of statutory providers, through internal markets, quality metrics or choice-based policies. Brian Salter argues these mechanisms have been largely unsuccessful due to the fact that health professionals staffed these watchdogs, such as the original Commission for Healthcare Improvement or the National Institute for Health and Clinical Excellence. The locus of control remained an internally focussed one.

The rise of Evidence-Based Medicine, (based on international best evidence and routinely collated clinical outcome measures) coupled to a concomitant rise in principles of public engagement and patient involvement function to introduce a range of external loci of control, all of them purportedly beyond the reach of direct professional manipulation, through an insistence on the veracity of scientific data. Anyone who has ever completed a market research questionnaire can tell you the proffered responses are never wholly adequate. A sophisticated respondent might go so far to say that these measures are more concerned with the intentions of the question asker rather than the question answerer.

If the goal of reform is to reduce the statutory obligation to provide healthcare, this means that come the next 12-18 months, less statutorily provided care is going to be available. More care will be available from non-statutory providers. In terms of political expediency, this may not be particularly popular amongst the electorate. However, this is where the purported objectivity and external validity of the scientific evidence comes into its own. Government can argue that it is not making any decisions about the availability of local services without consulting the four pillars of evidence. The trick involves demonstrating that what is in effect a predominantly economic decision has been taken for reasons of clinical benefit for the patient. Consider the example of East and North Herts Clinical Commissioning Group. This particular Clinical Commissioning Group has issued a media release that they will not refer overweight patients for routine surgery. They legitimise this decision through reference to a range of clinical evidence that demonstrates the heightened risk and the relative reduction in these risks following a ‘small weight loss’. Whilst the best interest of the patient may feature in this decision, there is no doubt in my mind that there is also an inherent assessment of risk, risk as construed not in terms of the patient dying, but risk as construed in terms of how undertaking these procedures with overweight patients might impact upon scores for the Quality Outcomes Framework, the Commissioning Outcomes Framework or the NHS Outcomes Framework. That is, an explicit calculation of the risk of treating the patient in terms of the financial health of the Clinical Commissioning Group. This introduces an explicit principle of conditionality in terms of free universal access to healthcare that may just be the tip of the iceberg.