F is for Fail by Ewen Speed

The King’s Fund this week published a mid-term review of UK health policy under the Coalition government. The report is organised around 8 key themes – Access, Patient Safety, Promoting Health, Managing Long Term Conditions, Clinical Effectiveness, Patient Experience, Equity, and Efficiency. The report identifies a number of successes – for example, 12,500 patients have utilised the new cancer drugs fund, and rates of MRSA and C.diff have decreased markedly. But there are another group of statistics, altogether more troubling. These stats would suggest the government is well ahead of their progress targets in terms of their dismantling of the NHS.

Granted, I am reading selectively, but there are a number of negatives – On issues of access there has been a 19% rise in the number of patients that were not seen within the four hour A&E target. In relation to long-term conditions, Department of Health statistics show that rates of diabetes increased by 25% between 2006/7 and 2010/11. Similarly the National Audit Office reported that 24,000 people died annually from avoidable causes related to their diabetes and that £170 million could be saved through better understanding and management of diabetes.

These stats demonstrate 170 million reasons why a government MP (see Tory MP (and GP) Phillip Lee’s comments earlier this week) might want to stress the importance of individual responsibility for diabetes management. However it takes quite a bizarre leap of logic to then insist that those deemed to be ‘irresponsible’ should be made to pay for the ‘excessive’ cost of their treatment. In this regard, Lee is guilty of conflating ‘poor’ lifestyle choices (his words, not mine), and ‘poor’ condition management, with an individual lack of responsibility. He compounds his error through the suggestion that ‘better’ symptom management would be assured by making people take financial responsibility for their treatment (at a stroke making personal responsibility an economic issue). Under his proposal, the logic holds that people could choose to continue with negative lifestyle choices, so long as they had the money to pay for the consequences of those choices. They could just pay for their ‘corrective’ treatment and continue as before, (i.e. as irresponsible condition managers). Those that could not afford to do this would need to modify their behaviours; by default Lee is proposing a two tier health system based on the ability to pay rather than need.

On issues of clinical effectiveness, the King’s Fund review showed that of the 16 OECD countries, the UK still has the highest rate of mortality amenable to healthcare. Conversely, mortality in relation to cardiovascular disease has fallen by 43% between 2000 and 2010, but there are significant geographical variations in access to and treatment of cardiovascular disease (i.e. a postcode lottery). Given the inherent localism contained in plans for Clinical Commissioning Groups (212 CCG’s will replace 151 Primary Care Trusts, PCTs) it is difficult to be optimistic about this situation improving.

Next up is patient experience. Under inspection from the Care Quality Commission in 2011, 20% of NHS acute hospitals failed to meet essential standards of nutrition and dignity for older people. Similarly, the number of written complaints received by hospitals increased by 23% between 2007/8 and 2011/12.

Equity is next. Data from the 2011 NHS Right Care report highlighted that there were “unwarranted differences in healthcare utilisation that reflect wider issues of inequality in relation to access to services”. For example, in treating patients with type 2 diabetes, the report showed a seven-fold variation in adherence to 18 ‘good care indicators’ between the 2.5% top and bottom primary care trusts. Just to be clear, this means there was a seven-fold difference between the level of treatment being administered to patients by health professionals across the top and bottom performing PCTs. This means that there was a variation in the treatment that patients received for diabetes. This variation was dependent upon which PCT they went to. How can we square this statistic (which demonstrates an organisational or structural effect) with Phillip Lee’s charge of the increase in diabetes being about a failure of personal responsibility?

This variation is a clear example of a structural failing that simply does not fit into Dr Lee’s view of the problem. It begs the question of what responsibility government has in ensuring equity of provision across the NHS? I struggle to see how we can resolve this inequity with a responsibilisation of the patient. Surely individual choice and responsibility are predicated on an assumption that the provision of care is the same for everyone? Until this level playing field is assured, Lee’s rhetoric is simply an example of old-fashioned right-wing ‘victim blaming’.

Lastly, in terms of efficiency, apparently the NHS is in surplus, (due to the much trumpeted Nicholson Challenge), with £4.3 billion generated through productivity gains in 2010/11, and a further £5.8 billion through the QIPP programme. At the same time, the Department of Health reports that 12 acute or ambulance trusts are not functioning financially, with 6 in ‘serious difficulties’. In addition, 15 foundation trusts finished 2011/12 in deficit; with the economic regulator Monitor stating that 4 of them are ‘not viable’.

I cannot help but feel that all of this augers in ‘a perfect storm’ that is brewing in the NHS. This perfect storm will, to all intents and purposes, ‘break up’ the NHS, such that the only possible solution is a vanguard of private healthcare corporations who will ‘man the flood defences’. Witness the statement made this week by the Australian company Ramsay Health Care, who are purportedly chasing their biggest ever deal in the UK. We might be half way through the term, but we are more than halfway through the dismantling of the NHS.