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November 14, 2024 - 2:30pm
“Reform” is an easy word to say, but a difficult thing to actually do — as Health Secretary Wes Streeting is surely discovering.
Consider his most recent proposal of drawing up league tables for hospitals, which isn’t exactly bad, given that more information is generally better than less. But in schools, where this policy really did help to drive up standards, it did so by providing that information for empowered parents, who could use it to choose different schools. They only had this power because New Labour and the Conservatives focused on widening school choice via free schools and academies.
In our overstretched NHS, no such bottom-up competitive pressure is possible across most of the country. The most a poor rating can do is attract the attention of central government, which isn’t half so effective at driving better outcomes for service-users as service-users tend to be.
There are plenty of other things that Streeting could do to ease pressure on the Health Service, even without a wholesale shift over to the sort of mixed-provision systems found everywhere else in Western Europe. Reinstating tax breaks for private insurance would encourage more people to take it up and divert demand away from NHS hospitals, for example. Encouraging more trusts to offer private care — as some of the big London ones already do — would see increased private healthcare spending cross-subsidising public provision. On top of that, allowing private hospitals to take medical trainees would ease the staffing bottleneck.
If he was feeling really radical, Streeting could make NHS trusts autonomous, grant-maintained institutions and have them be the legal employers of their staff. This would break the medical unions’ ability to pursue old-fashioned national pay bargaining, empower hospital leadership, and create clear incentives for both parties to embrace reforms that increase hospital revenues, such as private services. None of those proposals conflicts with what ought to be the fundamental point of the NHS: the provision of universal healthcare and to ensure it is available free at the point of use to those who need it.
Unfortunately, for many progressives the NHS itself is the point, and is defined not by outcomes but by structures and processes: the direct provision of care by a monolithic state institution, purely funded out of general taxation. There was no acknowledgement in Labour’s most recent manifesto that anything fundamental needed to change about the NHS. It might be on its knees, but surely that’s just because the Tories starved it of funds, or something.
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SubscribeI’ve rarely seen it put better:
“Unfortunately, for many progressives the NHS itself is the point, and is defined not by outcomes but by structures and processes: the direct provision of care by a monolithic state institution, purely funded out of general taxation.”
Correct. For these people it’s an ideology first and a health provision business second.
As the article suggests, one of the first things any real reform needs to sort out is getting rid of national pay levels in the NHS. This distorts labour markets and guarantees inefficient allocation of people and skills in both the NHS and the private sector. It also makes it far too difficult to recruit staff in high cost areas. This applies right across the public sector.
I’ve some sympathy for the local pay bargaining line, but it’d not be straight-forward or simple. Medical Unions would resist and for the moment more productivity gain through simply avoiding further strike action. Strikes disrupted 35 days of planned care activity in year preceding the GE. So I suspect pragmatism in play at the moment.
What’s missing is any real performance related element to pay, esp since local Clinical Excellence awards ceased. This is still tricky to implement as some specialities have simpler scope for this than others – e.g an Ophthalmologist doing cataract ops vs an A&E doctor dealing with great variation in emergencies. But we’ve actually gone backwards in performance element of pay and that can be corrected with some thought.
What’s missing is any real performance related element to pay, esp since local Clinical Excellence awards ceased.
The beauty of private enterprise is that it corrects poor performance automatically. That’s why continental systems are so much better – even though most care is still ultimately free at the point of delivery.
I suspect that beyond a cursory understanding of perhaps the US system, via no doubt your elite Undergrad US experience, you are not that conversant with how doctors are actually paid and the differences in approach within health systems. German doctors for example paid less than UK. French a little more. US alot more.
In the US a big cost pressure is from over-treatment/over diagnosis because of reliance on ‘fee per service’. The more a doctor gets you to have the more they earn. The salaried model in the UK avoids this tendency and there is no financial incentive for you to have, e.g that extra endoscopy or CT, unless it’s clinically indicated. US doctors earn 3 times UK equivalents but remarkably life expectancy lower in the US than in the UK. That tells us something about comparable efficiency, albeit it’s far from the only factor.
Nonetheless the Tories pushed the performance element backwards when they ceased the CEA process. I suspect the revolving door in Sec of State for Health appointees meant they never got sufficiently on top of their brief to understand what they were doing. Milburn was much more forceful on PRP during his time in Richmond Hse and interesting he’s now back in favour as an advisor. i think something is coming when they think they could get it past the medical unions.
Reforms my a****.
What does?
Good ambiguity-spot!
Fundamentals matter. No state run monopoly will ever deliver very good efficient responsive services. Which is why none of the Better European models are state run monopolies.
Wes Streeting’s scheme to shame NHS Trusts shows you exactly why he is the Blairites’ crown prince. But that means that if he made it clear that he would resign rather than accept the statutory duty that the Assisted Dying Bill would impose on the Health Secretary, then that Bill could not be given Government time, thereby guaranteeing that it would fail.
League tables on outcomes possibly.
League tables on outputs are dangerous and will kill people. More operations minister- no problem. Tired surgeons, agency staff, dont bother to clean properly and the numbers will top up. More folk will die but numbers will go up.
However more successful treatments measured by cured patients – that is worth considering.
Author latches onto broader role for private sector but shows he’s a few steps removed from practical reality. There is a role and it can be extended but it has limits as much because of what the private sector is prepared to do as any NHS ideology.
c55% of NHS work is non elective (emergency/urgent). The private sector much less interested in this. It’s too many unknowns and requires much greater 24/7 access. It’s much less profitable basically.
The private sector also likes to filter out the more complicated elective work again for cost risk reasons. Go and ask your local private hospital if they have an ITU.
And as regards being assigned trainees whilst the private sector may welcome some they may rapidly fail on training requirements. Fee payers don’t want the trainee either.
There is something in how National contracts work for medical staff. But to take that on ideally you want demand/supply to be more in balance first. I reckon Streeting wants to change terms & conditions but when time is right.
Of course the biggest impact private sector has on NHS is via Social Care. Currently it grossly under provides bottlenecking many hospitals. This can’t be solved by private sector alone but it’s a salutary lesson that left to itself the private sector does not do the job needed.
You make some good points.
However reform of NHS does not have to reinvent the wheel.
There are perfectly good templates available in Europe.
I have family in Sweden and Garmany and friends in Denmark and France.
Health systems in these countries work much better.
What is the difference?
These systems use some form of insurance top up, so not all health provision is funded from general taxation.
Every time it is proposed in uk cries come “privatising NHS”.
I already posted about my private and NHS experience of knee surgery.
Time and duplication of efforts in NHS is staggering.
When I drew timeline of both cases NHS had at least double number of steps, mostly because of incompetence of staff (wrong blood test work) and being asked 2 or 3 times for the same information.
To simplify work flow does not require investment but only willingness to change.
But NHS chose to give 22% pay rise to doctors when productivity is down by 30% since 2019.
Just read prof Darzi report.