Sunday, 4 March 2012

The health bill is a mess: lets pity the politicians

 Wednesday 15th February

The Health Bill is a mess: let’s pity the Politicians.

When you look at the health bill, what most people are agreed upon is that this is a chaotic mess. It has taken the NHS, which most of us understandably regard as precious. It has made a number of assumptions that many people strongly contest, and it is absorbing vast amounts of time money and energy in what appears to many to be entirely the wrong battle. In the process it is damaging our already fragile trust in politicians and the political process.

The battle that is currently going on in the Lords is trying to do two different things. It is about trying to save what the majority of people see as the essentials of the NHS, whilst opening a face saving option for both parts of the coalition government. The suggestions from Shirley Williams look as if they could potentially achieve both of these aims. It remains to be seen if her proposals will be followed. I want to take a look at how we could have got to this point and how can we stop it from ever happening again.

There has been a clue to this over the last couple of days.
 An article in the Lancet questions the assumptions by the Audit commission about the productivity of the NHS. The Audit commission had looked at a report based in an area where there was “patient choice”. It had seen improving results, and drew the conclusion that the patient choice caused the improvements. It also claims that NHS productivity as a whole had fallen over years that Labour were in power. This report was used by David Cameron to justify his view that a multiplicity of providers and patient choice would be the way to drive up quality.

The Lancet article by Nick Black strongly contests the findings of the Audit commission report, and draws the conclusions that productivity, quality and outcomes had actually improved. It drew attention to flaws in the Audit commission report, and the common error of confusing correlation with causation.

A spokesman for the Office of national statistics then appeared briefly on BBC Radio 4 Today and contested Nick Blacks report – pointed out that there are misunderstandings. They offered
the opinion that productivity had actually been more or less flat over the last 10 years.

The BBC interviewer at this stage understandably shifted to the view that if there is this amount of disagreement between experts then the whole exercise is essentially meaningless, and you might as well forget trying to measure quality and productivity. He also I am sure correctly made the point that where there is a conflict of this nature you will get the government using one set of findings and the Labour party using the other. 

 The ONS I think correctly replied that measurement matters, and that it is important to try and have transparent discussions about what these complex studies are actually showing us.

So if you ask me if productivity improved or got worse under Labour or as a result of choice I really do not have the answers, and would feel that I have to know a lot more about the writers of the reports, and what they were aiming to do before I could even venture an opinion.

Productivity is one of the areas when the politicians may have made false assumptions. I have written much over the last 4 years about the unreliability of the evidence behind the Midstaffs story, which may well mean that the basis of the assumption of a “broken NHS” and the “failure of bureaucracy” is also seriously flawed.

We know also of the extent of the lobbying that has been directed at the politicians that may well have distorted their assumptions about the virtues of the private sector. Politicians are overwhelmed by reports, and opinions. How are they to judge which ones to trust. So I pity the politicians.

Think about the process of coming up with a manifesto. To “serve” us politicians must first “win” elections. The electoral calendar is relentless. Politicians are not experts. They are elected to represent us, and their level of knowledge is very variable. There are some who do have a strong sense of the importance of getting the best evidence they can access, in order to form their opinions, there are other s who are happy to find “stories” that seem to prove the points they wish to make. Manifesto making is kept under wraps, to ensure that good ideas are not filched by the opposition, Politicians and communications experts want to “win” and will focus their message on what “public opinion” is likely to support.

In the 2010 election that public opinion had been shaped for several years by an astonishingly compliant media. Lobbyists and researchers know what you would like to hear and that is what they tell you. The reports and statistics that seem to confirm the opinions you want to hold are the ones that find their way to your desk.

Nowhere in all of this is there the necessary challenge to false assumptions or prejudices. And I pity the voters. We get the stuff filtered through the media, the press, election leaflets, all boiled down to the point of being more or less meaningless, and without the benefit of balanced debate. Then we get the political theatre – like 2010 TV debates, which are an attempt at trying to present balance, but turn out to be a dangerous distraction, a performance where the appearance and voice of the actor counts for more than the message they are trying to convey.

Going back to the Conservative party literature that came through my door in 2010 there is nothing, nothing at all, that could have led me to believe that a full scale structural re-organisation, or increased role for the “market” in the NHS was in any way considered. 

 As I am writing this the petition to “dropthebill” is gathering signatures at the rate of over 10,000 an hour. The public begin to see what is happening. They are concerned and they are angry. They feel that a sleight of hand has been performed, and as more and more of the assumptions that lay behind the bill are openly questioned they feel that the government is also incompetent. This is too simple. It would be wrong to blame the chaos that surrounds this bill on Mr Lansley, or Mr Cameron, or even on the people who fed them the information that led them to conclusions we now question.

The Health service professionals have been galvanised by this bill. We hear that that there have been more extraordinary general meetings by the professional bodies than have ever previously been called. The professions now see the importance of finding their voice and using it. For the moment the focus is on this process of stopping or at least neutralising the harm that this bill can do. But that is not enough. What we need to do as a result of what we have learnt is to create forums and bodies that can analyse the real challenges that do face the NHS, and can work together to look for evidence based solutions.

Let us be realistic in our expectations of politicians. If we want them to pass good legislation that helps to resolve the problems that we see, we must accept that it is our responsibility to ensure that they have good information. Good government is a matter of partnership. We have to begin to play our role. We are all learning valuable lessons about the kind of government we want from this bad bill. We should apply these lessons to give ourselves better government.

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