Friday, July 06, 2007


The NHS is not perfect. It needs reforming. (It needs more money, reply the doctors). Tony Blair puts in more money. Lots of it. But like Mrs Thatcher before hime he wants to be sure that the money is spent wisely. There must be closer oversight of how the money is spent.

So, one of the 'reforms' of the NHS brought in by the Labor government was the introduction of a greater regulation of the service. Two of the most prominent regulatory bodies were dubbed NICE and NASTY. NICE was an acronym - The National Institute for Clinical Excellence; NASTY was an insult for CHI, the Commission for Health Improvement, now renamed the Healthcare Commission. NICE's remit was to ensure the practise of evidence based medicine, though it quickly became apparent that its real purpose was to ensure that what doctors did was cost effective. Even then its real target was the new expensive medicines that pharmaceutical companies want to introduce.

There are plenty of practises paid for by the NHS that have no evidence base. This includes most of surgery, most of general practice, most of dermatology, almost all of psychiatry and virtually all of alternative medicine. A huge amount of money is spent on homeopathy for which there is not a slither of evidence and indeed not even a sensible rationale, but because it is the favored method of treatment for the Royal Family it is regarded as untouchable. When NICE began the UK spent £167 million per year on cancer chemotherapy compared to £2.2 billion on indigestion remedies. Yet the major attack of NICE has been on anticancer drugs. In fact, rather than change the way doctors have uselessly prescribed in the past they have concentrated on the really expensive drugs which may be needed for relatively few people.

CHI was instituted to improve standards. How do you improve standards without inspecting what the standards were to start with? Nobody likes being inspected, so CHI got a bad reputation from the outset. In fact, in pathology we had been doing this for years. Clinical Pathology Accreditation was the brainchild of pathologists and inspections were performed by pathologists. Reports were confidential to the laboratories concerned and were used as weapons against management to improve facilities.

The government developed the star system for hospitals which was policed by CHI. In principle hospitals had to meet certain targets, and getting more stars was rewarded with extra money. The problem was that the targets were surrogates and the hospitals (and other Trusts) gamed them, They achieved the target without making the improvement that the target was a surrogate for. So more money went into anti-gaming activities.

You can see how bureaucracy increases. Then there is choice. With the bureaucracy burgeoning someone calls for the discipline of the market. We must have choice. But it's a strange sort of choice. Most hospitals are 95% full, so there is no enthusiasm for increasing market share and nobody believes that the government would let a major hospital go to the wall. So the "choice" is a mirage.

There may be room for some rationalization, but very few patients want choice. For example Salisbury is a pretty market town in Wiltshire. Its (very new) hospital serves around 125,000 people in several rural communities. It has difficulty in making economies of scale because of its size. Compared with its nearest neighbors, Southampton, Bournemouth and Bath, each serving populations of half a million it is pretty inefficient. A hard nosed businessman would close Salisbury and transfer the patients to the surrounding hospitals, each about 30 miles away, but 30 miles takes at least 45 minutes to drive. There are already small towns out in the sticks that are 30 minutes from Salisbury. Imagine the outcry if someone announced that Salisbury Hospital was closing.

Given the choice, the people of Wiltshire would rather have a good enough hospital in Salisbury than a superb facility in Southampton. They don't want a league table of hospitals. What they want is a hospital within easy traveling distance that meets the standard benchmark of qualities. It's not me saying this, recent research has shown exactly this.

What conclusions do I draw from these impressions? It really doesn't matter how you organize your health care system, there are always going to be intractable problems and someone is going to complain. However, most people are satisfied with the system that they've got and wouldn't change it for what somebody else has got. We can learn from each other, though, and we should not be put off by slogans like 'socialized medicine' and '41 million uninsured'.

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