18/05/2012
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Published on the LSE blog, 05 March 2012
http://blogs.lse.ac.uk/politicsandpolicy/2012/03/05/bad-science-nhs-competition/
The drip feed of pro-competition studies from Zack Cooper at LSE raises serious questions for the academic community and the public about what constitutes bad science and what to do about its politicisation. Recently, on 21 February in the columns of the FT, the Cooper and colleague Julian Le Grand warded off serious scientific criticisms of the studies with an ad hominem attack, categorising those in favour of competition as empiricists and those whose work is critical of markets in health care as intuitivists. In so doing they sweep aside decades of careful economic theory and evidence which shows why markets do not work in health services and distract the reader from the facts that their work is ungrounded and far from empirical. Their repeated claims that competition in the NHS saves lives and improves quality and productivity have no scientific basis.
In July 2011, Cooper and colleagues at the LSE press-released an unpublished paper to coincide with the prime minister’s announcement on the Future Forum which had been set up in response to deep public concerns about the Health and Social Care (HSC) Bill. These concerns resulted in the government suspending the legislative process for two months to undertake a ‘listening exercise’ with the public. The FT and The Economist put their paper centre stage in the HSC Bill debate. The authors were sufficiently persuasive for the prime minister to declare that “competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.” The study in question claimed that “using [acute myocardial infarction] AMI mortality as a quality indicator, … mortality fell more quickly (i.e. quality improved) for patients living in more competitive markets after the introduction of hospital competition (to the NHS) in January 2006”.
The major improvements in outcome after acute myocardial infarction can be attributed to improvements in primary prevention in general practice and in hospital care, including the introduction of percutaneous IV angiography. The government’s own cardiac Tzar, Sir Roger Boyle, was sufficiently angered by their claims to respond with withering criticism: “AMI is a medical emergency: patients can’t choose where to have their heart attack or where to be treated!” It is “bizarre to choose a condition where choice by consumer can have virtually no effect”. Patients suffering “severe pain in emergencies clouded by strong analgesia don’t make choices. It’s the ambulance driver who follows the protocol and drives to the nearest heart attack centre”.
The intervention that the authors claimed reduced heart attacks and was a proxy for competition was patient choice. In 2006, patients were given choices of hospitals including private for-profit providers for some selected treatments. Less than the half patients surveyed in 2008 even remember being given a choice, and only a tiny proportion made those choices based on data from the NHS choices website. If patient choice was one of the two key elements of competition, it wasn’t prevalent and rather than being derived from the authors’ data, it was assumed.
Crucially, even if patient choice had occurred it does not explain why heart attack mortality rates fell. There is no biological mechanism to explain why having a choice of providers for elective hip and knee operations surgery (including hospitals which did not treat or admit acute MI patients) could affect the overall outcomes from acute myocardial infarction where patients do not exercise choice over where they are treated.
The problem of data dredging is well known; if you repeat an analysis often enough significant statistical associations will appear. But the authors make the cardinal error of not understanding their data and of confusing minor statistical associations with causation. Deaths from acute MI are not a measure of quality of hospital care, rather a measure of access to and quality of cardiology care. At best, what the paper appears to show is not the effect of choice on heart attacks but that if an individual has a heart attack in an area close to a hospital and their GP is near the hospital, then outcomes are better, but such findings are not new.
Cooper’s working paper which the government cited as supporting their reforms was subsequently published in the Economic Journal. That it got through that journal’s peer-review process is perhaps indicative of the poor understanding of healthcare and routine data from reviewers of that journal. Our response to their flawed work was published in a peer-reviewed piece in the Lancet. They responded with mainly ad hominem attack and we again responded with scientific criticism.
Last week Cooper and colleagues were at it again with another working paper (as yet unpublished in an academic journal) that was once again miraculously timed to coincide with an important event; the prime minister’s summit on the NHS Bill. This time the authors claim that length of stay fell more rapidly in NHS hospitals experiencing greater competition and that the risk of cherry picking by the private sector made a case for risk adjusted price. Once again, the authors were careless with the data and the study design.
There are three problems with their analysis of the data: they seem unaware that lengths of stay differ between the conditions they examine; they ignore the political context in which the data was generated; and finally, they show little knowledge of the particularities of the conditions they include and how these will affect the data.
Cooper and his colleagues use the average length of stay for four conditions, elective hip replacements, knee replacements, hernia repairs and arthroscopies, each of which differs widely in lengths of stay. Arthroscopy is usually done as an outpatient and may not be recorded on hospital episode statistics. Hernia repair is usually a day case although the average overall length of stay varies by type of procedure and with median lengths of stay of one or two days. In contrast, hip and knee replacements have median lengths of post-operative stay of four or five days again depending on the procedures and morbidity, with average lengths of stay in 2010-11 ranging from 5.9 to 8.2 days for hip replacements and 5.5 to 5.8 for knees. (See the Information Centre inpatient and outpatient data)
Thus, if providers have switched to arthroscopies and hernia repairs or to operating on patients who are well and healthy they will appear to have shortened their pre-operative and post-operative length of stay to less than a day. So a provider’s length of stay will depend on the mixture of operations and mixture of patients and how far they travel. The authors appear to have made no attempt to examine differences in case mix and length of stay. This is a serious error.
Equally, the authors do not look at how clinical coding changed following the introduction of the tariff in 2006. Gaming, upcoding and diagnostic drift are widely recognised in research on the NHS in the 2000s, with providers seeking to improve and increase their payments through fraudulent billing and accounting. This will apply especially where hospitals are under severe financial pressures and have strong motivations and perverse incentives to change the coding procedures. Arthroscopy procedures, which previously have been coded as an outpatient activity or not at all (i.e. it would not have been counted as an admission), may now be recorded separately as a day case inpatient procedure. These changes in coding distort measures of productivity so that providers may appear to be more efficient as they appear to do more work than they actually do.
Finally, length of stay is also a product of a range of factors related to the conditions in their data; pre-operative work for hip and knee replacement needs to take account of rurality and patient fitness for discharge, especially if patients live alone and have other co-morbidities and complexities. Patients who live close to a hospital may come in as an outpatient, while patients who live some distance away may require overnight stays. The authors should also have looked at readmission rates; premature discharge can result in readmission. The authors have not attempted to examine any of these factors, and neither have they considered the effect of hospital concentration on their data.
Le Grand and Cooper call themselves ‘empiricists’ and all those that disagree with them ‘intuitivists’. Unlike scientists, however, they have made no ‘real life’ observations themselves from which they have generated their theories. They do not appear to have the basic understanding of clinical practice. They have not made predictions, tested their theories with experiments, or adapted their models to see if they can do anything other than provide one explanation of many that could be derived from historical data. Moreover, they ignore the factors that underpin the generation of data and the need to understand how it is constructed and shaped. Data dredging has resulted in statistical associations but association is not causation. Bad science makes bad policy and bad policy leads to careless talk. Careless talk will cost lives especially when it is used in support of the HSC Bill.
18/05/2012
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In a speech on exports and growth on 10th November 2011, David Cameron went “off-script” and revealed his government’s true agenda for the NHS. Standing in front of a Union Jack banner and the slogan “START UP BRITAIN” the Prime Minister told his audience of small and medium enterprise people at the BFI on London’s South Bank: “We have a growth review, led by the Chancellor and the business secretary, which ensures that every minister has to come to the table with proposals to cut regulation in their departments and come up with ways of helping business in their sector, helping them to grow.” Then he said: “From the Health Secretary, I don’t just want to know about waiting times. I want to know how we drive the NHS to be a fantastic business for Britain.”
He really said that. It’s here on video: “I want to know how we drive the NHS to be a fantastic business for Britain.”
That same week Hinchingbrooke Hospital became the first NHS Hospital to be franchised to a large for profit health care company — Circle.
The NHS is already big business and some of the costs are there for everyone to see. (Much is hidden). The NHS is haemorrhaging public funds to hundreds of companies through a range of services, legal, accountancy, catering cleaning, PFI and health care.
For the last two decades government policy has been to divert billions of pounds of NHS spending to for-profit corporations, including the multi billion pound PFI debt programme. Inflation-proofed PFI payments absorb around 15 per cent of hospitals’ budgets and the figure is rising. No wonder facilities must close, staff are being sacked and patients turned away.
These sources of profit have not always existed. Viewing the English NHS and other European health systems as unopened oysters of profitable opportunity, corporations in the USA and Europe have worked long and lobbied hard to open public health care systems to the market.
Ten years ago, the United States trade delegation put it like this: “the US is of the view that commercial opportunities exist along the entire spectrum of health and social care facilities, including hospitals, outpatients, clinics, nursing homes, assisted living arrangements, and services provided in the home.”
Today market predators want more than NHS funds. Claiming, as they have always done, that buying from them will save public money, corporations now want the concession to charge and sell private health care to NHS patients and introduce charges for health care and private health insurance.
Politicians have offered no answer to the patient protests and ‘save our hospital’ campaigns that commercialization has generated so far. Protest will escalate as the new policy hits home. So, just as Europe’s bankers have got a technocrat to destroy Greece’s public sector, including its national health service, English politicians are distancing themselves from the fall-out from NHS privatizations by vesting responsibility in a hands-off board.
Commercial interests and right wing ideology lie behind the Health and Social Care Bill (the “secretary of state Abdication Bill” as David Owen, a former health minister, calls it). The Bill abolishes the Secretary of State’s duty to provide comprehensive health care and dismantles the bodies created to deliver it. In their place it introduces the structures and systems of patient and service selection and patient charges. Not patient choice but choice of patient will be the order of the day.
All of this is unpacked in a series of briefings for the Lords by health professionals.
In a two-pronged approach, public health services are transferred from the NHS to local authorities with the functions of both so poorly defined as to bring utter confusion to patients’ and citizens’ rights. The scene is set for a re-run of the transfer in the 1990s of long-term care responsibilities to councils when funding was privatized through means testing and charges. Worse: it’s returning to pre-1948.
Not everyone will be covered for all services in the new “NHS”. The government has gone to great lengths to ensure that the newly created commissioners of NHS services (the so-called clinical commissioning groups, CCGs) do not have responsibility for comprehensive care for all residents in one geographical area.
Instead the commissioning groups will able to recruit patients from GP lists across the country. This is not patient choice. It is commissioning groups choosing patients and purchasing what the commissioning groups deem to be the appropriate NHS cover. Selection will be the name of the game.
David Nicholson, chief executive of the NHS Commissioning Board, made this absolutely clear when he advised patients to shop around across the country for their GPs based on the range of services offered. (See briefing number 4: clauses 3, 4, 6 & 7).
Clever informed middle class patients may be able to shop around for the best choice of health plans and services, just as some now do for utilities. But there is no guarantee of success, as anyone who tries to navigate electricity, gas, telecom and rail providers know. And try making a complaint! The information is too dense and complex, and the costs too high for the average person to understand what is on offer from complex health care packages.
Patient choice is the great con. Patients won’t choose. They will be chosen on the basis of their risk profile. Many of the health care companies now active in the UK manage financial risk by placing time limits on care, introducing cost deductibles, copayments and restrictions on the number of GP visits, hospitals visits, operations. All are commonplace in private health insurance. They are the spectre of what is to come if the Health and Social Care Bill is passed.
The only hope is the House of Lords. So far peers have signalled general dissatisfaction with ill-specified transfers of fundamental ministerial powers. Lords Owen and Hennessy tabled an amendment that made precisely this point and although it was defeated it helped put other peers on notice that forensic examination of the Bill was needed on constitutional grounds.
With all party agreement on 3rd November the House of Lords agreed that Clause 1, which sets out the duties of the Secretary of State, would be paused and taken off the floor of the house for further deliberation until the Bill returns to the House at the Report stage. It is Clause 1 that severs the duties of the secretary of state to his people to provide and secure comprehensive care. (See our briefing here).
Clauses 4, 6, 7, and 10 give extraordinary discretion to the new corporations with powers to select patients and services.
The next few weeks are critical for the Lords. It is up to health professionals and the medical colleges to help them unpack the Bill and follow the amendments as the Lord scrutinize and debate the Bill clause-by-clause through the committee stage. Peers are taking this Bill seriously and giving it the scrutiny that the coalition’s majority prevented in the Commons.
The NHS will be abolished if the Bill is passed in the Spring. Were that to happen our immediate task would be to draft a short bill to restore it.
The briefings show that the structures and functions crucial to protecting our comprehensive health care system are being systematically dismantled. The analysis goes to the heart of what is needed to restore the NHS and it goes to the heart of the government’s lack of candour about the true purpose of its reforms.
Originally published on OurKingdom:
http://www.opendemocracy.net/ourkingdom/allyson-pollock-david-price/abolition-of-nhs-that’s-what-is-happening-0#disqus_thread
18/05/2012
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“Services do not need to close; that always has been and remains a political decision,” writes health expert Professor Allyson Pollock for Channel 4 News.
The UK government is proceeding with its plans to abolish the NHS and is implementing its new system in advance of the highly controversial Health and Social Care Bill becoming law. This is profoundly undemocratic, and combined with demands for £20bn worth of efficiency savings represents a looming catastrophe for public health care.
The efficiency targets are without precedent, according to the House of Commons health select committee. No country in the world has achieved a real terms decrease of £20bn in its health budget in just five years. Nevertheless, the government is allowing chief executives and finance directors to press on with a policy of service, ward, and hospital closure.
It is also continuing a policy of hollowing out the NHS as the government allows CEOs to use the excuse of deficits to offload services on to the private sector and risks of not being treated onto patients. Hitchingbrooke NHS trust hospital has been contracted out to Circle, private patient bed numbers increased in Maidstone, Kent, and US health care company, United, allowed to run primary care trust commissioning along with other companies.
These measures will add to, not reduce, costs to the tax payer because scarce resources will be squandered on redundancies, market administration, billing, management consultants, and payments to owners and lenders. As a result there will be growing disparities in access to health.
Grist to the mill
This is all grist to the mill so far as the government is concerned. It hopes that NHS disinvestment and public expenditure cuts will force through the market changes it wants.
The King’s Fund report today provides ready ammunition for service closure and more marketisation. Based on interviews with finance directors who make a case for cuts based on deficits, and in spite of reports of rising waiting lists as a result of cutbacks and local deficits, it argues for more service closures. However, what is not reported is that deficits are artificial and the product of an arbitrary market-driven pricing system, which is creating winners and losers among trusts. What is not reported is that rising emergency or unplanned admissions are due to cuts in other parts of the system. In fact, services do not need to close; that always has been and remains a political decision.
The real measure of performance should not be waiting lists but the extent to which need is being met and access and equity are being protected. But the government’s NHS reforms consign this approach to history: the bill repeals the founding duty of the secretary of state to provide comprehensive care to all his citizens.
Easy retrenchment
That will make a lot easier the policy of retrenchment that is even now being introduced. The surgeons this week in The Guardian were reported as writing to secretary of state for health Andrew Lansley about how eligibility for surgery is already being changed to exclude those with a genuine need for NHS care. Meanwhile, PCTs continue to draw up lists of procedures that will no longer be funded. Of course, this is one way to tackle waiting lists: if you are not eligible for care you can’t be recorded as waiting for it.
The decision to axe accident and emergency departments, wards, hospitals, and community services and make NHS staff redundant because of deficits is part of the same process.
Matters can only get worse if the bill becomes law. The evidence shows that providers and payers operating under competitive systems must select their patients and services in order to manage the risk of exceeding their budgets. Will the pause simply allow closures and chaos to mount unchecked or will decency and sense prevail? The answer lies in the hands of the Lib Dems and Labour; let’s hope they rise to the challenge.
Channel 4 News. Wednesday, 24 April 2011.
http://www.channel4.com/news/kings-fund-report-ready-ammunition-for-service-closure
18/05/2012
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Light-touch regulation of marketised health services, with the PM’s encouragement, has created horrors like Cannock Chase.
Originally published in the Guardian’s ‘Comment is Free’ on 18 March 2009.
Only days ago Gordon Brown was apologising for the global market financial failure which resulted in a taxpayer bailout to the tune of several hundred billion pounds. Today he is apologising for the suffering of patients hit by the scandal of “appalling” patient care at mid-Staffordshire NHS foundation trust, which includes Stafford and Cannock Chase hospitals. But he does not own up to the role his own market policies have played in this horror story.
The government has marketised the NHS, replacing an intergated public service with a market run by “purchasers” and commercially oriented providers under the same “light touch” regulatory system we have become familiar with in the banking sector. But ,according to Brown, bad care and neglect in mid-Staffordshire were the results not of this business model but of “low standards of management”.
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