"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Wednesday, 24 August 2011

Cost of diabetes

I am incubating a monumental rant over the government's policy to blame sufferers of long term conditions for the current problems with the NHS (problems which have actually been caused by this government). This rant will have to fester a little more before I will let it out. Until then let me just explain about the cost of diabetes.


There you go: simple isn't it? Complete idiots think that the cost of diabetes is in the drugs. It isn't, and it only takes a little thought to realise why. When diabetes is well controlled - whether type 1 or type 2 - the patient is a fully functioning member of society, no one will know that they have the condition. Indeed, many colleagues do not know that I have type 1 diabetes. The only visible sign of the condition is me injecting insulin before I eat and I have become adept at doing the injection surreptitiously under the table in restaurants (all you need to do is wait for the food to appear - people naturally spend a couple of minutes inspecting what's on their plate and not at you).

A well controlled diabetic is no different to a non-diabetic when it comes to contributing to GDP. The cost of diabetic drugs is fairly small. NHS Information Centre says that last year it was £725m. There are 2.5m people with diabetes (10% are type 1), so that means less than £300 per person.

I have written before that the cost of the drugs I take is small - a few quid a day. However, I only listed the insulin that I must take. I also take other medicine which are preventative: statins and two types of hypertension drugs one of which I am told protects me from kidney damage. These drugs cost pennies per day. The fact that they are preventative is very important because the real cost of diabetes is the cost of the complications from poor control. Long term high blood sugar leads to blindness, nerve damage (leading to amputations), kidney damage (needing dialysis or transplant) and cardiovascular disease. This is where the cost lies. Secondary to this cost of treatment is the monitoring once you show signs of a complication to determine when intervention is needed.

For example I have retinopathy where the blood vessels on my retina are weak and liable to burst. Since this was diagnosed 20 years ago I have had retina clinic appointments every 6 months. I have also had many tens of thousands of laser burns on my retinas to try and prevent vessels growing too big and when one did, and burst, I had an operation where the gel in my eye was removed, my retina cleaned of the bleed and the vessel sealed. That operation lead to me getting a cataract, so I have had cataract operations too. These interventions cost many tens of thousands of pounds: as I said, it is the complications that cost.

Incidentally, for the last 5 years I have been subject to "patient choice". Every six months my GP and my local optician send me a letter telling me that I need to have my retinas screened. Every six months I politely phone them up and tell they to take me off their marketing lists because I am seen every six months by a consultant at the hospital retina clinic. (I don't want to upset GPs or opticians, but honestly, do you really think you know more about my retinas than the specialist at the hospital?) Neither the GP, nor the optician, have shown any sign of removing me from their marketing list. Beware, AQP will open the floodgates to far more companies touting for business like this.

Today the NHS Information Centre published figures of the cost of diabetic drugs. Inevitably these figures have been misreported.

Diabetes prescriptions now account for 8.4 per cent of the entire NHS net bill for primary care drugs in England.
These drugs - if used correctly - will prevent a large range of complications and hence reduce demand on the NHS in the future. We should not focus on the cost of these drugs now, and instead we should focus on the cost of diabetes if we didn't spend this money.

Choice and Competition

Can choice and competition work in the NHS?

NHS funding is being cut so is it economic to have a choice over everything? Choice costs. For example, if you choose the exact day (and time of day) to have your cataract replaced, the provider has to have a timeslot available for you to choose it. The provider cannot guess what time you will choose and consequently to plan ahead (and ensure there will be the staff and theatre time) they have to provide over-capacity. They also have to have over-capacity to accommodate patients who switch providers, again, something they cannot accurately predict. This over-capacity means that more facilities and staff will have to be available than is actually needed, and this has a cost.

In their evaluation of the London Patient Choice project, Picker Institute says:
"Choice is dependent on the availability of beds and staff, so providers were encouraged to expand capacity and improve the management of existing resources to enable patients to exercise choice. Funds were made available for this purpose and several treatment centres specialising in elective surgical procedures (e.g. hip and knee replacements or cataract operations) were established."
The important point here is that hospitals taking part in this programme were given funds to create the extra capacity. Patient choice is not possible without this capacity, nor the funds to provide it.

The LPCP is used as"evidence" that patients want choice because in the project two thirds of patients offered chose took up the offer. However, when you look at the details, it is more surprising that a third did not take up choice. The reason is that in the project patients were given access to Patient Care Advisers (these are not available to current NHS patients) to help them have all the information they need to make a choice; they were also given free transport to the alternative hospital (one patient even chose to go to an overseas hospital). But crucially, the patients who took part in LPCP were had already waited over six months. It is rather surprising that anyone would not take up the offer to join a shorter queue, but a third did.

Two facts: the patients involved had waited more than 6 months and the hospitals involved in the pilot were given funds to increase their capacity. This raises the question: if the hospitals had been given the extra funding before the pilot, would this have prevented patients waiting more than 6 months and hence removed their desire to choose to use another hospital?

In a totally free market there are ways to fiddle such a system to make it more efficient. I used to work in computer training and when I started the job I looked at the company's brochure and noticed that the week-long courses I gave (I was the only trainer of those subjects) were often in two cities on the same day. I pointed this out to my manager and he replied that I would give the course that had the most customers, the customers who had booked for the other city would be told that "their course was full" and be given a discount to attend the course in the city where I would be. This system meant that during the year I worked for that company I never had a week when I was not training (from the numbers of people I trained, I estimate that the company took in £250,000 training fees; not bad considering that by the time I resigned I was on £23,000).

The problem is that the free-at-the-point-of-use system is not a free market, so it is not possible to use a discount to persuade a patient to choose another time. So if we have real choice of providers those providers must run at excess capacity. The cost of this over capacity is money that could be spent on more healthcare, and as we suffer more rationing (that no one voted for) there will be political pressure for providers to cut costs. My guess is that commissioners, recognising that the unpredictability of patient choice is a major source of inefficiency and will quietly remove patient choice.

[On Twitter I suggested using bed occupancy as a measure of this over capacity. Unfortunately health policy wonks misunderstood the point I was making and veered off in another direction saying that the number of beds in NHS hospitals are reducing. So what? AQP has not started in earnest yet and this reduction is being driven by NHS cost cutting.]

It is also often stated that "choice" improves quality. Again, I think that this is not possible. Looking through the board papers of my local hospital I see that a consultant has been asked to leave. The reason is the high number of letters of complaints about his attitude to patients (interestingly, not his clinical ability). The hospital did not count the number of patients using that clinic and use that data to decide whether to sack the "low quality" clinician. Of course not, there is a waiting list so that means there are already too many patients (d'oh!). Patient complaints raised the quality of that clinic, not patient choice.

If I get a poor service from, say, my GP and I decide to register with another GP, will that raise the quality of my previous GP? No, of course not, I am merely one patient. Do I now want to raise the quality of my previous GP? I have a new GP who I am happy with so the quality of the old GP is of no interest to me - why should I care? Of course, over time there may be other patients who decide to move away from that GP, but the important point is that it is over a length of time. It may take months or years before a threshold is reached when the practice realises that that particular GP is simply not popular. During this time more patients will get a poor service. Is it acceptable to allow patients to have a poor service over a long time?

The Competition and Co-operation Panel produced a report earlier this year on Any Willing Provider. In this they give the following graph as their "proof" that choice raises quality:

They say:
"adverse news about the quality of care at a particular hospital can also have a significant short-term impact on patient referral patterns. For example, in early 2010, shortly after the CQC’s findings of ‘systematic failings’ at Basildon and Thurrock NHS FT was publicly reported, there was a short, sharp decline in patient referrals for routine elective care"
Fine, there was a "short, sharp decline" but this is no proof that quality has changed at Basildon and Thurrock: after a couple of months patients returned! Why did they return? Well the CCP tells you clearly in the title of the graph "change in patient referrals for routine elective care following adverse publicity over quality standards", that is, once the publicity stopped, the patients returned, they didn't return because quality improved.

During those few months when the referrals declined staff will still have been employed, adding to the trust's costs, and since many electives are paid through payment-by-results there would be no income for the lost patients. So the hospital will make a loss due to this bad publicity. This is hardly the best way to invest in better quality.

Competition and choice are extremely blunt tools. When it comes to healthcare we are right to demand the best, and to get this every provider must be of high quality. Do we really want to stake our lives on blunt, largely ineffectual mechanisms to raise quality? I think not.

Thursday, 11 August 2011

What we teach our kids

We do not teach our kids to work hard, to develop their abilities and be good at what they do. Instead, we teach our kids that the best way to the top is to trample on weaker people. We are told that competition is king, yet for every winner it creates it produces a large pile of losers. We tell our kids that the only way to improve themselves is through a long list of beaten competitors. It is a bankrupt philosophy for a bankrupt country.

Over the last three decades we have seen the rise of predatory private equity funds, companies whose sole aim is short term asset stripping. They treat company pensions as an asset of the company, an asset that they can exploit, rather than the future of the staff. They have a short term attitude that the sum of the parts is more than the value of the whole. They break up companies for an immediate profit even when the long term profitability of the company is better when left intact. How can we teach our kids that working hard is important, when we see that the reward for that work can be exploited by predatory private equity, buying up your employer, stealing your pension and making you redundant?

Small companies are being brought to the brink of bankruptcy when the larger companies they supply decide to change payment terms so that invoices are paid months later than before. The large companies do this because they can. How can we teach our kids fairness, when businesses behave in such underhanded ways merely because their size allows them to be bullies?

And now the government is doing the same thing. We are told that Monitor exists to stop "anti-competitive behaviour" and in the Open Public Services white paper we are told that companies will have a right to challenge commissioners over the provision of public services. We see that even if a public provider is doing a good job, providing a service that the public want and appreciate, it may lose its contract to provide the service simply because a private company says that it would like to provide the service instead. How can we teach our kids that if they work hard and become the best they will be rewarded, when the government says the reward for hard work in public services is for a private company to take over the service, employ fewer staff and pay them less?

We see people making vast amounts of money by simply moving money around. Hedge funds and investment banks make nothing, they simply take money from one place (perhaps invested in company stock) and move it to somewhere else (perhaps government bonds) and then, when the time is right, move it back again. No hard graft, no innovation, no product made and sold; just moving money around and making vast amounts of money doing it. We see that one favoured way of making money – short selling – borders on dishonesty: the short seller sells a security they do not own hoping that they can buy it back at a lower price before they have to return it to the lender. we see the effect of short selling for profit as it devalues companies and the pension funds - our pensions! - holding the stock. How can we teach our kids honesty, when short sellers show that so much money can be made by selling things you do not own?

It's about time we started teaching our kids correctly: that hard work and using our abilities is rewarding. But for our kids to believe us that this is true they have to see results that prove the assertion, and we have to prove that doing otherwise is not rewarding. Sadly, hard work does and will continue to result in stress, poor pay and poor conditions leaving us open to exploitation. The government's plans to reduce our state pensions (or make us pay more for smaller public service pensions), and their plans to ration our healthcare when we are in our old age, shows that they do not acknowledge that hard work should pay. We should have used the financial crisis to rid ourselves of the high rewarding something-for-nothing occupations, but we've flunked it and it will take another generation before there is an opportunity to try again.

Wednesday, 10 August 2011

Rank Hypocrisy

Last year the government issued all Coalition MPs with a list of stock answers that they could parrot when asked about Lansley's NHS re-organisation. The government listed what they called "myths" and gave the government's response to each. It is now becoming apparent that most of these "myths" are going to happen. Take for example "Myth 6" and "Myth 7":
Myth 6 GP consortia will be forced to use the private sector
It will be up to GP consortia to decide their own arrangements.

Myth 7 Every NHS service will need to be competitively tendered.
Our plans for ‘any willing provider’ are precisely the opposite. Competitive tendering means identifying a single provider to offer a service exclusively. ‘Any willing provider’ means being clear that a service needs to meet NHS standards and NHS costs, and then allowing patients to choose themselves wherever they want to be treated. It is designed to avoid the need for costly tendering processes, unlike Labour’s ‘independent sector treatment centres’.
First, let's address "Myth 7". The government claims that services will not be competitive tendered and that patients will be able to choose "any willing provider". However, we learn today from Pulse that:
"NHS East of England plans to auction off £300m of services to GPs, private companies or a combination of the two, in pathways including respiratory and musculoskeletal medicine."
There is no patient choice at all, once these services have been outsourced patients will have to use them. This is simple, unadulterated privatisation of these services (showing that "Myth 6" is true, GPs will have to use the private sector) through competitive tendering ("Myth 7" is true because these services are being "auctioned off").

GPs are rightly concerned, Pulse reports:

"Dr Brian Balmer, chief executive of Essex LMCs and a GP in Chelmsford, said: ‘A lot of our GP commissioners don't know anything about these plans. The SHA's commercial wing these days is very, very ambitious. They are keen to be the first to do these dramatic things that could see us turn into an American-style health service that we can't afford and that will harm patients.'"

Where are the Coalition MPs who blindly parroted the Coalition line at the beginning of this year? How can they vote for the Health and Social Care Bill at the Report Stage at the beginning of September now that the hypocrisy of the government is abundantly clear?

I have addressed most of these "myths" on my other site NHS Futures (including "Myth 6" and "Myth 7"). 


The government's response to the Future Forum says:

"Therefore, we will outlaw any policy to increase or maintain the market share of any particular sector of provider. This will prevent current or future Ministers, the NHS Commissioning Board or Monitor from having a deliberate policy of encouraging the growth of the private sector over existing state providers – or vice versa."
So if East of England plans to increase the proportion of private sector providers in care pathways, that will contravene the statement to "outlaw any policy to increase or maintain the market share of any particular sector ... prevent ... a deliberate policy of encouraging the growth of the private sector". What is Lansley doing about East of England's auction?

Saturday, 6 August 2011

Our safety at stake in Lala land?

The 999 service is a lifeline to all for us, but in healthcare the ambulance service is expensive and open to abuse. Such abuse is often not intentional, how do you know whether your condition is an emergency? You are not trained to make such triage decisions. According to the NHS Information Centre the ambulance service receives almost 8 million 999 calls per year of which 2.5 million (32%) are classified as urgent rather than emergency and 37% of Emergency Department attendances are classed as "minor" problems. Clearly there is a potential issue that non-emergency calls are delaying access to emergency calls, and their is an issue of cost.

This is the reason for NHS Direct, if there is any doubt whether the condition is an emergency, you can call 08454647 (remember that number!) and a trained clinician will advise you. Of course NHS Direct is more than that, their clinicians will advise you on less urgent conditions too: support for patients with long-term conditions, pre and post operative support for patients and help and advice during health scares (like swine flu). Their primary aim is to give you advice which will ultimately mean that the NHS will work more efficiently and effectively by making sure that you get the most appropriate treatment.

NHS Direct was always intended to be an initial solution, and in 2009 the previous government commissioned pilots to extend the service with closer integration with urgent care providers and to use a software system called NHS Pathways. This new system was piloted in four areas of England to assess the effectiveness against NHS Direct. In 2010 the new government - before the assessments were completed - announced that the new NHS 111 service would be rolled out to the entire country. Sadly, this service is yet another one that the government wants to privatise by opening up to other providers.

Last year there was a fuss when it became apparent that the government wanted to close NHS Direct, and as a result of the outrage the service was given a reprieve. But like everything with this weasel government, the "reprieve" was only partial because the government merely said that NHS Direct would be expected to be just one of several providers of the new NHS 111 service. Yes, that is right, the government thinks that there has to be competition. Bizarre? Indeed. We live in Lala land ruled by people who think that nothing can work without enforced and inappropriate competition. My anger is not just with the government, Labour has accepted this situation: they thought the reprieve was a result. In fact it was a result: it was exactly what the government wanted, you cannot have competition without competitors and NHS Direct is, and always was intended to be, one of the competitors in this contrived competition.

Let's just look at the headline issue. After April 2013, the 08454647 number (did you remember it?) will be replaced with the 111 number (in the government's documents referred to using the management-speak as 3DN or a "3 digit number"). The government is making a big thing about this, and for good reason, why was NHS Direct given the entirely forgettable 08454647 number in the first place? In fact the policy to replace 08454647 with 111 is not Lansley's bright idea anyway (he does not have bright ideas) the last government intended to make the change too (as this document from OFCOM in July 2009 shows). I will leave it up to the conspiracy theorists as to why the Department of Health under Labour chose to allow NHS Direct to be created with a number that was not fit for purpose. However, the difference between a Labour government replacing NHS Direct with a 111 service and a Conservative government doing this is not simply the number (nor the new services that NHS 111 will deliver), it is who will provide the service. Lansley says that there has to be competition over who will provide the 111 service in your area. Lala land indeed.

How big is each area? Well, it would be plain stupid to make each area the size of the clinical commissioning groups (currently the median population size is 170k, but there are many who cover 100K or less, and one that covers just 14,000). Ultimately, it will be the CCG who will pay for the service and so we are in the bizarre situation that the CCG commissioners will have to pay for a service that they cannot commission individually because they only sensible way to provide the services is with other commissioners that have been contrived. At the moment the 111 services are to be rolled out on a Strategic Health Authority basis, and it is each SHA has to decide ("with full support of local Clinical Commissioning Groups and PCTs") who will provide the service.

Bizarrely, the we will move from the national service of NHS Direct (national: so people are familiar with its services and how to use it) to more localised ones so if you use 111 in a different area you'll have to re-learn what services they have and how to use them. (You, dear reader, may find this trivial, but will everyone? The service has to work with everyone.)

David Flory, Deputy NHS Chief Executive says:
"The NHS Operations Board also re-stated the need for commissioners, led by local clinicians, to take the lead in planning for the roll out of NHS 111, and developing a comprehensive directory of services, and associated referral protocols to underpin the service. We should remind you that the Department will not mandate specific content or software for NHS 111. This will be for local commissioners to determine, with appropriate clinical advice and support."
Remember that the NHS 111 services (like NHS Direct) will provide both a telephone service and a website. It makes sense to have local clinicians involved in the design of the telephone service since the service will use local providers: ambulance services, out-of-hours services (ie private GP companies who do the service that GPs used to do before the last Labour government privatised this service), GP "in hours" home visits (yet to be privatised as the government's "urgent service") and hospital A&E. But NHS Direct also provides a website with a symptom checker. It makes no sense whatsoever to have separate local websites to do this work, yet that is implicit in Flory's statement that "the Department will not mandate specific content or software for NHS 111".

I regularly read the websites of local hospital trusts across the country and the most irritating aspect is that they are all different, with different ways to get the same information. It is an issue for someone with reasonable eyesight, but what about someone with partial sight or no sight (and relies on screen readers)? Why hasn't someone come up with a brilliant idea like a best practice website design that all hospital trusts have to follow? NHS Choices and NHS Direct are both national systems that give a standard way to access their information regardless of where you live in the country. Yet Flory is now suggesting that SHAs can award the NHS 111 service to anyone using any "content or software". This is mandating fragmentation and confusion.

The NHS 111 telephone service will involve many providers to work together to give a single, comprehensive system within your local area. This is not an easy task, especially as we move to an NHS that is driven by competition rather than collaboration. And to make matters worse, Flory is introducing a deadline on awarding the contracts for these local versions of NHS 111 that GPs are calling "crazy". GPOnline says:

"strategic health authorities have been given seven weeks to tell the DoH how and when they plan to roll-out NHS 111 hotlines across their area ... one senior GP warned the deadline was 'crazy' given that the pilot NHS 111 schemes across the UK were either incomplete, or yet even to begin"

This behaviour is symptomatic of this government: fragmentation of a service that currently works (and was developing), privatisation, enforced unworkable deadlines resulting in an implicit designed to fail outcome. If this is happening to the websites of the new NHS 111 services, what will happen to the telephone services and what will be the knock-on effect to the 111 "urgent service" and ultimately the 999 service? Lala land.

(Updated 2011-08-07 after comments on Twitter)