I have never heard one politician use the word ‘evidence’ so persistently, and so misleadingly, as Health Secretary Andrew Lansley defending his NHS reforms. Since he repeatedly claims that the evidence supports his plan, let’s skim through what we can find on whether GP consortiums work, the benefits of competition, and the failures of the NHS.
Are GP consortiums better than Primary Care Trusts for commissioning? There have been fifteen major reorganisations of the NHS in thirty years. We’ve had GP fundholders, GP multifunds, primary care groups, primary care trusts, family practitioner committees, purchasing consortiums, and more. After all this change, lots of data should have been gathered on the impact of specific strategies.
In reality, few of them were properly studied. Here are four papers on GP fundholding, which is broadly similar to Lansley’s GP consortiums. Kay in 2002 found it was introduced and then abolished without any evidence of its effects. In 2006 Greener and Mannion found a mix of good and bad but no evidence that it improved patient care. In 1995 Coulter found nothing but gaps in the evidence and no evidence of any improvement in efficiency, responsiveness, or quality. Petchley found there was insufficient data to make any judgement. Lansley says he is following the evidence. I see no evidence to follow here.
Next, competition. Andrew Lansley has repeatedly denied that he is introducing competition on price. This is disturbing behaviour: his Bill explicitly introduces price-based competition – it’s in paragraph 5:43 of his ‘NHS Operating Framework’.
Does variable-price competition work in healthcare markets? Working from first principles, markets for healthcare in which people compete on price as well as quality might be expected to produce lower-quality healthcare, because prices are easy to measure, while quality, in healthcare, is surprisingly difficult to measure: so quality suffers.
It’s hard to research this kind of thing, but even the evidence on fixed-price competition – where you compete on quality – is mixed. There are various ways to assess it. Often people choose an outcome – like the number of people who survive a heart attack – and compare this outcome in areas of more intense or less intense competition. Sometimes competition makes things worse, sometimes better.
For variable-price competition, which is what we’re facing, things don’t look good. Its introduction in New Jersey in the 1990s was associated with a worsening death rate from heart attacks, while in the UK, stopping variable-price competition was associated with improvement. These aren’t clean, easy interventions to assess, but despite his using the word repeatedly, again the ‘evidence’ does not support Lansley here.
Lastly, there is the justification for reform. Both Lansley and David Cameron are – rather shamefully – overstating our mortality figures, in order to claim that the NHS is failing. Everyone wants more improvement, but money or a structural change does not produce an immediate and visible reduction in mortality from one thing, so it’s hard to use these figures to pin blame or credit on anyone; interventions take time to have an impact, especially on things that kill you slowly; and NHS treatment isn’t the only factor affecting how many people die of something. But since you’re interested, to take just two things: mortality from cancer has fallen every year since 1995, and heart attack deaths have halved since 1997.
The government claims that our rate of death from heart attacks is double that in France, even though we spend the same on health. Health economist John Appleby instantly debunked this claim in the BMJ, and his piece will become a citation classic. From static 2006 figures in isolation, the government is right. But the trajectory of improvement in the UK is so phenomenal that if the straight line continues – as it has done for thirty years – we will be better than France within a year.
I’m not in favour of – or against – anything here: genuinely, all health-service administrative models baffle and bore me equally. But when Andrew Lansley says all the evidence supports his interventions, as he has done repeatedly, he is simply wrong. His wrongness is not a matter of opinion, it is a fact, and his pretence at data-driven faux neutrality is not just irritating, it’s also hard to admire. There’s no need to hide behind a cloak of scientific authority, murmuring the word ‘evidence’ into microphones. If your reforms are a matter of ideology, legacy, whim and faith, then like many of your predecessors you could simply say so, and leave ‘evidence’ to people who mean it.