The Needle

Yes, the NHS is facing some weighty issues

2008-01-24T10:59:00.001Z

Whenever you hear a politician make an announcement, there are two things that should go through your mind. Who wrote the speech and who was the adviser behind this latest initiative. With recent health policy announcements it’s often difficult to tell who the speechwriter was. Style is overtaken by substance because the Department of Health farms out its speechwriting to an array of writers who are ready and waiting to do its bidding. So bland is the order of the day.

Advisers are a different matter. They go in and out of favour according to who is in the hot seat at Number 10. The current supremo is the effervescent Greg Beales – a former management consultant who cut his teeth under Blair but survived to tell the tale and is now indentured to Lord Brown for the next year at least.

Mr Beales is an affable chap who is clearly very clever. Listen to him talk about the future of the NHS and you begin to believe in a world where commissioning works in harmony with payment by results and fully-informed patients take responsibility for their health. The NHS constitution, he says, should operate like a contract that offers a guarantee of service levels as long as certain conditions are fulfilled. If you fail to turn up for three GP appointments in a row, you can no longer expect to be treated within four hours when you land in A&E with appendicitis.

The desire to tailor the NHS according to need and personal responsibility is understandable given shrinking NHS budgets and growing expectations. However, Mr Beales should take care when he starts on the blueprint for the NHS Constitution. He might kick off with missing GP appointments but where does it stop? Is he really going to suggest that the clinically obese risk losing their rights to treatment unless they sign up to personal weight-loss programmes.

The irony is that his talk of weighty issues facing this NHS comes painfully close to home. He is not a slim man by any measure and it’s very difficult not to question his commitment to a healthy lifestyle. Does the lure of a Big Mac grab him after a late night putting the finishing touches to the NHS master plan? Perhaps that’s why someone suggested he take a back seat at the launch of the government’s obesity initiative.

Do not rely on national health screening

2008-01-10T23:19:00.000Z

It’s difficult to imagine that Prime Minister Gordon Brown is really the centralist dictator that Private Eye would have us believe. But then he announces national initiatives, like deep cleaning hospitals and national health screening programmes, and you begin to wonder. Perhaps he really is the sort of man who issues a memo to Number 10 kitchen staff to ensure they put the plates in size order in the dishwasher.

The problem with national initiatives, besides the contradiction with the government’s own insistence that services are best delivered locally, is that they are often politically motivated and seem to ignore what we already know.

Screening programmes can be effective and, as Richard Horton points out in his blog, the Prime Minister and the Department of Health have chosen their screening wisely - heart disease, strokes, diabetes and kidney disease. But screening takes time and money. It will also fail if the results are not followed up in the appropriate way and are not used to improve the lives of those people who are at risk.

Why spend money on screening when sophisticated predictive risk tools already exist. We know how to find those people who are at risk of hospital admission not just tomorrow but in two year’s time. Primary Care Trusts are already using these tools to identify people with long term conditions. So finding these people isn’t the issue.

Encouraging the appropriate lifestyle changes is where the challenge begins. How do you encourage someone in their fifties, who has smoked since their teens and is presenting with the early symptoms of chronic obstructive pulmonary disease, that lighting up first thing in the morning is a ticket to a painful death.

As Hugh Fearnley-Whittingstall found out in his Axminster crusade, it’s hard enough to get people to buy free range chickens, never mind ditch their fags. People in Axminster thought Hugh was a posh bloke who was out to feather his own nest and his words fell flat.

How many of these same people read the news about health screening in their daily red top and thought there’s another posh bloke telling us what to do. Effective communication that leads to lasting behavioural change is perhaps the biggest challenge facing the NHS. To be honest, not many NHS communicators are up to the job. It demands a whole new set of skills beyond fronting up to the local media and until the NHS takes it seriously, prevention will never get out of the starting blocks.

Why NHS targets don't always work

2008-01-04T10:21:00.000Z

Tory leader David Cameron has pledged to make the Conservatives the party of the NHS. That’s a bold move but with the backing of experienced people, like shadow Health Secretary Andrew Lansley, and bright advisors at his side Mr Cameron might be well-placed to have a decent crack at it.

He was interviewed on the Today programme yesterday morning explaining that the way to make the NHS better is by placing more emphasis on patient outcomes, rather than relying on centrally-imposed targets. The Tories have cottoned on to the idea that giving greater emphasis to the patient voice fits rather well with their free market principles. What better way to ration healthcare than to make the patient/customer King.

Targets can have unintended consequences as the current government is only too aware. It has been very fond of imposing targets without really understanding the consequences. That’s why it had to back-peddle furiously by getting respected clinicians like Lord Ara Darzi involved in bringing round disaffected NHS workers.

Take the four hour A&E target for instance. Long queues in A&E are bad for patient morale and bad for headlines. Stipulating that every patient must be seen within four hours seems sensible. However, unless you have worked in an A&E department, or have listened to someone who does, you wouldn’t know that this target could have unintended consequences.

Figures produced by the CHKS Group and reported in The Times recently reveal that over the past five years 2 million extra patients were admitted to hospital through A&E units in England – a rise of 20 per cent. There was no rise in Scotland or Northern Ireland where the target has not been imposed. In Wales, where the target was delayed, admissions started rising in 2005.

One explanation is that patients often need to be monitored for complications – making a diagnosis straight away without seeing test results is perilous. So rather the having patients lying around in corridors it’s best to get them on to a ward. This happens to work in the hospital’s favour since under the NHS tariff it gets paid substantially more for an admission rather than if a patient is treated in A&E.

Hospitals will of course deny gaming but you can understand the motivation given they are now having to compete with one another and other providers. Payment by Results is actually payment by activity.

The four hour target might work in some respects but not in others which means Mr Cameron is right to think about other incentives. But patient outcomes data has to be handled with integrity and the Tories should tread carefully if they think they’ve stumbled on to a winner.

Disclaimer: the author has a commercial relationship with the CHKS Group