Not Born YesterdayA BEADY EYE
In the Kingdom of the Blind, beware the one-eyed trouser snakes
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the longest wait in the nhs is forthe truth
Last week, the March statistics on NHS waiting time reduction emerged - and what a transformation they were. Not only had a major leap been made, but (said The Independent):
'The March figures showed a more than 10 per cent improvement on February, suggesting the final target is likely to be hit well ahead of the end of year deadline'.
Even normally critical sources described the achievement of hitting the interim March targets as 'amazing' and 'an astonishing achievement'. Said John Appleby, the chief economist at health policy think-tank the King's Fund, "This is a fantastic achievement....it is quite staggering".
Which is, I'm bound to say, what I felt: staggered and amazed. Because whenever government statistics show something working, my amazement usually turns to scepticism. Especially when that something seems to have suddenly started working.
As late as January this year, the ever-punchy Civitas dismissed the waiting-time reduction targets as 'an impossibility', adding with ill-disguised glee that Ben Bradshaw's 10% 'buffer zone' on the aims was a naked attempt to lower the bar and manage expectations downwards.
On May 15th, the Financial Times reported that February 2008 data on waiting times progress showed the Government at 75% achievement of treatment within 18 weeks - 5% behind its 85% number on the way (in theory) to 90% at the next stage. The paper reported:
'If the milestone is to be met, a 10 percentage points improvement in a month will be required. That suggests the target will be missed, though possibly only narrowly, and chiefly in orthopaedics.'
Further, in what seemed like a mild form of Mugabeism, there was concern in some quarters that the reporting was a month behind schedule.
Other observers, however, chose to buy the figures at face value, but carp all the same. On 3rd June, the Pharmatimes website was quick to point out that
'Friday’s figures come with two important qualifiers. They measure how long patients still waiting have waited – not how long patients will have waited by the time they are treated'.
This is a fair point, in that the figures are open-ended - or put another way, a snapshot of averages, rather than case studies from start to finish. But there'd been an improvement - hadn't there? Yes there had, one anonymous senior NHS manager told the FT: because the NHS is ‘spot purchasing’ large numbers of operations from the private sector at the last minute to achieve these reductions. The Mole went on to add:
“I know of examples where the NHS has recently paid the private sector 140 per cent, and even 160 per cent, of the NHS price to try to hit the waiting time target.”
While generally enthusiastic about the new statistics, The Independent pointed out another cost of reduced waiting times:
'The British Medical Association said the figures clearly demonstrated the "hard work" of NHS staff in the "ongoing transformation" of the health service - but warned that it was also delaying the treatment of emergency patients.'
However, the overall media comment was favourable. So you'd think, would you not, that a DfH victory as big as this one would be the first flashing panel to be seen on its website - but like the two Ministers Bradshaw and Johnson, civil servants seem almost modest about what's been achieved. Indeed, I had to go through quite a bit of navigation before a pdf containing the all-important tables popped up. (On the newly created UK Statistics Authority site, I couldn't find them at all)
One of the great all-time cliches is the thing about 'lies, damned lies and statistics' but like many such things it misses the point: statistics never lie - but those presenting the columns and rows of figures will arrange the beginnings and ends of things such that, by the time they've finished, the numbers can be made to mean everything between two polar opposites.
There are two forms of waiting being measured by the ONS monitor of Government progress. One is the time between being told one needs hospital care, and actually getting it; the other how long it takes from GP referral to seeing a consultant as an outpatient.
The time slots used to break up the total periods are fairly random, and the total periods monitored equally so. As the final sections are open-ended (26+ and 13+ weeks respectively) there will always be a degree of uncertainty about what has actually been achieved - although the numbers in these extra-long delay quartiles are now so small, this seems unlikely to be very significant.
The problems start for me when one realises that (a) the quartiles themselves - especially for inpatient care waiting times - cover thirteen weeks each and (b) a '0-13' patient can be created relatively easily from a '13-26' patient. If the name of the game (and for those being set silly targets, trust me - it's always a game) is to shift patients from a long-wait quartile to a shorter one, it isn't as tough a job as one might at first think.
Let's say we want to get 30,000 patients into the 0-13 slot who were previously in the 13-26 slot. We simply grab everyone in the 0-4 weeks sub-slot and allow them to jump the queue. This automatically pulls everyone who would've been at 16 weeks by the end of the audit period back to 12 - and as this group isn't separated out, nobody will notice.
Far-fetched? Absolutely not. Says Jonathan Fielden of the BMA:
"All that has happened is that the government has put an end to the really long waits and the really short waits."
One can pull this stunt in every slot but only for so long: more to the point, what one can do is pull the stunt in a major way once - ie, whenever the targets are slipping and you badly need a good result. Nudge, nudge, wink, wink.
There is also the issue of success breeding success. Nothing wrong with success: but it's apparent from the new ONS statistics that between 2005 and 2008, the total universe of patients waiting fell quite markedly. Thus if one takes the total numbers waiting for inpatient care in 2005, it was 815,881. By March this year, it was 533,195. If one does the same for those awaiting a consultation, by 2008 the huge 2005 figure of 1,337,330 had become a considerably more manageable 781,279.
When I rang the DfH press office and asked why the figures had dropped so markedly, they predictably answered with the success story. Fair enough: but when I said that - on fixed staff levels - the job was getting easier and easier (and thus less of an achievement) they had a complete breakdown of understanding. They didn't see it that way, they said.
This surprised me, because we are not comparing like with like. With completely different patient universes at every stage, we are not comparing identical efficiency improvements - and in some ways, we cannot be sure for certain what happened. Did the results of the six months before this simply mean that without anyone doing anything more than normal, the waiting times were bound to go down? Did NHS administrators work all their days and weekends during March 2008 to achieve a result to get them back on track? Did the NHS simply hire a thousand more consultants? Or did the consultants decide to work 20-hour days until the numbers were back on target - and if so, why? The bottom line is that, after a certain point in the process of backlog reduction, it is not just difficult to assert for sure that greater efficiency is behind the result - it's almost impossible.
I asked the DfH for their 'line' on that, and this is what they emailed back:
'Reducing the backlog of patients waiting for NHS treatment required was the result of better organisation.'
There is more than a hint of the disingenuous in that - the response makes the success sound like a structural improvement that we can expect to continue. But this isn't the first time the backlog has been dramatically reduced: as the BBC's Panorama programme noted in 2004, the then total of 856,647 had been reduced from 1,287,543 in 1998 - a decrease of 33%. And the DfH's own response had told me that the numbers waiting when Labour came to power a year earlier were actually less - 1,058,00 t0 be exact. So, um....let's get this straight: in the first year after wicked Toryism, the list grew by 200,000. It then fell by a third in six years, and then went up by more than that in following year.
So, I said to the Minsitry, this patient universe thing isn't what you'd call a constant is it? The point earned me a harrumph from the Ministry as follows:
'People forget that ten years ago, it was not uncommon to wait more than 18 months and people died waiting for vital operations'
True Mr DfH, but then they also did more recently under New Labour. In 1997-98 the average waiting time was 99 days. That fell to 90 days in 1999-2000, but then climbed again to 95 days in 2004. But let's not have a heated debate: the Tories were quite happy to watch long-waiters die before they got a vital operation, and on the whole New Labour has tried to eradicate that - with commendable success.
It's just that - call me a picky terrier here - I was still wondering about the broader possibilities in relation to how the patient universe was cut this time around.
There are some clues available. Systemic changes in the NHS as a whole will produce fewer people coming into the referral system per se. Compared to 2005, most GP group practices are doing far more procedures at their level by upping the expertise they have - expertise that previously only existed in hospitals. This must have reduced the number of day-patients in the queue: but then, that is both better organisation and a better result for the patient. Problems arise when those desperate for a result start to abuse the new system. Fielden again:
"Doctors have been stopped from using their clinical judgement and pushing people through the system."
It's at this point that I have to return to the original point made at the outset: given the pressure on Brown in general and the NHS wait reduction project as a whole, did some ball-tampering take place to boost this latest set of figures? I wouldn't be making such a meal of this if it hadn't been apparent just before this last reporting period that leaks, expectations and careful Bradshaw gerrymandering were all leading our media to the conclusion that yet another New Labour target was going to be missed.
I can't reach a categoric conclusion here - and I doubt if anyone can. What I hope this piece has shown is that it wouldn't have been that hard to do it. (And I must add that numbers-fibbing has been done before in the Health arena - most notably by Johnson's predecssor Patricia Hewitt).
There is also a final - and key - observation I'd make. The DfH press release does, I think, give away what's really been going on during the last six weeks or so. Read the tone of this bit and see what you think:
'The NHS has met its commitment that by 31 March 2008, 85% of patients who require admission to hospital and 90% of patients not needing admission started treatment within 18 weeks of referral from their GP. This demonstrates that the NHS is firmly on track to meet the target that by the end of this year, no-one in England will have to wait more than 18 weeks from referral to treatment'.
Sentence one says 'we made it' - so there. Sentence two says 'and so we're not off course after all'. The plot has, again, been lost: the goal is no longer patient care quality in this statement, but rather 'we were asked to do something, and we've done it'.
By hook or by crook, perhaps. It's clear to me from experience going back two decades that the trouble with targets is one can bugger around with the system in order to meet them. Except that in Health, the ones who really get buggered in the end are the patients
Equally, there are some broader ramifications here. As one might expect him to, Jonathan Fielden, the chairman of the BMA's consultants committee, called for the number of consultants to be increased. "Now we need to move further and ensure that the driver for reform is genuine quality – not crude measures of progress," he added. Except Jonty that, er, if there's less to do, why do we need more of your chaps? Once again we must remember that proper interpretation of statistics can make the difference between right and wrong policies in the long term.
We must also keep things in perspective: even if the new ONS data really do point to genuine progress, twenty-six weeks is still half a year. Average waiting times haven't moved since 1997. Here in France, that would be totally unacceptable. The UK still lags behind other leading countries for death rates from cancer and for five-year survival from the most common cancers. It also has much higher death rates than a range of leading countries – France, Germany, Australia and Canada, for example – for people aged under 75 with conditions greatly influenced by healthcare.
Do I think the figures mean much? Not really: targets breed cheating, take eyes off the ball, and are often the wrong targets in the first place. Progress is quite possibly being made, but after the constant stream of lies under Hewitt, it'll be a long time before I believe anything emanating from NHS sources - even if the monitor is independent. The historical evidence strongly suggests that the Johnson/Bradshaw team haven't started an NHS reform in any real sense here: they have simply delivered New Labour a win when it badly needed one.
In 1971, Ted Heath powered through the area health authority reform. An attempt to decentralise, it succeeded only in creating thousands more civil service jobsin the NHS.
Heath....more pen-pushers
Margaret Thatcher tried to drag the NHS into her free-market asylum, but achieved only an absurdly cash-starved organisation competing with itself.
Thatcher....bonkers internal marketeer
Patricia Hewitt didn't seem to know what she was doing beyond telling nurses they should work for nothing, and patients that they should be grateful for her supreme intelligence. She achieved little beyond the world record for lying to the House of Commons.
Hewitt....arrogant, serial liar
Squeaky-clean Ben Bradshaw is the acceptable face of homosexuality, 'married' to his partner Neal Dalgleish. He is a Christian Socialist, and is passionate about preserving marine life. He used to be a Beeb journalist before entering Parliament in 1997 and being fast-tracked by the Blairites. That's it: he is an uncontroversial and unquestioning suppporter of the New Labour hierarchy. No ideology in sight, as such. Probably a very nice bloke, but unlikely to be amusing at table.
Bradshaw...er, um.....
Alan Johnson hails from the Not Very Bright but the TUC Like Him wing of the Party. The degree of Alan's thick-skin can be judged by his wonderful award of the work-homelife balance idea to New Labour in a recent speech. "Ten years ago, we started the debate on work-life balance" he lied, adding shortly afterwards in relation to disabilities, "Disabled people are increasingly breaking down the prejudice and ignorance that confined them to unemployment or menial work. As a boy, David Blunkett was told that the best future he could hope for was to become a braille typist or a piano tuner." The muse that such a conclusion to Flunkit's life would have been better for all concerned seems to have passed Big Al by. My dog Foxie's tail has a better chance of coming up with an original health reform idea than Alan Johnson.
Johnson...card, pack, not the brightest etc etc
the sacred camel: time to slaughter it?
For nearly twenty years now, there hasn't been an influential politician in Parliament (or a think tank nearer to home than the lunatic fringe) with a single thought about health reform which goes beyond something called 'the NHS'.
Socio-economic changes have been so myriad and massive since 1947 (the year of its foundation) there are times when I can barely believe we still have the same basic framework as that devised by our last true reformer, Aneurin Bevan. The service has become a kind of Crossbench Clause IV: 'it shall not pass'.
Imagine if you will an alternative 2008 in which no British citizen was allowed to take more than £500 abroad. Where there were Party Line telephones issued on a strictly rationed basis by a Government monopoly. Where every schoolchild still had free full-cream milk every day at school. Where cigarettes were free in the Armed Forces, and men who drove drunk were jus' good ol' boys.
Because a heavily centralised, non-means tested, monopolistic, Whitehall-run sacred cow NHS would be entirely at home in that environment.
Fine, say the pundits - but we don't have that. And it's true, we don't.
We have a centrally answerable, randomly and fractionally means-tested, GP-practice devolved, internally privatised, nationally measured, Area-Trust run, largely monopolistic, Opposition-blackmailed sacred camel NHS instead.
It is as if the GPO of 1950 still existed, the mail competing with its own internet service. To hit targets, the GPO is buying services off TNT. It is sticking stamps on every email, using Post Offices as signal-receptors for mobile phones - and offering free surface mail until the budget runs out - at which point all the post boxes are blocked up, and a laudable surplus declared.
The latest round of 'NHS in rude health joy' leaves one (or rather, it does me) feeling yet again that the Health Service many decades ago became one of those Soviet institutions of which Solzhenytsin used to write so superbly in books like We Never Make Mistakes and Cancer Ward.
That's to say, a combination of time, size and cynicism have turned a miracle into a sacred camel - and then an icon which must not be desecrated, or the sky will surely fall in. 'Hands off our NHS which is safe in our hands and the good old NHS is Sixty this week' is the sort of sentimentalist clap-trap that would've had Nye Bevan falling down upon the perpetrator in a fit of bucolic Welsh anger. (Within five years of creating the Service, Bevan was to remark on several occasions that a time must come - dictated by the condition of the population and cost - when universally free health care would no longer be either possible or wise.)
This is not to say I want to abandon widespread free health care. Having worked with (and suffered at the hands of) both private and State medicine, I know only too well how much more honest the NHS is as a form of medical help - and how quickly private care would rise beyond the means of all but a tiny minority were no form of free service to be available.
But as ever, I regard money as the crucial factor - both as a criterion for means testing, as something that has grown to come before efficacy, and as the Devil to be avoided at all cost among the professionals delivering the service. The current fiasco of GP hours and remuneration is a classic example of what I mean, the cost of health insurance for anyone over fifty in 2008 is another, the use of hopelessly outdated medications another still.
The NHS today is just too damn big. So huge and complex, in fact, that several generations of politicians, management wonks, Lords, Knights and former medics have tried to superimpose their own agendas upon it - and succeeded only in adding humps to the already overladen camel.
Since Labour came to power, we have seen a staggering nine actual or attempted reorganisations on a grand scale - including one that was introduced just three months after Chancellor Brown's famed injection of £60billion into what had been there before.
The culmination of waste and flash ideas was, it goes without saying, the Connecting for Health IT project. Currently running at a cost of £12.7billion (another lie unchallenged by a lazy Opposition unable to prove that the figure is nearer £23billion) the system is not as such running at all.
Its two main 'suppliers' Accenture and Fujitsu have fallen grievously wounded by the wayside, and the Lorenzo patient administration system, which is earmarked for hospital trusts across the midlands, east and north of England, is no longer expected to meet its already much-delayed release date of October 2008. The southern version (Millennium) has been installed in eight out of 41 acute hospital trusts in the region, but the feedback has been awful. Medics, IT staff and even local MPs have labelled installations "not fit for purpose".
Earlier this year the NAO stated that the system would not be finished until 2014. Lately the DfH has been letting slip the odd release suggesting that there are (as the obscene old saying has it) two chances of that date being met.
Yet at no point in this huge financial and political disaster has it seriously occurred to anyone that scaling down and devolving the administration of a newly-designed and newly funded State health service might obviate the need for such a ludicrously complex IT system in the first place.
The NHS website is headed with 'NHS - Your Health, Your choices'. Oh do fuck off marketing people and strapline writers: people who are ill want to be treated quickly and expertly and like human beings. There's no choice about being ill: the only choices facing sick people in today's UK Health Service are either getting better - or living with chronic illness/dying. If they can't get an NHS cure, they have no choice but to go private. And if they can't afford that, then they have no choice at all.
Sadly, we are still in the era of 'what can we get away with?' And it's the end of this that everyone desirous of a proper state health service is waiting for.
Problem with mixed wards? There aren't any. Gone over budget? Close some hospitals. Accused of being wasteful? Make a surplus. No money for Aricept? Aricept won't do you any good. Feeling depressed? Try this one - it's out of copyright: useless, but cheap.
Returning to the Russian genius for observing bureaucracy gone mad, all these 'solutions' are straight out of something Dostoyevsky might have written about government inspectorates - that is, a yawning fantasmagorical chasm between what they were interested in, and what the average citizen wants, needs or worries about. Because they are political solutions, not health solutions.
The hobbling, spare-part surgery aided nine-humped three-legged camel we see today is, more than anything, the product of a hugely missed opportunity in 1997. For if ever there was a chance for the Party which invented it to launch a new model, that was it. But Blair and his Spin-suits were too busy courting the media and its celebrity creations to bother dirtying their manicured hands with such tedium.
Now, sadly, the New Labour modernising tradition is in such disgusting odour, it dare not attempt such a thing; and naturally, no Tory Party (not even Thatcher's) would ever have the balls to take on this thankless, uphill task - least of all the guilty Old Etonians around the Macaroon.
Regrettably therefore, the most likely outcome is that over the years, the NHS will morph slowly into a sort of reverse Northern Rock, sliding gently into 'temporary private ownership' before disappearing forever - and leaving our Sceptred Isle to the tender mercies of private GPs steeped in marketing, consultants steeped in overcharging, surgeons steeped in the art of rubbishing physicians, and physicians steeped in vice versa.
Yet there is no need for this to happen. There are three fundamental nettles which must be firmly grasped by all involved in a genuine plan to make survival from illness not a question of one's financial means.
1. The existing NHS is neither fish nor fowl, but rather a vast collection of previous layers and ideologies half in and half out of Whitehall. In short, it is a genetically created Thing incapable of independent life. We need to retain the assets, and start again.
2. The first and most important starting point is a radical, practical and fair approach to funding.
3. The second and almost equally important beginning would be the acceptance of a means-tested service.
Anything other than this will be either unaffordable, or obvious prey to future carpetbaggers keen to reassure everyone about just how nice they're going to be really.
The requirement before any of this got off the ground would be a serious national debate about the options. But that's not going to happen, because none of our legislators have the bottle.
Sad, but almost certainly true.