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December 4, 2015

Welsh Institue of Health and Social Care Blog
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» Walking Backwards for Christmas

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy Glyn Griffiths is one of the noble band of WIHSC Associates on whom we rely for much of our work.  A pharmacist by training, and a … Continue reading

November 20, 2014

Welsh Institue of Health and Social Care Blog
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» At last, a way of viewing politics with maturity

Last week’s Wales Report (BBC1 on 12.11.14) on the NHS turned out to be a real demonstration of how to support public scrutiny and democracy in a different, more modern way. Health and Social Services Minister Mark Drakeford’s performance was … Continue reading

December 13, 2012

Welsh Institue of Health and Social Care Blog
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» Defending standards in a time of austerity

The governance of the NHS is probably not an obvious spectator sport, much less one you would thinking of taking part in.  (What does it mean, even?)  But we really should be pulling on our boots and getting ready to … Continue reading

May 14, 2012

Welsh Institue of Health and Social Care Blog
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» What’s wrong with our hospitals in Wales?

Do you ever wonder what’s really happening to the NHS in Wales?  There’s lots of talk about hospital ‘down-grading’, shortage of money, patients treated without dignity… and equally, stories of marvellous care, lives saved and miraculous research.  But what does … Continue reading

November 29, 2011

Welsh Institue of Health and Social Care Blog
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» Big strike day on Wednesday, but only if you’re flying?

The media coverage of this week’s public service industrial action provides us with further evidence that the value base of society has changed and continues to change.  If the strikes are as successful as the Unions intend, we are facing … Continue reading

April 6, 2011

Welsh Institue of Health and Social Care Blog
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» The NHS and Competition

The NHS in Wales and England have been on a different trajectory over the role of competition in healthcare for some time. The role of competition is contentious, but recently the work of economists like Carol Propper[1] has been important in … Continue reading

» The NHS and Competition

The NHS in Wales and England have been on a different trajectory over the role of competition in healthcare for some time. The role of competition is contentious, but recently the work of economists like Carol Propper[1] has been important in apparently settling the question of whether or not competition is effective in improving the quality of healthcare. The contention that competition on price drives down quality, but competition in the context of regulated prices (the English system of Payment by Results based on national tariffs) saves lives at no extra cost has had a lot of publicity and has been influential.

However, what seems to have been established is a correlation between competition and health outcomes (mainly centring on Acute Myocardial Infarction (AMI)) – but causation is not, I think, established satisfactorily; Gaynor et al (2010) do not take a whole system perspective, largely ignore the role of teaching hospitals and clinical networks (which are fundamental to cardiac care); and omit the advent of the NSF for Coronary Heart Disease in 2000 as a relevant policy to improving outcomes! The idea that patient choice policy beginning in 2006 would have a discernable impact on the figures for AMI by 2007/08 seems to be very unlikely – especially in the context that AMI is an emergency, not elective – and overall only 45% of patients remembered being offered a choice at all. (There is no comment on the proportion of this 45% who actually went on to exercise choice).

In the context that I think the jury is still out on the impact of competition, my perspective on NHS Wales includes the following:

  •  integration and co-ordination are more important than the last Labour UK Governments’ version of choice and competition, because most people using the health service are older people with multiple health and social issues;
  •  it is fundamental to make our system work well to demonstrate that there is an alternative to the English system. At the moment commentators like Chris Ham are dismissing the Welsh approach because the Welsh NHS ‘lags behind England on some metrics’. We must be in a position to demonstrate progress on metrics that make sense to us in Wales, including on health outcomes and on process metrics that matter to the public, like waiting times; 
  • Wales’ integrated model has the potential to deliver integration and co-ordinated care, co-produced with communities, patients and carers, but only some of the mechanisms to counterbalance unresponsive bureaucracy are in place. In particular, there needs to be greater local democracy. The potential for mutual models (without asset transfers) to give everyone within a health board area a stake in their board’s governance is worth exploring. There is also a role for development support, regulation and peer review.  Appendix 1:http://wihsc.glam.ac.uk/documents/download/26/ shows a model created as part of WIHSC’s response to the NHS reorganisation consultation in 2008 that indicates how the various elements of the system could link together;  
  • Wales needs to acknowledge and work in partnership with the private sector because it has a role in health and social care that impacts profoundly on some of the intractable problems of NHS Wales (including inappropriate admission and delayed transfers of care). Domiciliary and residential and nursing home care is largely run by private companies in Wales. Designing services with the private and voluntary sector as partners rather than just commissioning services from them could lead to much more innovative and responsive services; however
  • the UK Coalition policy on GP commissioning of any qualified provider is likely to lead to a pre-1948 patchwork quilt of services and the dissolution of the NHS as we know it.

 If there is to be competition in England, this should be between integrated organisations akin to our health boards that plan, commission and provide integrated health and social care, including some aspects of housing.

The planning and (re-) design of services needs to be co-produced with citizens, patients and carers, but clinically led by multi-specialty groups that include primary and secondary care clinicians. As well as not creating artificial barriers between primary and secondary care as the English system will, multi-specialty groups under the wing of the Welsh Health Boards would also recognise the reality that the most powerful clinicians, chief executives and finance directors are (and always have been) co-located in acute (secondary and tertiary) settings. One of the main reasons that LHBs and PCTs have struggled is that they are on the wrong end of the knowledge-power axis. I think that this is a fundamental fault line that means that even with substantial amendment to the UK Coalition Government’s Health and Social Care Bill that now seems to be in the offing, the English experiment will not work. 

 Written by Julia Magill, Visiting Senior Fellow WIHSC  


[1] see, for example,  Gaynor M, Moreno-Serra, R and Propper, C (2010) Death by Market Power: Reform, Competition and Outcomes in the National Health Service. Bristol: Centre for Market and Public Organisation, University of Bristol.

March 31, 2011

Welsh Institue of Health and Social Care Blog
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» These lapses in caring for the elderly show how stretched the NHS is

Disturbing press and media coverage about recent reports exposing the shortfalls in the care of older people in our hospitals is very worrying. While the snapshots these reports provide do not give a true picture of how all hospitals and … Continue reading

March 18, 2011

Welsh Institue of Health and Social Care Blog
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» Dis-integration of the NHS

The following contribution to the fierce debate on the reform of NHS England is published in today’s Guardian from WIHSC Visiting Professor, David Hands. Dear Editor You are right (editorial, 16 March 2011) to suspect that the government’s proposal, in … Continue reading

February 17, 2011

Welsh Institue of Health and Social Care Blog
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» Why GPs Should not Commission Specialist Health Services

Contrary to manifesto promises and most informed opinion, the UK government is imposing a radical, expensive and ideologically driven restructuring on the NHS in England.  The central feature is the proposed delegation of the £80 billion annual budget for hospital and specialist services to consortia of GPs.  Although these changes do not apply in Wales and the other devolved administrations, they will have serious repercussions across the UK. 

This policy is misguided for many reasons.  First, it reinforces the misconception that hospital and specialist services are the core of the NHS.  However, only ten per cent of GP consultations trigger referral to a Consultant. 

Primary care is internationally recognised as the essential foundation of any effective national health-care system.  UK primary care, in which GPs play a leading part,  is amongst the best.  However, it is still not good enough. 

Choosing a GP is the most important decision a patient has to make.  Unfortunately, there is no credible public information on which the quality of a GP practice can be judged.  Many GPs are excellent.  Others are unacceptably poor.   

GPs are independent contractors to the NHS, not employees.  They determine how they spend their time, including private interests.  This pragmatic arrangement has generally worked well since 1948.  A clinically independent and trusted GP is important for patients.  The drawbacks include professional isolation, variable quality and a tendency for some GPs to confuse their personal interests with those of their patients.

 Advancing technology has progressively enhanced the diagnostic and treatment capacity of primary care.  However,  many GPs have abdicated from services traditionally associated with the holistic ‘family doctor’.   These include maternity, some disabilities and chronic conditions, home visits, preventative services and mental health. 

Despite the introduction of ‘NHS Direct’, many patients, particularly in deprived areas, still find it difficult to access acceptable GP services.  This has not been helped by GP withdrawal from  ‘Out of Hours’ services.  This has led to clinical discontinuity and, in some cases, negligent incompetence by substitute doctors. 

Many such changes have occurred during successive renegotiation of the national GP contract.  GP remuneration is fundamentally based on ‘capitation’ (the number and types of patient on a GP’s list).  However, this principle has been gradually eroded by supplementary ‘ fee-for service’ payments.  It is difficult to avoid the impression that GPs continue to be paid more for doing less. 

GPs are trained in the convergent skills of diagnosis and treatment of individual patients.  They do not necessarily have the skills required for leadership, long-term planning and development of comprehensive services.  GP involvement with commissioning is not new.  ‘GP Fund-holding’ was introduced with the NHS ‘internal market’ by the Thatcher government in the 1990s.  Most GPs were not interested in the scheme which was expensive to run and brought marginal improvements.  GPs have continued to be intimately involved with commissioning in the English Primary Care Trusts which the government now intends to abolish. 

The fundamental problems lie in the perverse, financially orientated and divisive  incentives of the ‘internal market’.  English PCTs have consistently found it difficult to balance the interests of patients against the self interest of service providers, particularly GPs whose (frequently undeclared) business interests are not always congruent with the needs of patients. 

Conflicts of interest are likely to become even more significant in future.  Probity requires public money to be entrusted to a properly constituted and transparent statutory body which is elected, or otherwise selected to be broadly representative of local interests.  A consortium of independent contractors to the NHS cannot possibly constitute a valid authority, either for distributing public money or monitoring their own performance.  Such bodies must also harness the experience of all health professions, and valid representatives of patients and public. They must not be hostage to any particular professional group.

The government’s (under)estimate of the costs of this upheaval is £1.4 billion, during a time when public services are being decimated.  After experienced NHS managers have been sacked, GP Consortia will be obliged to employ commercial consultants to fill skill gaps.  This will further inflate management costs and diminish public accountability.

In future, in England, it will be possible for NHS services to be delivered by ‘any willing provider’.  GPs are the government’s stalking horse for further fragmentation and privatisation.  On past performance, GPs may not choose the best quality or most cost effective options. Longer term considerations (such as training) and less powerful interests (such as mental health) are likely to take a back seat. 

The budgets available to Consortia will be cash limited.  Demand will continue to rise.  Consortia will overspend.  Ministers will blame GPs for the inevitable unmet demands.  GPs will be obliged to ration services but the basis for their decisions may not be  transparent.  The relationship of trust between patients and GPs (which is currently untainted by financial considerations) is likely to be damaged. It is also likely that GP practices will progressively merge.  

International evidence unequivocally demonstrates that markets in health care increase costs, reduce quality, distort access, increase inequalities and diminish choice.  They corrupt professional practice with financial considerations and increase the incidence of inappropriate, dangerous and ineffective treatment.  A former member of the Thatcher cabinet aptly described the introduction of the NHS internal market as “a triumph of ideology over experience”. 

The NHS is one of the most equitable and cost cost-effective systems in the world.  If the government wants to improve it, it should commission a comprehensive assessment of health challenges and consider NHS achievements in comparison with other systems.  The UK faces dramatically increased prevalence of many complex, chronic and debilitating conditions.  Many are closely associated with longevity but several, such as stress, obesity, substance misuse, diabetes, heart disease, cancer, mental illness and accidents have links with the environment and personal behaviour.  None will be resolved by simplistic market ideology which damages professional cooperation and patient interests.  

Effective medical interventions require the sound foundation of competent, multidisciplinary primary care, underpinned by locally integrated, but nationally coordinated, secondary and tertiary specialist services.  An independent review of the adequacy and funding of the totality of primary care services would be a good place to begin evidence-based consideration of the future direction of the NHS. 

The blinkered commitment of UK politicians to market solutions for social problems threatens the very existence of the NHS.  There is a better way.  In Wales, the internal market has now been abolished.  Local Health Boards (the Welsh equivalent of PCTs) and NHS Trusts have been combined into single authorities which are now accountable for the integrated development of all local NHS services.  Community Health Councils have been strengthened.  Scotland is further down a similar path.  Both countries should be confident that their chosen route will prove more cost effective, equitable and true to the founding values of the NHS.

Written by David Hands, Visiting Professor in Health Policy and Management