Editor's blog Wednesday 11 May 2011: Why Mark Britnell is incorrect - key NHS reform issues not about funding system

Former FT and SHA boss and DH director-general of commissioning and system management Mark Britnell is a formidably bright and very charming guy. I'm sure he's doing interesting work with KPMG now as their global head of health, and it's always good to hear him speak at an event.


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So it is with regret that I take issue with his new comment piece in Health Service Journal, for its core implication that the big issue in NHS reform is about funding. (UPDATE: A short reply from Mark (to my e-mailing him the text of this piece) can be found at the end, and is published with his permission).

This is the opening appeal of his piece, calling for "sophisticated discussion on how – and how much – the health service should be funded".

Post hoc and propter hoc
Mark seems to be confusing his post hoc with his propter hoc, in what looks uncomfortably like the politician's syllogism from Yes Minister:
1. Something must be done about an NHS financial crisis that has been brewing quite obviously since September 2007
2. Altering how and how much we fund the NHS is something.
3. Therefore altering how and how much we fund the NHS must be done.

The NHS has got used to having 6% real-terms cash growth for almost all of the past decade. It is now having to get used to as near as damnit real-terms zero (and given the latest Bank Of England predictions on economic growth and inflation, possibly real-terms cuts).

There is already severe financial pressure in parts of the NHS, despite a few years of erudite policy documents whose titles made me think that they were being written by meteorologists rather than health economists.

There will be more financial pressure, as reductions in the tariff are made to do the heavy lifting on driving acute service change and reconfiguration, as Simon Stevens pointed out in his recent HPI interview, the risk is being parked there. Not unreasonably, after a decade of growth.

Productivity
Mark's point about a relative 20% decline in public sector productivity over the past decade when compared with the private sector may or may not be statistically accurate (he knows well that productivity metrics are much-debated, and quality gains are hard to capture).

However, it ignores a bunch of salient facts: the private sector is allowed to select its consumers by price and other methods; is not obliged to offer universal provision; in healthcare, does not offer training at any meaningful scale; and has definable and enforceable end points in its relationship with its consumers.

Specifically in healthcare, it is not possible to meaningfully compare a private healthcare provision sector which offers in the main episodic, predictable elective care with a cradle-to-grave NHS service. Insurance explicitly cuts your care off at fixed points or refuses to cover you: theoretically, the NHS does not so explicitly do so (but in some cases, does).

Equally, it is bizarre to ignore the healthcare funding catch-up gap compared to European neighbours outlined in Wanless' reports for HM Treasury, which the past decade has seen being filled.

The real issues
First among the real issues is an inability of the NHS to see major financial problems ahead,  even when there is the best part of four years' warning. The UK economy took a nosedive into the unflushed toilet in September 2007, when the global financial crisis showed that magical money doesn't really work. It's a real issue, but it's nothing to do with the NHS funding system.

Second of the real problems is that a decade of cash and top-down shouting has done far too little to affect the real problems of every healthcare system in the entire developed world however funded: weak purchasing; cost-inflation, unacceptable variation in activity and outcomes; poor community management of long-term conditions. These problems have all persisted for a long time and in systems of all kinds of funding mix. They are real issues, but they're nothing to do with the NHS funding system.

Third, crap purchasing. Mark got the DH job "to make commissioning sexy", and he gave it a good crack. But it wasn't a good enough one: the health select committee reports and many others revealed that the real NHS dentistry crisis was that its commissioners lacked teeth. Weak commissioning is a real issue, but it's nothing to do with the NHS funding system.

The concept that insurance-based funding makes people better commissioners is a charming concept, and one for which I am yet to see any evidence. It looks like a psalter from The Book Of Things That Are Asserted And Yet May Not be So.

More to the point, Mark is making the case that we ought to consider insurance funding models splendidly close in time to the bankruptcy of a big German health insurance fund. If your German is a bit rusty (or non-existent, like mine, an English(ish) translation is also available.)

Brewing up a Berevidge in a teacup
Mark picks the Bismark rather than Beveridge examples of Netherlands and France. The former is a system I know less well; but France has serious and challenging problems with the unaffordability of its mixed funding system, and more rationing via gatekeeping has been introduced to the French system in recent years. He doesn't mention this, curiously.

The Singapore example is also interesting. Mark mentions that it is relatively small (which aids cheapness), but ignores the fact that it is culturally homogenous to a degree the UK is not at all.

He quotes its PM Lee Hsien Loong as decrying "'all you can eat' welfare states: because everything at the buffet is free, it is consumed voraciously'. This is just not an intellectual model I think has much relevance in healthcare. I don't voraciously consume joint replacement and cateract sugery and treatment for diabetes because I don't need them, despite being able to get them for free: I am certainly far from unique in this.

Here we go again
It's an old line but true: most of us consume meaningful amounts of healthcare (and so generate significant cost) in the first two years and last six months of our lives - and in any maternities we may have. The NHS system works at all because this is so.

The danger of moving to a health insurance system is that we collude with the healthcare spending 'arms race' on bogus treatments of limited effectiveness and very high cost.

I like Mark: he's a good guy, and I hope he's written the piece in a spirit of intellectual inquiry. I have a feeling that the next instalment of The Maynard Doctrine may see The Good Professor have a look over the article too.

Update - a reply from Mark Britnell
I emailed Mark the copy of this piece prior to publicising it. He sent the following reply.

"I'm not saying any of these systems is superior; I'm just saying that if we continue to dance on the head of a pin about these current reforms, we'll almost certainly miss a trick for the medium term.

"You know I love the NHS, and it will survive - but I want it to prosper; not just scrape through. The worst thing we can do is kill the NHS with kindness and pretend that we're not facing much bigger challenges than another re-structure.

"We shouldn't be trying to finish off the last decade of reform, but pushing ahead with the next decade. Finally, I hope we don't remain in a polemic 'public good, private bad' reform discussion, as that is also a distraction.

"I think the real point about commissioning is that if you really want good commissioning, it has to disrupt existing value chains and patterns of supply - and a centralised monopoly industry finds that very difficult indeed. World-Class Commissioning was supposed to be a five-year journey; not a two-year sprint.

"All the best, Mark"