Report from the Centre for Health Enterprise annual debate

First published Oct 31st 2011

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition.

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident.

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend.

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough.

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

  • defines the basis on which professionals make their decisions about treatment;
    sets a clear expectation for patients and carers to make their choices;
  • defines the benchmark performance against which different providers will be compared;
  • enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed.

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests.

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

Trust them with the numbers

First published on Oct 28th 2011

In 1972, Archie Cochrane launched the new phase of healthcare, when he observed an almost random level of variation in successful outcomes of supposedly similar treatments at different hospitals.  The seeds were sown for evidence-based medicine, and application of scholarship to discover what constituted best known practice for medical treatments and interventions.  His name is immortalised through the work of the Cochrane Collaborative which relies on the collective efforts of many scholars critically reviewing and synthesising published research to establish gold standards for all to see – doctors and public alike.

So, nearly 40 years down this road,  some of the best minds have been pressured into agreeing a new indicator which seeks to predict what levels of mortality are to be expected at each hospital in the country.  If you have been following the debate, you will be aware how much this has led to intense deliberation, argument, counter-argument and near rebellion on occasions.

No-one is claiming that this is an easy task.  We know, for instance that there are direct links between disease and socioeconomic status, geography, gender, ethnicity and lifestyle factors such as smoking.  We also know that different treatments and interventions carry different risks.  We aren’t surprised therefore, to realise that the predicted mortality rate for a hospital will be affected by the complexity of care it provides and the characteristics of the population it serves.

So you would expect it to be difficult to predict accurately how many people are likely to die within 30 days of being treated in hospital.  That is what standardisation is all about, and why the indicator is called standardised hospital mortality indicator (SHMI).  No-one has ever pretended that delivering healthcare is easy.  Doctors have to do difficult things  most days.  Nurses do different things, equally difficult.  Managers too have their share of difficult things, but, despite being politicians’ favourite targets for abuse, they contribute to the success or otherwise through their planning and management of resources to keep the healthcare system running.

So it is right to expect people who do difficult things to be accountable to the public whom they serve.  You would expect someone to be accountable for predicting the likely number of deaths a hospital can expect.  You would expect the publication of such information to be contentious because it takes away some of that air of mystery that professionals can generally get away with creating.

Two surgeons with the same mortality rate can in reality be at the opposite end of performance – the very best and the very worst sharing the same raw number.  The one who takes on all the cases that are too risky for anyone else to consider, and in so doing saves many lives, offers a completely different level of care from that of the incompetent surgeon who fails on even the easy cases, and ends up taking lives that didn’t need to be lost.

And raw numbers can indeed tell such a tale.  Unfortunately, within a society where most people run scared of numbers, our first reaction is more likely to be to worry about how people will misuse such raw figures, instead of concentrating on helping overcome their fear so that they do know what to do with them.  I always say that the data rarely provides answers, its power is in helping you to understand what questions to ask.  And asking the right questions in the above example very quickly leads to a clear understanding of what is happening.  Only the incompetent in our example has something to fear amongst an educated population, and rightly so!

So, when we look for the evidence on mortality, we expect clever people to work their magic in such a way that they can help Joe and Miranda Public to see whether their local care services are doing a good job or not.  The experts need to put twice as much energy into educating people how to interpret those numbers, than they do in producing the right values in the first place.  The sort of good job Archie Cochrane was worried about back in 1972.

So when the Information Centre published its new evidence exposing the considerable variation in performance between hospitals, we expected transparency on the numbers, supported by meaningful education to allow people to make sense of it for themselves.  Instead of this, energy seems to have been spent on building the smoke screen behind which the hospitals and clinicians can continue hiding from the ongoing and horrific reality of unwarranted  variation.

Of course we want all hospitals to offer the same high quality outcomes, but we aren’t there yet, and until we reach such a utopia, we should each have the chance to make the personal choice of how much inconvenience we will accept so that we can get to the very best, if we so wish.  Alternatively, we might choose the extra risk so that we have minimum disruption.  And that trade-off is not as obvious as you might think.  People diagnosed with cancer in the Isle of Wight frequently choose a regime with an inferior prognosis so that they can stay at home on the island, rather than choosing a much more intensive treatment regime away from family and friends in Southampton. That is what choice is about, and why it is so important.

But sadly, those clever people in the Information Centre have determined that the data on mortality is far too complex to translate into an accessible form for the public to digest. Instead it is presented, buried in complex, highly caveated reports aimed at fellow statisticians.

Now I know a thing or two about statistics.  I know that most people do indeed have more legs than the average person!  So I’ve looked at the data with interest.

I live in Ipswich, and I know that no relative of mine has had a good experience from my local hospital, and that its leaders only ever face the light of day defensively.  I was pleasantly surprised to discover that its performance is pretty close to the centre of the band you would expect it to be in.  I was even more surprised to discover that the hospital local to Cass is predicted to have a similar number of deaths each year, despite providing much more specialist care as well as facing the more complex health demand of its east- end population.  But instead of the same number of deaths as predicted, it positively glows at number two in the country for lowest mortality.  It only had around 68% of its predicted number of deaths.  Well done Barts and the London!  But if I got off the train in Colchester by mistake, then instead of a similar number again, this time I would have found data pointing to worse mortality: 5 deaths for every 3 at Barts and the London.

We may be delivering more sophisticated treatments, and calculating some pretty clever stuff to produce these figures compared with Archie’s day.  Like him, we know that we must avoid ascribing too great a precision to our findings because the statistical significance of each of the standardised mortality figures is never better than 5-10% or so.  But even though these subtle niceties may be lost in translation for many people, we have to trust the public with such serious trade-off as 5 versus 3.  After all, this isn’t 5 tins of beans from Morrismart for the price of 3 from Markrose.  This is about lives.  Shorter than necessary lives.  Well and truly short-changed!

 

Time for hand washing

First published on Oct 14th 2011

There seems to be general agreement that the DH has lost the plot on tackling obesity.  No-one seems to have a good word to say about it.  The country seems to have lost faith completely in professionals, so instead of turning to a public health expert for the story, the Guardian leads on the nations most acknowledged expert on such matters.  One Jamie Oliver.

He doesn’t quite use these words, but he basically accuses the Government of washing its hands of the problem of obesity.

So I decided to find out just what the government has said.  Easier said than done!  Only this week, the Chief Knowledge Officer recommended Google as the best way to find anything on the DH website, and how right he was.  It took a little while to find out that Change4Life is where I should have been looking.  Or should I have been looking at the Dietary Energy Recommendations Report?  Or the Responsibility Deal?

We are told that if we reduce our consumption of caffe latte by four Olympic swimming pools worth each year, then we will hit the target of a 10% reduction in Calorie intake and reduce our average BMI well inside the recommended figures.  It is not clear if that is before, or after we have increased our exercise rate by swimming in the coffee we have so carefully tipped into our four new swimming pools.

But the Guardian has it all sewn up.  Alongside Jamie’s pronouncements, we discover the real solution to the problem.  A report that one in six mobile phones is covered in faeces, because we don’t wash our hands well enough.

So the answer is – swim in coffee to work off any unnecessary fat, spend more time on the phone, helping to raise taxes and stimulate the economy, then run to the facilities for a quick weight loss exercise, as diarrhoea takes hold.

Oh!  By the way!  Tomorrow is Global Handwashing Day.  The highlight for all cabinet ministers everywhere.  The day they can legitimately gloss over all those problems they aren’t tackling.

Can we learn about health reform from the US experience?

First published on 13th Oct 2011

Within the NHS, there are always some antibodies to the idea that we might learn something about health from the US system, which costs twice as much and delivers poorer outcomes.  But the reality is more complex.  Almost certainly the poorer US mortality figures are caused by the institutionalised inequity, and when you look to the best of the best, there is clearly much to admire and seek to emulate.

Having spent my early career in engineering and materials science, I understand integration as a necessity to reduce boundary and hand-off effects which in turn are sources of risk and failure.  So the current mounting pressure to achieve meaningful integrated processes for care is a great encouragement.

One of the most promising approaches is the Accountable Care Organisation model.  It is important to understand that the term “Organisation” refers to the alignment of processes, not a physical entity.  I’m hoping that a paper I have co-authored on ACO will appear soon in the BMJ – there is real potential for breakthrough with ACO, simply because the defining characteristic is that it aligns incentives throughout the system, directed towards the desired outcomes.

Well, the Americans have been putting considerable emphasis on the wonder of ACO, since their reform bill recognised its potential.  An ACO approach is also one of the few hopes that Christensen has for overcoming inertia of health systems and truly disrupting the health system so that it can tap into the order of magnitude improvements which have happened in almost all other industry sectors but healthcare.

So here is the rub!  Some of the thinking about the power of the ACO model comes from looking at the most successful health systems – Mayo clinic, Intermountain, Geisinger, Cleveland Clinic.  Federal policy being made after taking a good look around, finding the best and seeking to stimulate an environment in which the very best can be built on and replicated.  Sound familiar?  Well, it appears that the programme to stimulate such adoption of the best has wrapped the very best in so much centralised bureaucracy, that the best are declining to party.  The federal approach appears to be stifling the very stuff which has made it the best!

Let’s hope this is one lesson that Sir David N will choose to learn from the USA!  The best are best, because they have worked at it, understood it and given a real sense of ownership to the front line people who make it the best.  The very thing which makes it the best, is the very thing which no centralised administration can replicate or, heaven forbid, succeed in imposing.

 

What of the bill?

First published on Oct 11th 2011

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them?

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid.

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

  • that are better at adopting innovation,
  • in which all elements of the system drive together towards best possible outcomes for available resources,
  • that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

  • detail of how Clinical Commissioning Groups (CCG) will be held to account;
  • how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
  • how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards.

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives.

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour.

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.

The perils of squeezing out judgement

First published Oct 6th 2011

Our recent past is littered with large scale systemic failures, each of which has led to probing reviews, a myriad reports and the inevitable rewriting of regulation, each time marking a new dawning of governance and protection for innocent casualties.  Maxwell!  Enron!  Clapham!  Barings!  Baby P! Bristol!  Alder Hey!  MidStafford!

In some ways the review findings are predictable.  Technology has enabled practice to outstrip and outsmart the regulator.  The regulator caught napping!  Regulators essentially caught colluding with the deceit – Enron was the first of these to reach my consciousness.

When you peel the layers away, every one of these is a failure of risk management process.  Inadequate consideration of, and planning for, the risk that things might not work out as we want them to.  Insufficient integrity in those controls which should have been starting to glow red as the likelihood of impending failure rose.  Insufficient emphasis on assurance – that triangulation process which seeks independent confidence that all is well.

But then, risk management is too easily relegated to the “process nerds” who interfere with innovation and shun entrepreneurial flair, demand that proper time is allocated to consider complex issues in depth.

An opportune moment perhaps to rewrite that perception?

In 2009, Sir David Walker’s report on the failure of banking recorded some of the most memorable words from a governance review:

“……improvement in corporate governance will require behavioural change in an array of closely related areas in which prescribed standards and processes play a necessary but insufficient part. Board conformity with laid down procedures such as those for enhanced risk oversight will not alone provide better corporate governance overall if the chairman is weak, if the composition and dynamic of the board is inadequate and if there is unsatisfactory or no engagement with major owners. The behavioural changes that may be needed are unlikely to be fostered by regulatory fiat, which in any event risks provoking unintended consequences. Behavioural improvement is more likely to be achieved through clearer identification of best practice and more effective but, in most areas, non-statutory routes to implementation so that boards and their major owners feel “ownership” of good corporate governance.”

Earlier this year, Professor Eileen Munro reported on the circumstances of the Baby P tragedy, concluding that the child protection system had been built up of layer after layer of so-called assurance, which ultimately diverted attention away from the very purpose for which the processes existed, recommending that energy in safeguarding needed to be brought back to its core aims:

“These forces have come together to create a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children, young people and families”;  and:

“instead of ‘doing things right’ (i.e. following procedures) the system needed to be focused on doing the right thing (i.e. checking whether children and young people are being helped)”

Can the combination of Walker and Munro mark a sea change in thinking about risk management and governance?  Yes, process is an important part of the story, but it can never be seen as more than just a part.

I have a few simple mantras which, if applied in a few more places could improve effectiveness.  One of these applies here.  Information rarely gives you answers – it simply helps you understand and formulate the important questions to ask!

Put simply, it is the duty of management to use the best available information and evidence, combine it with experience and professional judgement, and subject it to peer review from as wide a cross section of perspectives as practical.  That for me is a statement of good governance and the duty of both individual managers and whole boards.

So, when we read the litany of misfortune and the apparent disarray within CQC, we have to be worried, even after stripping out the undoubted misreporting, exaggeration and sensationalising of the telling.

Easy to make a transcription error that puts the wrong number down for the number of inspections carried out last year, but impossible to misjudge your core business by a factor of two!  Valuable for board members to be setting aspirational plans for how they want to see processes becoming more consistent and controls being tightened, but unacceptable to then misjudge the gap between today’s reality and that future goal.  Commendable to see an internal review conducted when staff properly raise concerns about process quality, and easy to understand why sharing such a review publicly would need careful handling, but impossible to see how an organisation whose very raison’d etre is to provide public assurance, could misjudge the importance of transparency and consider disciplinary action as a first resort.

And the biggest question of all!  What can be done to enable the CQC board to achieve Walker’s sense of “ownership of good governance”, to generate an effective balance between process and culture, when the government imposes increasing demands, expands the scope and reduces resources at the drop of a hat?  Where is the meaningful consideration of risks, the integrity of the controls and the confident, independent assurance and exercise of professional judgement.  Surely, at the very heart of this governance minefield, it is ironic indeed to see the Department of Health acting almost in the role of Shadow Directors of CQC, removing the very ownership the board should have in determining how to square this shrinking circle!

This feels to me to be the very antithesis of the assurance process for which CQC exists.

The perils of ambition

First published Sep 22nd 2011

The Department of Health has today issued a press release headed “Dismantling the NHS National Programme for IT”, and I am wondering how that core message will be conveyed across the media in the coming days.  There is clearly a headline waiting about the dreadful waste of money.  Or another one bewailing another Government IT failure.  Perhaps a triumphallist roar of “about time too!”

But underneath the surface of the report are some facts worthy of a moment’s consideration.  The programme’s total outlay has been much less than the agreed budget at “only” £6.4bn.  Big numbers?  Well, no actually!  Around 0.8% of the NHS’ operating budget over its 9 year life, and Wanless demanded at least a 2% growth in IT spending to around 4% of budget, to modernise the NHS’ ability to deliver world class care.  Comparable customer service industries spend maybe 10-15% of their turnover annually in the tools of understanding and supporting their customers.

And whatever sensational stories you read about this programme, the Cabinet Office report from the Major Projects Authority notes that around two thirds of this £6.4bn has delivered important contributions – some on technical infrastructure including connectivity, some on the tools and information to enable better planning and management, and some on hugely important clinical tools such as the PACS technology which all hospitals have adopted to bring diagnostic imaging out of the dark ages of ordinary films.  But I doubt if you will read elsewhere that the UK is the only health system in the world where our primary care physicians – our beloved GPs – have received specific payments for the last 7 years based on quality.  And the National Programme delivered the support for that without a fuss, so that some of our population health data is now the envy of the world!

So, with all the hype, there is a little more than £2bn which the programme has wasted over 8 years.  A few bankers’ bonuses misplaced perhaps!  Around a quarter of a percent of the total NHS budget which has failed to deliver the expected improvements.  Contrast that with maybe as many as 30% of interventions which are unnecessary, inappropriate or unsuccessful, and contribute to wasted budget.

So, the travesty is not in the money, valuable though that could have been.  The travesty is in the lost opportunity!  The dashed ambitions!  The desperate need for real, valuable information by which care outcomes will be improved and efficiencies achieved.  More than any other area of healthcare, it will be better information which will drive this quality. Better information helps ensure the right treatment, at the right time.  Better information prevents errors.  Better information allows clinicians and managers to plan their resource needs more effectively.  Better information helps the doctor-patient dialogue.  Without better information it will be impossible to respond to the challenges constantly battering at our health and care system.

What matters now, is that the nail in the coffin of the NPfIT marks the beginning of renewed confidence throughout the care system that it is worth investing in systems that do work.  Those which present the clinicians with the best possible information to direct them to the most effective interventions.  It is worth investing in the sort of management information systems which will allow good leaders to transform organisations and teams from being burdened by administrative problems, to being at the heart of well oiled intelligent systems.  No more grand scheme heroics trying to solve the world, but real, local health intelligence systems that pool information, agile technologies that can respond in a matter of days to innovative ideas, and above all, a workforce confident in using the very best information and tools available.

What does it take to shock us?

First published 16th Sep 2011

However deplorable the terrorist attacks were a decade ago, and however much the impact has reverberated around the world, it remains a mystery to me how we can be shocked beyond measure by one circumstance, whilst another source of pain to society remains almost unnoticed.

There were just under 3000 awful and premature deaths on September 11th 2001 – devastating terorist strikes, destroying the hopes and plans of 3000 families;  reverberating across New York communities, leaving orphans and widows in its wake.  There have been almost daily incidents around the globe since then, with too many of them causing death tolls above 100.

But in the decade since then, nearly 7000 US citizens (military personnel and contractors) have been killed on the war fronts of Afghanistan and Iraq.  It is difficult to count the deaths on the other side, but estimates vary between 25 and 50 thousand directly killed and maybe 20 times that number of “excess” deaths caused by a combination of sanctions and war conditions.  What an awful term: “excess deaths”!

But where are our thresholds of unacceptability?  The same decade has seen around 150 thousand homicides across American society – 15 Americans killed by local violence for every single one killed either in the twin towers or in the war zones since.  And what of the 360 thousand Americans killed in road traffic accidents – casualties of life.  Are these any less devastating to the friends and relatives?

But here is the real rub!  Nearly 1 million “excess” deaths across the USA because the American health system has so many holes in it!  If the life expectancy in the USA was equal to the average value across the OECD nations, more than 900 thousand lives would have been saved in the last decade.  Investment in UK health reform in the same period has successfully closed the gap from its poor performance, so that in 2009 – the latest full year data, the UK crossed over to better than average life expectancy.  But procrastination about American healthcare reform  has seen its gap continue to widen almost every year, so that the average American can expect to die 4.8 years sooner than his or her Japanese counterpart, and 2.1 years sooner than the average throughout OECD countries.

How does the shockwave of such appalling devastation of life and relationships pass by so unnoticed?

Bring back reason

First published 7th Sep 2011

You will be aware of the importance of the vote through the Commons this week on the health and social care bill.  You will also be aware of the many vested interest groups which are lining up their forces to deepen the degree of polarisation of the debate.  The 38 degree pressure group is emailing widely about the “crunch NHS vote”, painting a single all-or-nothing picture.  As I’ve previously pointed out, the biggest demand from experienced and engaged NHS managers of all professional backgrounds over the last few years has been to remove the fickle hand of influence of the politicians from the tiller, so that the care service can be run as an effective business sector in which the diversity of players is a valued asset.

We are desperately worried that, yet again, the real debate is being derailed by emotional arguments which completely ignore the challenges which need to be addressed.  Please help us find the middle ground.  A ground in which the discussion can separate the challenge of understanding the changing needs for care, from the very different challenge of finding the solutions.

To help avoid the usual polemic, I’d like to suggest that the need should be expressed in terms of guaranteeing equality of access to a high quality service of care.  That service must be designed to achieve the maximum wellbeing and independence of the whole population at an affordable cost to the public.

Similarly, the solutions should be defined in as neutral a language as possible.  The solutions are perhaps best described as comprising a range of services offering appropriate, patient-centred care and support, able to take full advantage of advances in both medical science and other relevant innovations and new developments which can be used to advantage in the whole care process.  Such advances may be in terms of leadership, business management, entrepreneurial ventures, organisational behaviours, partnership working and social engagement to select just a small range of domains which are fundamentally important to achievement of the care vision we have.

The biggest threat to the health of our nation, the fabric of the NHS and all other partners in the delivery of care, is to entrench them in business models and compartmentalised structures because the real issues to be debated have been lost in the partisan emotions of polarised rhetoric.

Please help join our demand for a reasoned debate which seeks to focus on really understanding and defining what the scale of health needs are, and seeks to encourage solutions to this need which are available equally to everyone who needs then and achieve the very best outcomes we can afford.

The middle way

First published 31 Aug 2011

The latest controversy surrounding the Coalition’s health and social care bill stems from the legal advice obtained by the campaign group, 38 degrees, that the revisions allow the health secretary to wash his hands of the duty to provide a national health service.

This report has brought the expected response from many quarters, demanding that the health secretary retains full controlling influence over the NHS.  But for many years, when senior health leaders have been asked to cast their vote for the single most important change required for the NHS, the overwhelming demand has been to remove the whimsical hand of politicians from the tiller.  So clear has been this demand, that in 2007, the Nuffield Trust published a thought piece exploring various models which would indeed sever direct political influence.

This is just the latest example of the complete polarisation of debate whenever the NHS is discussed.  We seem destined to end up at loggerheads between the two ideological extremes of “preserve the NHS ownership in public hands at all costs”, and “the NHS needs to be subject to market forces before it will get the best from efficiency, innovation and quality”.

Where and how is the middle ground to be found?  Certainly not in the ill-informed rhetoric and the knee-jerk reactions which dominate.  As we have argued elsewhere, the NHS provides only a small fraction of the overall care, and much of that is already in the private hands of small businesses.

What we need is an enlarged vision of a care ecosystem, in which the existing diversity of contributions from all manner of providers is properly recognised, whether they go under the name of social services, NHS, volunteer carers, social enterprises, or private for-profit companies.  The most compelling and urgent case for reform, is that we stop the partisan fighting over organisational form, and start concentrating on setting out precisely how “free at the point of need” translates into a nationally consistent and coherent entitlement, delivered in a locally relevant context.  The only question relevant to the Health Minister is What?, not How? or When? or Which? or Who?  I could perhaps sit on the fence when it comes to Why?