Mark Hellowell argues that the government’s own rhetoric during late 2010 and 2011 may be responsible, at least partly, for the precipitous decline in satisfaction with the NHS.
The biggest ever drop in public satisfaction with the National Health Service (NHS) has been recorded by the British Social Attitudes. The precipitous fall, from 70 per cent in 2010 to 58 per cent in 2011, follows a more or less consistent trend of annual improvements in satisfaction since 2001 (with 2004 being the only exception).
The new data was published by the King’s Fund (which now sponsors the health questions in the BSA) on 12th June, along with a number of competing explanations for the drop in satisfaction. It argues that we cannot take the data as an indication of weakening performance since the most observable quality indicators, such as waiting times and rates of health care acquired infections have remained stable.
In addition, as the health minister Simon Burns has been so keen to point out in response to the survey, there is not yet any evidence of deterioration in the quality of care according to the patient experience surveys undertaken by the NHS.
So what to make of this sudden reversal of a 10-year trend? As the King’s Fund’s chief economist, John Appleby points out, it is hard to avoid the conclusion that the heated debate around the Health and Social Care Bill must have played a role. If he is right, the government’s own rhetoric during late 2010 and 2011 may be responsible, at least partly.
After winning office, the coalition had a major political management challenge in relation to its health care policy. Having made a clear manifesto commitment to leave the NHS alone, post-electorally Andrew Lansley and Co began work on a reform programme “so large it could be seen from outer space”, in the words of the NHS chief executive Sir David Nicholson.
This incorporated the creation of a new economic regulator to set prices and promote competition among health care providers, and transferring commissioning budgets from Primary Care Trusts to groups of GPs. The reforms were underpinned by a radical vision of an NHS that would finance health care, to ensure equitable access and avoid the well-understood market failures associated with private financing, but would cease to own and manage the means of health care production.
At the same time, in handing budgets to GPs and providing them with financial incentives to manage demand for tertiary care, ministers also hoped to transfer responsibility (and thus blame) for unpopular rationing decisions away from bureaucrats and ministers, down to the most trusted part of the health service.
The political management of this extraordinary U-turn incorporated two principal elements, both of which are likely to have had a role on public trust in the NHS:
(1) To persuade the public that the NHS had a quality shortfall and/or was in crisis.
(2) To persuade the public that the expansion of competition in the market between health care providers was the best method of driving up quality.
In terms of the first element, ministers drew public attention to the poor performance of the NHS compared to other OECD countries in terms of cancer and heart attack survival rates. The official ministerial briefing for the (first) Health and Social Care Bill stated that, despite spending the same on healthcare, the UK’s rate of death from heart disease was double that in France.
This was, it might be noted, a rather cynical presentation of the facts. A more judicious assessment might additionally have noted that the UK had experienced the largest fall in death rates from heart attacks between 1980 and 2006 of any European country, and trends indicate it will have a lower death rate than France as soon as this year. Ministers might have added that UK health expenditure is till pretty low by comparative standards – and certainly much lower than France as a percentage of national income.
In terms of the second element – the central importance of greater competition as the route to NHS salvation – ministers talked up a number of econometric studies which seemingly show the benefits of patient choice and competition in the market for hospital services. A number of these studies (especially Gaynor et al and Cooper et al) were referenced in ministerial briefings, and were discussed at some length in documents related to the Bill, such as the equality impact assessment. These studies have proved highly controversial, although some of the criticisms appear to be based on a misunderstanding of the econometric methods employed by the authors.
However, the theory underpinning the causal link that both these studies purport to show has also been criticised. The claim is that competition in the electives market provides incentives for hospitals to improve elective surgery and that delivering such improvements requires a general improvement in hospital management such that across the board enhancement in hospital quality are achieved.
As Gwyn Bevan and Matthew Skellern have pointed out, it is equally plausible that such competition for elective surgery might, through diversion of management effort, have negatively affected the quality of other hospital services. In short, the authors argue, the chain of causation is not adequately understood.
So, while the government’s focus on competition probably did not constitute evidence-based policy, it may have helped to create the impression in the public mind that, where services were uncompetitive, patients are not getting good care and are dying unnecessarily.
Apart from headlines about the poor performance of the NHS, it is likely that the real-terms freeze in NHS funding and the associated programme to improve productivity has had an effect. From the coalition’s point of view, it has been important to blame New Labour’s “poisonous NHS legacy” for the various uncomfortable policy decisions that have had to be (and are still to be) made in this budgetary environment. One manifestation of this has been the focus, by Andrew Lansley, on the role of the private finance initiative (PFI) on the finances of NHS Trusts.
Lansley suggested in a briefing with The Telegraph that the PFI was the leading cause of financial problems among 22 NHS acute trusts which were “on the brink of collapse.” The media largely reflected the line that the coalition government faced with the task of cleaning up Labour’s “mess,” and that any hospital closures or service cuts could be blamed on them.
This was a rather risky element of political strategy. The account was highly misleading – as was subsequently pointed out – not least by many of the 22 trusts themselves, who argued that their financial problems ran far wider than PFI. In addition, as many of them noted, they did not all have a PFI deal in operation.
But the misrepresentation helped to maintain the picture of an NHS as a fiscally unsustainable, underperforming health system, weighed down by a poisonous legacy by a profligate government, and in dire need of market incentives to improve quality.
Following such a barrage of propaganda, the public’s loss of faith in the NHS is at least explicable. Of course, the collapse poses political problems for the current government (hence the anti-Lansley briefing from some Conservative MPs and at times lukewarm support from Number 10). But to justify a massive top-down reorganisation of the NHS after promising to leave the NHS alone, this was probably inevitable. And, as the Secretary of State says, he’s not interested in “winning a popularity contest”.
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Mark Hellowell is Lecturer in health systems and public policy at the University of Edinburgh and the special adviser to the Treasury Select Committee in relation to its recent reports on the Private Finance Initiative.