Simon Jenkins, Guardian columnist, ex-HIV Denialist and public health skeptic has a column up at the Guardian that contains his recommendation for dealing with the NHS. Unsurprisingly, his basic recommendation (like every other article he writes on public health risk) is – let them eat cake. Essentially worthless, in a roundabout way it aims at a solution and provides a couple of examples of the kind of magical thinking that lots of free market “solutions” to the NHS’s problems are prone to – and shows why they discredit the real, simple market solutions that might make the NHS work better.

But before we get onto the substance of the article, let’s just contemplate what Jenkins’ presence on the pages of the Guardian has to say about journalism as a profession. This is a man who for several years in the early 1990s was so staggeringly wrong about the science of health that he sided with the HIV denialist movement, writing articles that opposed the link between HIV and AIDS long after the dust settled. The consequences of HIV denialism in Africa are pretty well understood now, and very sad, but here we have this man still writing on health-related topics – and specifically, on disease prevention – in the pages of a major UK newspaper. This is like giving editorials on NASA to a moon-landing skeptic. But somehow journalism manages to struggle on in this way, giving a dangerous idiot high profile space to spread idiocy and lies. And the lies haven’t even changed – his work on swine flue alarmism used pretty much the same arguments as his HIV Denialism. Oh journalism, what happened to you?

So now Jenkins has moved on to health policy, ever an important topic in the UK, in the wash-up of a report from the NHS Ombudsman on appalling mistreatment of old and/or very sick people in some hospitals. The report itself is summarized here and here. Jenkins provides us with a long list of the reorganizations that have been tried in the NHS over the past 50 years, and concludes that the NHS is “too big” and is best broken up – sacking 24,000 back office staff is a good start, apparently. We find Jenkins wondering why no-one has bothered to try and properly reorganize the system, and instead done all this tinkering at the edges, and suggests that the NHS is so big and powerful that it won’t allow internal change. And he also suggests that instituting top-down targets will encourage staff not to care about their patients. I want to look at these ideas in a little more detail, because they illustrate some of the common problem ideas that strident armchair observers force into the debate – ideas that are unproductive or even harmful to the interests of health policy in the UK.

The NHS Is Too Large To Change

Jenkins’ first point is that the NHS is too large to change, that it can successfully resist external tinkering because it is its own monster. He points to the long history of attempts at reorganizing the NHS and asks why they all fail. He says that

Its interests are too institutionalised, its lobbyists, especially the doctors, too powerful, and its internal controls so pervasive as to seize up the system.

but he doesn’t consider a far simpler explanation. The NHS is the main source of healthcare for 64 million people, and there is currently not a great deal of health care capacity outside of it. Has it occurred to Jenkins that the reason attempts to reorganize the NHS fail is that they need to occur slowly and cautiously? It’s very easy to propose radical solutions from the outside, as a senior journalist who can guarantee himself access to what little private health capacity exists in the UK. But for someone like David Cameron or Andrew Lansley actually attempting to modify the system, there are the interests of another 63,999,999 people to consider. You can’t afford to just break that shit overnight with a radical change – you need to be absolutely certain that the system won’t tip over. Yes, let’s break it all up – and if rather than breaking it up, we just break it, who suffers? Certainly not the top opinion writers at the Guardian.

The reason that the NHS has so much institutional weight is that, even though it isn’t the best system in the world, it works, and it works for 64 million people, most of whom have grown up with no alternative system, and couldn’t afford it if it were there. As a politician, it’s not just your own career on the line if you fuck that up – it’s a lot of people’s health. You tread carefully with a system that has that much weight.

The NHS Is Too Large

The next complaint Jenkins makes is that the NHS is just too large. It should be less mammoth. But if it is so large, why is it underfunded relative to the rest of Europe? As a nationalized health system, there is every possibility that it is not large enough, and needs further injections of funds before it can be said to be large enough to do its job effectively. It may be the case that the NHS as a single institution is too large to be effective, but it may just as well be the case that it is not large enough to serve the needs of its population. The more diversified health systems of Europe may be doing better, but they’re also getting a lot more money and have been getting a lot more money for a long time. We don’t have any evidence that the NHS would be performing worse than those systems if it had received the same historical funding.

Targets Discourage Caring

This is arrant nonsense. Health care organizations have always had top-down targets, regardless of the system they work in. Here’s an example of a target: we want 0 post-operative mortality this year. Here’s another: We want 0 prescribing errors this year.

Do those targets discourage ordinary staff from caring for their patients? No, quite the opposite. The impact of a target depends on the system it is instituted in, its suitability for the staff it effects, and the amount of funding and system support for the achievement of that target. It also depends on staff supporting it, and on the existence of infrastructure and management systems that help that target be achieved. The oldest Doctor’s target – first do no harm – is pretty useless, for example, if you have to treat HIV with ineffective medicines because some thick journalist convinced the government that HIV doesn’t cause AIDS.

For some reason a lot of British journalists and health critics have a problem with targets that way exceeds their meaning. Sure, targets can be useless – they can even make it harder for staff to get their job done – but this critique doesn’t necessitate the level of demonization and magical thinking that attends the dreaded T word in some journalistic and (largely, though not exclusively, Conservative) policy circles in the UK. Caring, wholesome nurses don’t suddenly become dark eyed witches because the government set a target on the number of teen pregnancies in their health area that year. Such a suggestion is magical thinking at its finest.

Sacking “Back-office staff” will get the System Working

This is another common refrain of the “common sense” brigade, the old-school unionists and (again, largely, though not exclusively, Conservative) policy radicals throughout the world. Its of a piece with the misperception of publicly-funded health systems as inefficient “public service” that employs people for make-work jobs. And, it’s largely impossible to conceive of as a sensible policy recommendation if one has ever actually worked in a hospital environment. Once one has, it is pretty obvious that these “back office” staff – supposedly so useless compared to their brave and peerless contemporaries, so-called “frontline staff” – are much harder to define and much more necessary than the policy radicals recommend. Exactly which back end staff should we be sacking here – the ones who process the salaries? The ones who enter the data that we use to track hospital quality? The ones who clean the floors? The ones who process the purchase orders that get the syringes to the bedside?

I worked as “Back office staff” for 3.5 years in a community health centre in Sydney. During this time:

  • I implemented a new methadone maintenance dosing database that reduced the risk of dosing errors (that can kill)
  • I merged this system with a client management system that enabled a coherent system for managing dangerous and troublesome clients, reducing (potentially very dangerous) confrontations
  • I implemented a new system of direct data entry that enabled us to reduce the amount of staff time spent on data entry – freeing staff up for frontline service!
  • I helped to coordinate the development of a statewide data standard for collecting information on hepatitis C treatment and management
  • I implemented a client management system for the newly-opened Medically Supervised Injecting Centre, which enabled us to both research the efficiency and effectiveness of the service, and manage client movement and injecting in what could best be described as a challenging work environment
  • I provided data analysis for ministers, health service planners, and my organizations staff – for training days, tracking new problems, and monitoring our performance

So, who was going to do this if I didn’t? And how in the long-term is the health system going to continue to operate at its best if these functions are retarded and slowly disappear from the organizations that form the whole? Do the policy radicals and idiot journalists who vent this type of inane policy “fix” consider that every private organization beyond a certain size has a similar set of “useless” back office staff, who keep the frontline people working smoothly? No, because they see the word “National” in “NHS” and a red film descends over their eyes. It’s a publicly funded service, so anyone who is not directly and immediately doing something that can be described as “health” must be wasting the public dollar.

This is ideology, not sense. But you’ll read it all the time in critique of publicly funded services everywhere.

The Private Market and the Grain of Truth

Of course, Jenkins has managed, by driving his buick very haphazardly, to swat the fly. The NHS could be improved – it could be made more responsive to patients, to health problems, to new threats and new technologies – by

denationalising, regionalising, introducing market forces, contracts, choice, anything to reduce bulk

and he correctly notes that this has been the plan for 20 years. Ultimately the way to improve the NHS is to “break it up” in some sense – to move towards the more decentralized mixed systems of Europe and Australia and Japan, where private and public providers compete for public money to treat patients who largely pay for the service they receive through taxes. Every movement in the NHS over the last 20 years has been towards this system, if not in essence then in practical fact. But no matter how much policy radicals and idiot journalists rant about it being too big, the fact remains that the health system in the UK is underfunded – in private and public contributions – and has been for a long time, and until it catches up with the European standard, too-rapid decentralization would be a disaster. Furthermore, with the British private sector very underdeveloped relative to other nations, time and investment is required. This can’t happen overnight because to dump 64 million people onto the tender mercies of a system that has been moribund and underfunded for 30 years, with no alternative, would be a policy disaster. So health policy in the UK moves slowly and consistently towards this goal, as successive governments find ways to loosen up the NHS and prepare the groundwork for a more flexible, more modern system, while people on the far left and the far right of the debate[1] watch the whole thing, and miss the point.

But the absolute worst thing that could happen while that movement occurs is for the people in charge of it to start thinking that the cause of the NHS’s problems is its overall size, and start hacking into it with gleeful abandon. Which is why people like Jenkins really need to stop talking about health and talk about something better suited to their moral and intellectual stature. I propose football.

fn1: And with health care, in the UK at least, it seems like you don’t have to stray very far to the left or the right to start behaving like you are “far” from the centre. The state of commentary on healthcare in the UK is really rather woeful.