Tuesday, 21 May 2019

Yes, the NHS has big problems but stupid populist headlines won't fix them

Several popular news stories in the last couple of weeks have shown that attention-grabbing headlines do more to distract than they do to improve the NHS. You have to know what the problem is before you fix it and too many popular discussions on the system's problems identify the wrong problem and get in the way of actual improvement.

If your idea of what is wrong with the NHS is based on reading popular news stories, then I have bad news for you. Headlines are, more often than not, driven by lobbyists with an agenda or journalists looking for link-bait and not by people who are really concerned to fix anything. In some cases they are simply pushing a partisan agenda with little regard for the facts about where the real failings are; in other cases they are deliberately trying to distract you from the real problem. 

Here are three examples:

Here is what is wrong with those campaigns and the headlines they generated.

It is the NHS not the anti-vaccination movement that is to blame for low vaccination rates

In the last couple of months both Simon Stevens (the boss of NHS England) and Matt Hancock have publicly complained about the influence of the anti-vaccination movement on vaccination rates in the UK. There have even been well received suggestions that the government should introduce compulsory vaccination as a way to combat the trend. Surely all right-thinking, well informed, people should agree that low vaccination rates are a problem and that the government should do more to combat the malign influence of the scientifically illiterate anti-vaccination movement?

Here is the problem: the cause of low vaccination rates in the UK isn't the strong social media influence of the anti-vaccination movement. The real problem is inside the NHS where the processes that should ensure vaccinations are carried out are poorly managed and coordinated. This blog from the Science Media Centre quotes some of the experts:

Research by the Royal Society of Public Health seems to support this suggesting that drops in vaccination levels may be due to timing, availability and location of appointments. And Dr Mary Ramsay from Public Health England has said they believe that sending out reminders and making GP appointments as convenient as possible will make ‘the biggest difference’ in reducing numbers of unvaccinated children.

It points out that the best evidence we have suggests that the influence if the malign anti-vaccination movement is weak. The uptake of the first dose of the two-stage MMR vaccine for example, is much higher than the uptake of the second dose which would not be true if parents objected to the vaccine but is far more likely caused because of poor reminders to have the second dose or poor availability of clinics or appointments that offer it.

In the pre-Lansley NHS, PCTs employed vaccine coordinators to organise campaigns and make sure vaccinations happened. Those people were mostly culled in the orgy of management cuts when CCGs were created (which were supposed to direct "more resources to the front line"). But, as I've argued before, this slogan is as dumb as a box of spanners. The NHS was undermanaged before those management cuts and cutting management further has just made the actual work done in healthcare less coordinated and less effective.

In short, the NHS leadership's attempt to blame low vaccination rates is fake news designed to distract us from the real problems caused by foolish historic NHS policy and current NHS failings.

Popular campaigns to fund treatments the NHS won't pay for are nothing to do with a lack of NHS resources

A recent tweet from the CHPI said the following:

The BBC reports that patients unable to access NHS care have raised £20 million through crowd-funding to pay for care privately. As NHS underfunding continues it is sadly inevitable that more patients will have to pay out of pocket to get healthcare

It referenced this BBC story about parents who had raised money to fund a cancer cure the NHS wouldn't pay for. The BBC story was somewhat more balanced than the CHPI tweet, noting the family's doubts they had done the right thing and that the cure had, ultimately, failed.

But while children dying of cancer and the NHS denying them treatment make good news headlines, they tell us nothing useful about NHS funding or policy. Even an NHS with an unlimited budget should not be paying for dubious, untested "cures" which, most likely, won't work. If parents want to crowdfund large sums of money to buy themselves false hope, fine. But no health service that cares about using evidence should have any obligation to fund those false hopes.

It is bad enough that the NHS has–against the advice of almost every health economist who can count–wasted billions on the Cancer Drugs Fund (designed, essentially, to pay for expensive treatments of dubious efficacy that have been ruled out by NICE, the body that evaluates the costs and benefits of new medicines). The fund's real purpose is to minimise the number of bad headlines. No health system that takes evidence seriously should have any obligation to pay large sums for treatments that, most likely, won't work. And linking such decisions to a shortage of money in the system is purely a distraction from the hard choices any health system–however well funded–has to make.

The length of GP appointments is not the government's problem

Many groups in the NHS like to deploy any evidence they can lay their hands on to lobby for a bigger slice of the pie for their part of the system. And the general argument that more resources would help is often true. But, sometimes, the argument a major distraction and gets in the way of effective solutions. So it is with the recent argument that the 10 minute GP appointment is "inadequate".

The RCGP argument is roughly this:

The 10-minute appointment that is usual across the NHS is no longer adequate given the growing number of people who have several long-term illnesses, according to a report from the Royal College of GPs. 

However, while longer consultations are needed to ensure proper patient care, they will only be possible if the staffing of GP surgeries increases significantly, the college admits.

Or, more simply, patients need more time so we need more GPs.

The second part of this is probably true: we do need more GPs.

It is the first part that is a problem. For a start, there is no obligation for all appointments to take 10 minutes or to be conducted face-to-face. GPs are free to choose a mix of flexible consultation lengths or to do consultations online or by phone. Some do. But many others don't, not least because their professional body keeps complaining about the idea that all appointments should consist of a 10 minute face-to-face meeting in its lobbying campaigns.

Secondly, the self-imposed inflexibility of 10 minute slots being the primary way a GP interacts with patients is a major cause of GP overload. GPs who break this assumption have found they can do a much better job for their patients while controlling their workload. Evidence from online consultation tools like askmyGP (COI: I provide their analytics) suggest that perhaps ⅔ patients wanting help from their GP don't need a 10 minute appointment. Some can get a satisfactory response online or by telephone. When GPs triage the patient need before offering an appointment, far fewer patients need to visit the GP and the time saved by the GP can be used to offer more flexible slots for those who do need to be seen. See the video in this tweet for a story from a GP practice who have experience this change.

In short, a better-designed, more flexible process for responding to patients delivers a better service for patients and lower stress for the GP. None of this solves the overall shortage of GPs but it can make it easier to solve by lowering the stress and increasing the attractiveness of the work making it easier to retain and recruit staff.

But every time the RCGP talk about 10 minute appointments as a basis for lobbying for more GPs, they distract from such solutions by reinforcing the inflexible view that the only way to serve patients is to offer inflexible face-to-face slots. Again, the easy headline damages the ability to seek better solutions to the problem.

So what? Don't be fooled by headlines that distract you from the real issues
The message is simple: what looks good in headlines often gets in the way of your understanding of the real problem. Good analysis of what is broken in the NHS rarely makes a good headline; nonsense that distracts from the real problem often does. Don't make policy from headlines; apply skeptical analysis; don't be distracted by fake news.