A lot depends on whether the competition is fair or unfair.  For example, when you go out to buy a car, the competition is generally fair.  Most people know what to expect from a car, both tangible (how many doors, comfort, performance, fuel economy) and intangible (marque, implied warranty), and most options are available to most people in most places.

Healthcare is a little different.  People don’t necessarily know whether they need a hospital visit or whether care nearer to home will actually be better for them.  Often no-one explains (in terms they can understand) what they will get for the different choices they make, and there’s no-one to ask advice – and these decisions come at a difficult and emotional time.

So this isn’t helped when people are arguing till they are blue in the face, about competition (incidentally, I suspect that a trip to hospital is NOT necessary when you are blue in the face; perhaps it’s time to stop talking and start listening?).

In PM Tony Blair’s time, everyone assumed that competition would be fair, in the sense that all healthcare was only delivered to the best possible quality.  So people (including government, I’d like to think) got a bit of a shock when the private providers came in and all sorts of distortions and unfairnesses emerged – cherry picking the easy cases but still charging the full tariff, getting paid for activity not carried out, poor quality of care with the problems then passed on to the NHS hospitals to sort out.

The arguments will toss back and forth, and like any good commentator, I say “follow the money” – look at the motives behind each of the people.  For example, Mark Britnell is widely respected and is one of the key voices saying “any competition is good competition”.  Well his consultancy benefits from advising governments to change policy (well, you wouldn’t get asked in for the next job if you just said “things are fine as they are”); from implementing policy; and from clearing up the mess and designing a new policy (“well you didn’t implement it the way we said”).  Nick Clegg needs to put clear blue water between himself and David Cameron.  PM David C needs to support the international healthcare providers who funded his election campaign.  And so on.

But at the root of it all, we need good regulation.  This means clear measurement of the things that are easy to measure (Full Consultant Episodes, Outcomes, Costs, Waits), but also of the things that are less easy to measure (complexity, staff use) and of things that emerge as needing measuring.  It means teeth – a range of sanctions from fines to restricted practice before the nuclear option of removing a contract or removing a license to act. And the regulator needs to be locally accountable.

How will we get to this?  That’s a subject for another paper.

Is there such a thing as patient choice?

Healthcare is now so complicated that the patient would have a great deal of trouble making a choice. If they want to know what is the best treatment for their condition, they're pretty much entirely reliant on their GP. If they want to actually choose which hospital or specialist service provider to go to, then what are they going to rely on? Probably not the league tables.

Most likely, patients will choose the most convenient option, the hospital that has the monopoly on care near their home. Even if they consider changing, it will probably be based on rumour and PR. Is this an opportunity for organisations with big marketing budgets? You bet it is! And do public service organisations have big marketing budgets? Well, they certainly don't understand marketing like private health care providers do.  Does this make competition bad, and the introduction of private providers a disaster?  No, but there are issues which need addressing.

The GP has a menu of services provided under Choose and Book. There are currently discussions about whether Any Willing Provider (AWP) or Any Qualified Provider (AQP) will get onto the Choose and Book menu, and whether prices will be determined as tariff, or whether competition in pricing will also be allowed.

My last post pointed out how naive England is about private providers. Many are outstanding, excellent. But there's nothing in the system to prevent the bad apples coming and spoiling the whole bushel. They enjoy a different regulatory regime. This makes it easier for them to publicise the good PR, and to hush up the bad – to get to the patient, and persuade them to choose on the basis of advertising rather than on the basis of merit.

Gearing up to provide universal health care is expensive. Short-term contracts (three years, five years) represent too much of a risk. Investing tens of millions of pounds in the building and equipment to provide services to modern standards is a big risk without 10 or 20 years to spread the risk, but our current commissioning competence is woefully inadequate for signing long-term contracts.  Let’s look at where private healthcare is the main provider, and where the bulk of the population (well, 70%) actually use the healthcare provided.

The example is the USA: health care costs a whopping 15% of GDP – that's around $8000 per man, woman and child, $1 in every  $6 that circulates.  This compares with the UK: 8% of GDP, $3500. The important question, I suppose, is why are we trying to imitate them?

This is particularly difficult to answer. We in the UK, and the US, are rich enough to kill ourselves. We can afford far too much alcohol, far too many fats and calories, we can afford to do nothing – to kill ourselves through inactivity. Life expectancy at birth in the US is around 78 years for a female; compare this with 79 in the UK, and an average across Europe of 80.5. Compare Japan's life expectancy of 83 years – on second thoughts, don't. A recent examination of pension fraud in Japan estimated that around one third of pensioners claiming pensions were in fact dead, and had been for many years. It's quite possible that life expectancy in Japan is not quite as exemplary as we've been told!  What we don’t know is whether healthcare is to blame for US having worse life expectancy than UK, or is it traffic accidents and guns.

Put simply, choice relies on perfect knowledge, and we definitely don't have so much of that in healthcare. It is very easy for an independent provider to distort the patient perception. Driving up quality needs a level of regulation which is not in the current health proposals.

Let’s explore quality in the next blog post.

When I arrived in Sheffield in 2004, my first task was to "kill" the ISTC (Independent Sector Treatment Centre) that had been "imposed" on the South Yorkshire SHA by the Blair government.

The local Chief Executives, of the PCTs, of the Teaching Hospital, Children's Hospital and Mental Care Trust, and most of the surrounding Trusts, couldn't see the point.  I went  about it in my usual diligent way, talking to people who knew about ISTCs in the Department of Health, in private healthcare providers, barking to a few dogs ("talking to everyone and their dog"), doing the numbers, working it out for myself.  It's not that I'm suspicious, just that I like to check for myself.  The numbers stacked up, I presented my report, and the ISTC was canceled before it left the drawing board.  Of the 38 originally imposed by the Blair government, 2 were canceled, 34 were terminated during the due diligence phase (at a cost to the tax payer of many £millions), and the remaining went into production.

An ISTC worked extremely well in the North West.  It triages patients and prepares them for operations, which are then carried out in NHS hospitals (at least, it did then).  It was brought in with the agreement of all parties, and filled a gap.  It was a success - but one size doesn't fit all! 

Reform of Urgent Care in London

I then did the numbers for a plan to overhaul Urgent Care in the capital - work which subsequently made its way into the Darzi review.  The political strategy this time was right, but it had still been formulated without a proper analysis and could easily have been as embarrassing as the ISTC debacle had been, and the Darzi centres were about to become.  This evidence justified the use of specialist heart centres, on the grounds that patient outcomes were better and ambulances responded to the right cases, even though some hospitals complained bitterly that they wanted the income from patient arrivals.  It made me ever so slightly sick, to think that some hospitals would rather get the fee for an A&E arrival, than let the patient get the best possible care in a specialist centre, care that cost the NHS exactly the same amount.

Coping with Darzi Centres

Firmly in the middle of front-line healthcare, I was involved in pulling together GP consortia, one to bid to run a Darzi centre (I think we were too honest about numbers and costs - the (private) company that won it already knew that they would buy in cheap doctors and understaff, on the grounds that no patients ever turned up), and the second to take over the activity of a Darzi centre once its 2 year lease had ended.  The local GPs didn't want anything to do with the centre, and ended up ignoring the building (exactly as the patients had done) but the service was provided cost-effectively in more appropriate and acceptable locations.

AWP, ACP, AQP

The current round of change and opportunities for GPs and the independent healthcare sector (the companies that Mark Britnell is encouraging to buy KPMG consultancy to join in) has gone through a number of titles, and there are subtle but important differences.

AWP - Any Willing Provider is a tacit term for "Anyone already in the NHS or already holding contracts with NHS".  Although anybody is supposed to be able to bid, in practice various reasons have been created to keep the services "in the family".  This upset Blair and subsequently Cameron, so they came out with a new title

ACP - Any Competent Provider was quickly morphed into AQP Any Qualified Provider after the usual round of "how do you know they are competent?"  It was rather inevitable.  However the change is important - basically AQP means that you (the supplier) has to be really determined to bid for a service, with all of the bid costs that entails, because this is about showing on paper that you are competent, not pointing to a track record.  In effect, the GP practices that "just look after our patients" find themselves excluded, and the aggressive for-profit companies can present the most convincing paper cases.  Almost a reversal of the AWP situation, and this is reflected in the legal cases brought by disgruntled losing companies against the commissioners of the services.

So why explain this?

It's important to understand where NHS is now.  The money may be "National", but the providers are in danger of becoming anything but - "International" might be a more appropriate description.

Is this necessarily a bad thing?  Not on the face of it, but small companies each providing their distinct part of the healthcare system can increase the cost of bureaucracy, reduce continuity of care for patients, and start an endless "blame game" when something doesn't work or a target isn't met.  I faced all of this when working with the group of GPs to take over a failing OOH and urgent care service - this is exactly why it was failing.

The NHS does have national standards, but every population is different, every network of healthcare providers is different, and the solutions must, necessarily, be different.  It wold be nice if we could simply take a template for healthcare out of a drawer and say "here is the solution", but just as a GP can't say to every patient with COPD "I don't care what else you have, take this drug to relieve your COPD", so those who make policy actually work have to tailor the solution to the need.

This is perhaps the biggest challenge, when introducing competition in health care.

It is very difficult to measure quality in health care, and even more difficult to measure it contractually and enforce it. One of the biggest challenges is that healthcare is changing so quickly, that we have to learn as we go along. So one month we measuring the level of blood clots, and the next the number of bedsores. This is practically impossible in a contract. Unfortunately, in an environment where money is paid under contract, and providers are driven by the profit motive, there are rather too many opportunities to cut quality and improve profit. It happened under Blair, and it's likely to happen this time around – especially if the comments being made to the US health provider sector, about the UK health market, are anything to go by.

Large integrated organisations, such as UK hospitals, can run extremely efficiently, delivering very expensive and highly detailed and complicated operations, and at the same time providing Accident and Emergency services. With a pool of staff, it's possible to fund the training and experience needed, by performing mundane and routine operations, so that the team is available when something more demanding comes up.

This falls apart when routine operations are taken out of the system and given to an independent provider. That's not to say that a bit of specialisation went improve quality – it often does – but it's incumbent on those planning and making strategy to recognise these challenges.

Keeping track of improving quality

Unfortunately, the so much variety in health care, the maybe very small numbers of each individual type of activity. With small numbers, one complication can completely distort the hospital's ranking, and give a false perception of quality. Because of the small numbers, numbers are aggregated over many years, which means that by the time action is taken against a poorly performing doctor, the figures will take years to recover. An organisation may be unfairly penalised, when they took the action they should have.

Who is capable of enforcing minimum standards?

The Health Secretary has made a big thing of ensuring that the experience gained by the PCTs is retained in the system. In order to commission services, and to enforce the contract, you need a set of skills:

• understanding the reports that come in from your provider
• understanding what they mean in context (taken account of small numbers, and the services in the round)
• the diplomatic skills to raise a query without resorting to the letter of the contract
• the legal right to demand that the contract being forced
• the teeth, or financial muscle, to enforce a contract, if this becomes necessary

I don't believe that units based on the size of the GP commissioning groups (effectively, in many cases, the size of the pre-2006 PCT's or smaller) will have any of these. If they're supported by "commissioning support" teams, made up of staff from the old PCT, then they may be able to understand the numbers. But it takes a director or chief executive to have the diplomatic skills; it takes an organisation the size of the new PCT's to have the economic muscle; not only do the hospitals have all of the information, this time round, in many cases, they also employ the community team, so the GPs have nothing to fall back on. For example, if the GPs want to set up a new heart failure pathway, then they will need trained nursing staff; the nursing staff are now employed by the hospital trust, who can easily say "there are no staff available", which prevents the GPs from setting up a new pathway, and means the hospital keeps the old pathway that they favour – and their income.

Who is the Regulator, and who is the Commissioner?

Part of the debate has been on the role of Monitor – the foundation trust regulator. Monitors ended up in a ping-pong match – will they be there to encourage competition? In which case, they're not in a position to demand a minimum standards, would withdraw licensed to provide services from someone in an area where there is little competition. Will they be there to encourage cooperation? In which case, what does cooperation mean in an environment driven by profit motive?

Will they be able to enforce minimum standards, then there are also required to encourage AWP (Any Willing Provider), or AQP (Any Qualified Provider)? Given the amount of political interference going on at the moment, will they be able to enforce anything without interference?

The best solution would be local enforcement. Quality, and improving quality, driven by the people for the people.

This doesn't mean elected members on GP consortium boards, because imposing someone on a board that it is designed to make GPs responsible. With resentment and end up being manipulated. This means separating the task of referring from the task of commissioning.

Commissioner should be the local authority, which has a lot of experience of commissioning, and has frameworks in place. Specific health experience can be gained by retaining the best of the commissioners from the PCT's, but as they join the local authority, they will John endowment where the commissioning framework is tried and tested, and well understood.

GPs can get on with doing what they do best; diagnosing, referring patients, and designing new pathways. To be no more conflict between "Commissioner" and "provider", as GPs are responsible for a flowing, and an independent body is responsible for ensuring probity.

And because the local authorities are accountable to the people in their areas, services will be appropriate to local needs, and we'll no longer have to dance to the Department of Health tune.

Politicians seem to be always walking on thin ice. Some seem to stumble from disaster to disaster, always managing to survive, perhaps because so little is expected of them.  Some fall at the first hurdle, and then are lost forever - perhaps more was expected so they have further to fall.

The campaign by the Daily Telegraph to discredit Liberal Democrat ministers seems to have found a weak point and exploited it.

One after another they tumbled. Much was expected of this – third – party, the last bastion of integrity. Thinking people voted for them at the last election in the hopes that they would bring some of that integrity back into politics.

Then the Liberal Democrats found themselves in power, as the junior partner. Perhaps it was deliberate on behalf of the Conservative strategists, perhaps it was inevitable, but the policies that they were asked to endorse were almost universally the ones that a glib party in opposition would scream for without thinking, but in government they would meet massive opposition.

So the Liberal Democrats are the fall guys, the Conservatives come up smelling of roses.

You could almost feel sorry for them, if they weren’t politicians. It suits the Conservative and Labour party to prolong two party politics, and a strong third party could mean an end to the comfortable gravy train of Westminster, which politicians of both parties have enjoyed so much.  But the Lib Dems know this, and should be wary.

WWJD? What would Jesus do?  Is Christmas an appropriate time to ask this question?

Jesus didn't compromise."forgive your brother seventy times seven" He says at one point, and He was never one to condemn.  But a personal injury, perhaps unintentional, is one thing.  Jesus was not backwards about coming forward about things that were wrong.  He criticised the Pharisees, and He criticised the moneychangers in the temple courtyard.

Integrity is often painful for the person with integrity, but without it, you become "mere bulk and body without breath, cold leg of lamb without mint sauce, cold slops, weak tea - you make me sick" (G K Studdert Kennedy).

The easiest job - an opposition front-bencher

Perhaps it is the easiest job in the world to be the party in opposition, and even easier to be the third party that will never see power; perhaps the Lib Dems got too complacent and have had what was coming to them.

But Britain will be the poorer.  We need our MPs to be a little off balance, with a challenge to serve the people not themselves. Many MPs are of course excellent, but too many got selected as party candidates for favours of the past, and now treat their privileges ias their reward.  There are very few poor MPs, whatever their background.

Perhaps nobody will ever vote for Liberal Democrats again? Let us hope this is not the end of three party politics for Britain.

You only have one chance to make a first impression. 
In fact, you only have one chance each time, to make a first impression that sets the scene for that day, that job, that opportunity.
Downhill skiiers get one chance to put in a really good time - this contrasts with some Olympic sports where the competitor re-runs the same activity and the judges take "best of 2" or "best of 3".  This means you can afford to make a mistake (but the competition's still intense - everyone else has the same rules!).  Even in one-on-one competition such as Judo, each competitor gets a second chance to redeem themselves from an earlier mistake.  It becomes a game of "who makes the least mistakes wins".
But in Management Consultancy, you often don't get that lattitude.  One mistake, one slip of concentration, and you are damned. 
Of course you can approach other clients, start other jobs, but can you really afford to lose out?
Athletes train for years to prepare for the Olympics, putting in thousands of hours of intense practice for their 100 seconds of glory.  Athletes train just to attend, knowing that others will almost certainly walk away with the medals.  But it's worth it.
It does take effort, keeping up with the latest developments, focussing our solutions on the needs of our clients rather than on an approach that "should work in theory".  We put the effort in, and I believe the results speak for themselves.

Why do so many silly ideas become law?
Most of the politicians I know have exceptionally good memories, and studied history. So why do they repeat the mistakes from former years? Perhaps because they've learned the lessons that apply to them, and the mistakes that apply to the general public don't apply to them.
A perfect example of this is seen in both the public sector and the commercial world. A manager or leader has built their reputation on always balancing the budget. They are sent in to troubleshoot failing divisions: they cut spend immediately, usually by terminating all the R&D, and everybody praises them because now costs are lower than income. Then they move on to the next piece of troubleshooting.
And what happens?
within a year or two, the lack of R&D means that this organisation's outputs (services or products) are no longer fit for purpose. It falls to the next manager to take the blame -- the previous self-serving manager retained only the glory of having balance the budget. Of course the previous self-serving manager is also great deal more senior, and is therefore in an even stronger position to make sure the blame lies elsewhere.
You can achieve the same result by terminating overtime, cutting staff, and making everybody work harder. It takes a little while before everybody goes off sick, and people start resigning and finding other jobs. The canny self publicist is well aware of this time-lag, and has moved on quickly. A very clever self publicist will identify where someone else has just done the right thing, and unseat them in time to reap the rewards.[reference available in Freakonomics]
How long does it take for the pigeons to come home?
Typically the effects are visible between 18 months and two years after the change. That's why I call this the two-year rule.
Look around you -- how often have you seen this happen?