Supply and demand

Tweet Over the years I’ve sat in a number of meetings with health service managers and professionals who have patiently explained why there is no need for anyone to worry about reductions in the number of beds in our hospitals.  Their logic has always struck me as impeccable.  Treating more people in the community, shorter hospital stays, less invasive surgery – all of these should indeed lead to a reduction in the total number of beds required.

Logic, however, isn’t enough if there are underlying problems with the data and assumptions.  And if the starting point is not right in the first place, then simply moving the goalposts in line with changes in all the factors listed simply perpetuates any mismatch between total demand and total supply.  Sooner or later such contradictions will inevitably be exposed.

This report a week or two ago that 2600 routine operations were cancelled because of a “lack of beds” should come as no surprise to anyone, in that context.  What was a surprise however – even to a hardened old cynic like me – was the way in which health chiefs explained the situation.  Even more surprising is that they appear to have got away with it.

The problem, to listen to them, is not on the supply side at all – it’s on the demand side.  There aren’t really too few beds – just too many patients.  It’s not their planning and assumptions that are wrong – it’s simply that too many of us became ill last winter.  In short, it’s our fault not theirs.

The problem with dismissing the problems of last winter as some some sort of blip as a result of too many people becoming ill is that no proper action is taken to address the underlying mismatch between supply and demand.  And unless that is done, we can probably expect a repeat at some point in the future.

How on earth are those in authority getting away with this one?

Centralising health care

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When organisations engage consultants to tell them what to do, they usually already know the answer; they just need an outsider to boost their credibility.  It’s why consultants are often referred to as people who borrow your watch to tell you the time; as often as not, they simply write down in black and white exactly what you want them to write.

Those paying the outside consultants inevitably have a degree of influence over what they write; and those who have the most influence are those who choose the consultants and write their brief.  In all of this, governments and public sector bodies are no different from private sector companies; he who pays the piper calls the tune.

No-one should be surprised that the report on the Welsh Health service written for the Welsh Government comes down in support of the Government’s changes; that was pretty much guaranteed from the outset.  The danger is that politicians get so involved in trying to discredit both the report’s author and the minister, for largely political reasons, that they lose sight of the underlying arguments.

As far as I can see, there is a high level of consensus (albeit not unanimity) amongst health professionals that there needs to be a shift in the balance between what is delivered locally from a number of generalist units and what is delivered more centrally from a smaller number of specialist units.  That is being driven by a number of factors, including the increasing specialisation of practitioners, the need to maintain specialists’ skills through them seeing an adequate number of cases, the increasing cost of some treatments and equipment, and recruitment difficulties. 

None of those factors have a terribly high level of respect for the rurality of Wales.  But neither is there anything in any of those factors which undermines the argument for most of the more routine cases to continue to be dealt with locally.  The problem is where to draw the line – and what happens when, as many of those believe is now the case, the line needs to be moved?

There is a natural tendency for people to want to retain as many services as possible in their local hospitals – and there is a natural tendency for politicians who want their votes to support them in that desire.  (And it isn’t limited to opposition politicians; some Labour AMs have been equally quick to make the same arguments, even if it’s their government behind the changes.)

So far, the government has simply not been getting its case across effectively.  When opposition AMs – and even government AMs – denounce any and every proposed change as a ‘downgrading’ of one hospital or another, the rational argument for some change quickly gets lost in the shouting and demands for resignations.  The government hasn’t always helped its own case; the concentration has always seemed to be on what’s moving from a hospital rather than on what’s staying; but then, that which is changing is always more interesting than that which is staying the same.

Faced with such difficulties, it’s hardly a surprise that the government sought some outside help to examine the situation and shore up its position.  Nor is it surprising that the expert selected is sympathetic to the government’s position; the majority of other experts in the field would have been equally sympathetic.  So why are they in such a mess now?

I suspect that it’s partly because the move to make changes is to some extent anticipatory rather than reactive.  The search for the ‘killer’ arguments about how the current system is letting patients down is a vain search if the problems being addressed are those of the future rather than the past.  The danger is that waiting for the killer arguments is likely to mean that they become exactly that – killers.  Waiting until there are a sufficient number of excess mortalities to prove the case isn’t really what I want of government.

And yet, without those arguments, it can, and frequently does, look as though the government is acting for financial rather than clinical reasons.  And the e-mails released this week give the appearance of a degree of selection of relevant facts and statistics to support a pre-determined outcome.

Whatever the outcome of this week’s hoo-hah, the underlying problem will not go away.  We need a sensible and rational debate about what local hospitals can or cannot continue to do, safely and effectively – and what requires a degree of specialisation which simply cannot be provided locally.  I’m not seeing much of that debate at present.

Nice little earner

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PFI has been a nice little earner for those companies who’ve been able to take advantage of it.  The theory is that it’s some sort of partnership between the public and the private sector; the reality is that one part of that ‘partnership’ has benefited, whilst the other has lost out.

Those cash-strapped public bodies who found themselves pushed into using the approach have found that they have got shiny new hospitals and schools which they could not otherwise have afforded, but are faced with huge ongoing annual costs about which they can do little.  And that, in turn, has constrained their ability for further investment in other facilities until the end of the contract period.

The companies, on the other hand, have found themselves with a guaranteed source of long-term income, whilst all the risk remains with their customers.  It’s a completely unequal partnership, and has been from the outset.

No real surprise then that the CBI – which represents the sort of companies which have benefited – is again pressing for Wales to use PFI.  From their perspective, it’s a neat way of transferring resources from the public sector into the private one.  But over the long term, it also means that the public sector gets less for a given amount of expenditure – the opposite, in effect, of what the CBI and other organisations have long been urging on government.

The Welsh Government is absolutely right to rule out PFI – and I hope that they will continue to do so.

Andy and Ben

Tweet I bet that Ben Bradshaw is glad right now that he was reshuffled out of the Health Department in June, given that the Health Secretary has announced today that car parking charges will be abolished in English hospitals, following the lead set by Wales and already followed by Scotland. If he was still at health, he might well have found today's speech by Andy Burnham to be a bit too much to swallow.

When Wales set the pace, Bradshaw claimed it would be at the expense of reducing waiting times.

When Scotland followed suit, he said that it was not a "sensible use of limited resources". He also seemed to be saying that it was not a decision which could be taken centrally, since "In England, hospital car parking charges are decided locally by individual trusts to cover the cost of running and maintaining a car park".

Twelve months on, and the English Health Minister declares to the Labour Party conference that it's not only possible; it's both desirable and a priority for use of resources. Amazing how an impending election concentrates the mind and enables objections to be overcome.

There's a wider lesson to be borne in mind as well. When a Labour Minister says that something can't be done, (s)he is not necessarily telling the whole truth.