Thursday, 10 May 2012

Interview : Prof Ian Shaw on the NHS

The BFTF radio show recently featured a fascinating interview with Prof Ian Shaw who is the Professor of Health Policy at the University of Nottingham’s School of Sociology and Social Policy, and is also (amongst other things) a Non-Executive Director of NHS Nottingham City Primary Care Trust.

The interview covered ground ranging from pandemic preparedness to Gujerati eating habits but focussed mainly on the NHS, and where it might be heading as a result of the recent Health and Social Care Bill.

This post contains a transcription of the key parts of the interview relating to the NHS, where is might be heading as a result of the recent changes and what you can do to influence it’s direction (the time-poor or attention-span deficient amongst you may wish to read an extra-condensed version here).

BFTF :So, Professor, what is your role at the University

Ian Shaw : The day job is as a Professor of Health Policy at the University of Nottingham. I have a personal chair which means that I can do, essentially, what I like in terms of research unlike some Professors who are tied to a particular activity because they are in a sponsored post. . .the day job is really about health service evaluation and my interest in that.

The Non-Executive NHS post sort of complements the day job, which is essentially why the University lets me do it. I spend one day a week working for the NHS as a public service duty and the University is very good to let me do that. “Non Executive” is a role that is there to advise on the strategy of the organisation but also to assure the organisation around quality, around performance, around risk management and around finance - to bring an independent voice to those issues.

I was appointed as a non executive director of Nottingham City Primary Care Trust in 2002 when it was first formed and it is coming to an end in April 2013 so it has been a good run and I have had 4 re appointments during that period so I must have been doing something right. And from August last year I was also appointed to the county PCT as part of the transitional arrangements for the Health and Social Care Bill.

QMC, Nottingham

BFTF: What is it like being on high level boards like these?

Ian Shaw : A: It is a particular sort of environment. Actually most of the work is done in the committees which is why the board is just one day a week. At board level non-executives are in the majority so the non-executive voice is strong in the PCT. That is changing a bit with the reforms but because of that if you are appointed you are generally bringing something to the table. Non executives are bringing different things, different sets of expertise so you can stand there and say “Does this make sense?”. You provide a challenge and they have to convince you that it makes sense

BFTF: How can people find out more about what the directors of the NHS are doing?

Ian Shaw : The best thing to do at the moment, because we are in a period of transition, moving from PCTs being in charge of the buying and selling of health services. . .to the clinical commissioning groups doing it. If you google “NHS Nottingham City” you’ll get the website with both the CCG and the PCT and all the board papers are on there, published at least a week in advance and the public is welcome to ask questions which are read out in board and to attend the board meetings as well. The other thing I’ll just mention is that the “gig” is coming to an end because of the reforms and the organisation (PCT) is ending in April 2013. The new organisation, the Nottingham City Clinical Commissioning Group is starting in 2013 and they are advertising today in the Nottingham Post for non-Executive Directors, or lay-members as they are called.

BFTF: How much to you get for being a non-Executive Director?

Ian Shaw : It varies from CCG to CCG, I think it is about £7,000 a year, which you are taxed on.

BFTF: And what kind of people do you think might be interested or would you suggest should think about this?

Ian Shaw : People with a degree of experience in community, academic or business organisations. Somebody who can bring something to the table. One of the new posts is on community engagement so people who are involved in community engagement might want to apply.

A&E Department, QMC, Nottingham

BFTF: Moving on the Health and Social Care Bill, and the NHS generally, you have a very interesting blog that is hosted at the University of Nottingham website and one of the posts was about the “Kidderminster Effect” and how competition doesn’t always pan out to be a good thing. Can you give a little more information on this.

Ian Shaw : Kidderminster was a district general hospital, a bit like the QMC only a lot smaller, in Worcestershire. And Worcestershire had three district general hospitals serving around 526,000 people. Now Nottinghamshire has two big district general hospitals - Nottingham University Hospitals Trust, which runs the QMC and City hospital; and Sherwood Forest up in the north of the county. And the population of Nottinghamshire is about a million, so you can see that they [Worcestershire] didn’t really need three district general hospitals so they decided to beef up two and Kidderminster.

And they did it BADLY.

They didn’t tell people WHY they needed to close Kidderminster, there was an A&E department at Kidderminster there so people were thinking “Oh my goodness, I’ve now got to travel further, if something happens to me I’m going to die in the ambulance”. . . they just announced that they were going to do it , it was a way of rationalising resources and for the Health Service to save money - they could save £20million by selling the site - but, to use a cricketing analogy, they didn’t roll the turf before they bowled the ball and if you don’t do that then the ball can bounce all over the place.

Harltey Road Medical Centre, Nottingham
BFTF: How could it have been done better? How could they ever have got the staff at the Kidderminster hospital on board?

Ian Shaw : Well, you need to explain to the staff why you are doing the changes that you are doing. You don’t need to get them on board but you need to explain that there are going to be jobs elsewhere, that they aren’t going to get laid off.

It is the community which is the big effect. You have got to flag up to the community at an early stage and explain why. The community doesn’t like to listen to me, or NHS managers - it likes to listen to doctors, and if they are GP’s, if they are the leading doctors in their community and they tell the community that this is a good idea, they they’ll listen.

But [in Kidderminster] it wasn’t explained to the doctors in the communities, they just decided to do it. And it was a misunderstanding about who owns the NHS. The managers thought they owned it. They don’t - the people own it.

BFTF: Just to pick on one point there about people thinking they are going to die in the ambulance - your local hospital 500yds down the road closes and you are now, by definition, further away from treatment. How can you ever pitch that as a good thing?

Ian Shaw : Well, this is getting topical because the QMC is going to be turning into a trauma centre so people from all over the East Midlands are going to be travelling into Nottingham.

The question is - is the journey time worth the benefit of the treatment at the end? So there is going to have to be very good triage by the paramedic in the ambulance- telemedicine, whereby there are videolinks with consultants at the hospital, can help with that and decide where that person goes. Do they go to their local District General Hospital or do they go to the QMC and how do they get there. . .

In north London at the moment, there are four A&E departments that are going to close - that is going to take an awful lot of “rolling of the lawn”.

But it’s not just the big services, it’s the small services as well, like GPs relocating into one unit, as you have in West Bridgeford, for example, which is an eminently sensible idea because you can get more resources in there. . . but wasn’t necessarily explained to the practice community very well and there has been some resistance.

MEMS, Nottingham

BFTF: One thing I perceive is that when you have these centres of excellence, the doctors there get a critical mass of cases that they see and they see more of the rare cases. Is that a significant factor in having these kinds of centres of excellence?

Ian Shaw : Yes, there are two things - economies of scale but also centres of excellence. If you are having an operation you don’t want someone coming along and doing the operation who says “Oh I haven’t done of these in a while”, you want someone who is doing it day in and day out [as is the case in centres of excellence].

BFTF: That feels, as a layperson, to be quite a good argument- your local hospital is being scaled back but you will have these better facilities a bit further away.

Ian Shaw : You have to explain that it is a movement, that there are costs and benefits but overall the benefits are better. There is some concern about Ambulances sites closing for example. But Ambulance stations are different because ambulances are strategically placed, in laybys and supermarket car parks for example at all times so that they can respond quickly to an incident. So it doesn’t matter where an ambulance station is, it’s not like a Fire Station, which is where the fire trucks are, so if you move the Fire Station 3 miles you have a longer response time.

Linden House Neuro-Stabilisation Unit, City Hospital, Nottingham

BFTF: Moving on a little to talk about competition. On the one hand superficially you can understand it, people are competing, they’ll try harder. But then you think about within an organisation - suppose you have an engineering company with five engineers - if they are all each keeping their good practice to themselves, they are hoarding their secrets, they don’t want to co-operate with the other engineers - that company isn’t going to last very long. How do those two drivers relate to the NHS?

Ian Shaw : There is what’s happened historically and there is what is going to happen in the future - so I’ll handle those separately.

What has happened in the past is that going back to 1997 when the Labour Party came in, although I don’t want to get political, at that time there were people waiting for nine months on waiting lists - and that wasn’t uncommon so what the NHS did was say, here are some more resources, we want more facilities but also, if you can use the private sector sensibly where there are large queues to take the pressure until this new money in the NHS can build capacity then that is a sensible way to do it. It was also useful in that it corrected one of the original conflicts of interest that was built into the formation of the NHS in the first place. In order to get the NHS formed, Bevan told the doctors that they could do private work as well as their NHS work. Now if you have that situation then the length of your waiting list interacts with the likelihood of people to want to go private so where was the incentive to want to reduce the waiting list? Giving the commissioners, these new primary care trusts, the power to buy services from the private sector where these waiting lists were long essentially took the power off the consultants to manage these waiting lists for the benefit of their private income and brought the waiting lists really down and what we saw was private insurance going really down as well because why would people have private insurance if they can get good quality free care on the NHS.

So that was the situation before the introduction of the NHS and Community Care Bill. The situation after its introduction, which is now is that all significant contracts are going to have to be put on open tender. That means that the private sector can compete with your local community NHS service for example or your out-of-hours doctors service to compete for that service. They will compete on costs and on quality and it is up to the primary care trust at the moment, CCG’s soon, to procure those services through a contracting procedure and monitor them once the contract has been done.

Nottingham Radiography Centre, City Hospital, Nottingham
BFTF: How does European competition law and the wish to balance cost and quality affect how decisions might be made?

Ian Shaw : If - IF - the contract continues to be based on quality so that it is the same quality going across and what you are doing is competing on quality then that is not necessarily a bad thing. The problem is that you have in some areas - In fact Virgin has just taken the NHS to court and lost for predatory pricing i.e. they [the NHS] weren’t taking a profit out of the system so therefore he couldn’t compete against them. It’s get into difficult waters if you start competing price, if you compete on price you are goinf to be driving the quality levels down. Competition has got to be done on quality and at the moment the safeguard is still there for competition to be done on quality but it’s literally a very small safeguard. At the moment all conditions have a price based on the average cost of doing something, so for example the average cost of doing a hip replacement. So everyone [providers] gets paid that price and so long as everyone [patients] gets the full range of work then that price is fair. . . The problem is that the NHS, because it has accident and emergency centres and all this acute care in case something goes wrong, can take more serious cases and the private sector can’t. So the private sector says “we can’t take these more expensive cases, these more serious cases because something might go wrong so we’ll only take the easy cases. Which means they are not playing on a level playing field, they are cherry picking the best cases on the basis of clinical risk.

BFTF: Do you think that might end up with the private sector saying “Look, we can do hip operations for x pounds whereas the NHS operations are costing twice as much”. Is there a possibility of that argument being made?

Ian Shaw : Well, because the NHS is doing the full range of work and if you give the easy work to the private sector then yes the NHS is going to have the harder work, will take longer to do it and will be more expensive. So they will be getting the same pay for more difficult work so they start running into cost problems. So the contracting is going to have to be careful to state that the full range of work should be available, all the different types of cases.

Sign, City Hospital, Nottingham
BFTF: Outside of this interview, you have mentioned a House of Commons report that stated that transaction costs were 14% of NHS total costs, but that there was no evidence that these transactions delivered 14% more productivity. Could you just elaborate on that a little bit?

Ian Shaw : At the moment, this was House of Commons select committee report in 2009, which showed 14% of the total budget going transaction costs - they buying and selling of goods and services in the market, the contracting and the monitoring of these contracts

BFTF: Admininstration essentially

Ian Shaw : Exactly, and there was no evidence at all that this was creating 14% of added value in terms of productivity or quality. Indeed in Wales and Scotland there is no contracting. . .Scotland started to do contracting and then realised that they were not getting any benefit from it. There is some evidence that competition works between trusts and teams within the health service, aiming to get a better status or reputation. But bringing in the private sector doesn’t seem to have any positive impact as far as the NHS House of Commons Select Committee was concerned. And that committee was run by conservative MP and ex Secretary of State for Health Steven Dorrell.

Moving forward the issue is that there is going to be more contracting, so more and more transaction costs and particularly in terms of monitoring the quality. Now we’ve seen problems in the quality of the private sector recently with care homes, learning disability homes, mental health and you cannot just give people contracts, you have to monitor what they are doing in the contacts to make sure they are delivering because you have patient care and patient experience as a strong moral duty if you are commissioning. A big worry for me is that the level of management costs in these new commissioning groups is capped so it is going to be challenging to do all of the monitoring of the contracts, the quality assurance that they are going to have to do with increased numbers of providers.

Departments, City Hospital, Nottingham
BFTF: Can ordinary citizens challenge their local Conservative or Lib Dem parties or the Dept of Health and say “Can you assure me, as a Citizen, that these contacts are going to be monitored adequately?”

Ian Shaw : I can’t see the Bill getting changed, it’s in so it’s going to be in until this government ends. The big thing is the Health and Wellbeing boards which are set up by local authority area and decide the health and social care strategy for the communities which they serve. The elected representatives, councillors, form a large group on that board so that the attitudes of the councillors are REALLY important for how this is going to role out within a locality. Now, the national politicians know this - the Labour party is campaigning in local elections on this issue, and that is really them saying that they want their councillors in the Health and Wellbeing boards and we want to see that this competition isn’t working adversely.

BFTF: Why am I hearing these clearly defined points from you? Why didn’t I hear it on the news? Why didn’t I hear it from the MPs? Why has it taken getting you into this studio to hear all this stuff?

Ian Shaw : That is a long argument. Twitter has been alive with criticism over the BBC particularly on their reporting of the NHS reforms and particularly the protests against the NHS reforms. There is not one single Royal College or Union which has not stood up to these reforms. They are trying to impose reforms on the NHS when all the Royal Colleges and unions are against it, so it is going to be interesting to see how that plays out. And that is why the Health and Wellbeing boards become important because there is resistance in the system against this which is why getting a policy through at government level is not necessarily the same as it happening on the ground.

The BBC has come under criticism. . .Al Jazeera covered the NHS protests far better than the BBC. The fact that the chairman of the BBC has large shares in private health companies probably has nothing to do with it.

It is very strange, it is a national institution, of national importance, health is crucial but it has not been fully covered by the BBC and there have been hundreds of complaints against the BBC over this.

Services at Mary Potter Centre
BFTF: One other point about the Bill, perhaps a bit of a technical point, but one that is often mentioned is that the Bill allows Trusts to take up to 49% of private work. What is the concern here?

Ian Shaw : The concern is two fold. Firstly, most of the big NHS Trusts are working at full capacity anyway, so where are they going to get 49% of free space to bring in private patients.

And the second thing is, why on earth would someone want to go privately when they can have things done free, to a good quality, in a timely manner within the NHS where they also have choice. Why would they want to do it? The concern is that it signals what might be about to happen to happen to the NHS in terms of limiting its budgets, in terms of cutbacks to services and if you get to a stage where waiting times start to get political, if you get to the stage where people are thinking “Well, I might have to go private to avoid these things” or some costs become privatised then that is the worry. It’s not what’s happening now, it’s what that signals is going to happen down the track.

BFTF: And how does that 49% compare with how the legislation stood last year?

Ian Shaw : It was a cap at 3%

BFTF: Again, I’m just gobsmacked that I’m hearing this for the first time, quite unbelievable. Before we wind up the interview, is there any key message you want to get across to the public.?

Ian Shaw : There is concern about the direction of travel of the NHS. I don’t think anything is going to happen now. I don’t think anything is going to happen this parliament. I think it depends on who gets in next time and what sort of platform they are on for the NHS. But I am concerned that the “free at the point of use” bit - which is there now, it’s there with these new reforms but I think it might be under threat in the future. Bevan said that the NHS would be there so long as people defend it and I think that people need to be aware that it needs defending.

BFTF: Do you think it might go the way of dentistry has gone?

Ian Shaw : Well that is one of the scenarios on under this direction of travel. You might get the basic service free but they might say, “well, you’re in a bed, we’re changing your sheets, we are going to charge you hotel fees and we’re feeding you so we are going to charge you for food”. You can see the ways in which a cash starved service might keep to the letter of free-at-the-point-of-use but actually the add-ons become very expensive and in the US almost half of all bankruptcies are because they cannot afford to pay their medical bills and I would hate to see Britain move to that situation - nobody is suggesting that they are moving to that situation at the moment but I think that really we need to be alert to the possibilities that the direction of travel is moving.

BFTF: I guess we all have a role, we can all lobby and tell our elected politicians what we want and what we don’t want.

Ian Shaw : Exactly

BFTF: Ok, we’ve come to the end of the interview and the final question, that is asked of all guests is quite simply “What do you think is the best thing about living in the UK”?

Ian Shaw :. . . I think it’s two things. One is that there is a degree of security here, you can walk the streets and you can live fairly peaceably. I think the other thing is that there is a degree of social justice and I think that some of the institutions of social justice, like the NHS, help to frame that - but you see this, community spirit occasionally like if you are on a train that has broken down, it’s hot, there’s no water and people start sharing, start chatting and all of a sudden you know why people are doing visits, why they are on the train, that grandchild they are going to visit. You scratch the surface and there is a good community there and that’s what I like.
NHS Flag, QMC, Nottingham

br /> Image Sources: All BFTF's own.