Quality and Competition in Health and Social Care

LSE Seminar Tuesday 5.7.11.

Professor Alistair McGuire (from the LSE’s Health and Social Care Department) introduced researchers Dr. Zack Cooper (LSE)  “Does Hospital Competition Save Lives? Evidence from the English National Health Service”; Dr Irine Papanicolas (LSE) “Payment by Results and Quality in the English NHS” and Professor Julien Forder (PSSRU Kent and LSE) “Measuring Quality and Outcomes in Social Care”.  (Papers are on the LSE website).

The Seminar was part of a series funded from an HEIF 4 Bid to communicate research work to the general public.  Fifty people or so attended yesterday, but several individuals who asked questions identified themselves not as members of the public but as employees, variously, of the Audit Commission, the Department of Health, NHS managements and a local authority.  One questioner declared himself to be a researcher like the three platform speakers and a group of young people who might have been LSE students left midway through the event. Of questions in the meeting which came out of personal experiences of ordinary members of the public, a ‘Unite’ official described her reaction to being told she had cancer and a mother described an ambulance driver deciding to which hospital she and her two children should be taken in a recent emergency.   Both said that in those crises what they wanted was the best treatment as soon as possible rather than being presented with a choice of hospital. Barry Silverman spoke from the floor as a medical doctor and member of the FRCS, describing three projects he worked on in London whose results were opposite to the results claimed in the two health researchers’ work.  Likewise Robert Bourne, from the SHA, speaking as an actuary offered an opposite result to theirs of research he had carried out into three hospitals where he had found no “acceleration in improvement from 2006” the year decisive for the credibility of the  two researchers’ conclusions. (“At 2006 there was a fork”, Dr. Cooper claims of his graphs and data).

Dr. Cooper said his research had attracted attention from the British newspapers and approval from the Prime Minister.  It was, he said, about evidence based policy but he began with theory:  “No country in the world is not trying to slow down hospital costs” he said, “because hospitals are where the money is”.  The aim (of lowering costs) was achievable through choice and competition which were, he said, the third phase of management that will have been tried in the NHS.  Dr. Cooper defined the first phase as “Trust” (where the medics were in charge of management); the second as “Command and Control” (instigated, he said, by Tony Blair) where “you measure and then you punish”; third was “Choice and Competition” where you measure first what matters to patients.  “The name of the game for me,” said Dr. Cooper, “is ‘value’ or ‘more for less’. In my opinion money should follow the patient because patients choose better hospitals”.  As for validating his own work he challenged, “What I’m trying to sell: did it do what I said it would do?”.  The whole thesis was summed up on one graph below a power point title which read “Hospitals located in competitive markets began to lower their mortality rates more quickly from 2006 onwards”, or explicitly, “patients live longer in competitive hospitals”.  Parallel with his own research Dr. Carol Propper at Imperial College London had studied and reached the same broad conclusions in another economics paper.  “Nothing we could throw at them” (the conclusions) had invalidated them, he said.

Dr. Wendy Savage however queried Dr. Cooper’s reliance on data from Birmingham about choice of hospital made by ambulance drivers and maintained that waiting times had reduced because of money spent on hospitals, not because of competition.  To the question “Has your paper been peer reviewed ?” Dr. Cooper answered that the U.S. ‘Economic Journal’ had his paper for peer review.  Following the meeting, he said he expected the ‘Economic Journal’ to finish the peer review in two years time.  He confirmed no peer review yet exists. This point was repeated in the seminar by a questioner who pointed out that the ‘Economic Journal’ is concerned with economics.  No health journal has peer reviewed Dr. Cooper’s study.  I have since established with Dr. Propper that her research, likewise, is a ‘working paper’ with an American economics journal expecting to be published in 3 -5 years.  It is not yet peer reviewed.

Dr. Irene Papanicolas presented “Payment by Results and Quality in the English NHS”.  Like Dr. Cooper’s, this presentation required agility to comprehend a succession of graphs, formulae and acronyms in power point screens.  A disadvantage for a lay audience is in the volume of data, its complexity, jargon and strangeness.  Dr. Papanicolas’s conclusion was ‘payments by results’ (PBR) brought improvement, which Professor McGuire as Chair endorsed:  he said two million people were in the study by Dr. Papanicolas and fixed prices (the so-called fixed price tariff) had improved the NHS. A former NHS manager who was speaking, she said, as a layman supported PBR:  before PBR her hospital received a block contract and had had to do extra work for the same money, whereas when paid for the work actually done, the hospital could afford to employ more staff.  In addition, PBR meant doctors looked at their clinical performance, she said.  An Audit Commission representative however said they questioned the improvement brought about by PBR.  In response Professor McGuire asked “Who wouldn’t want an improvement of 30% ?”. Dr.Papanicolas cited hospital re-admission rates with the warning that they did not by themselves imply poor quality.  She mentioned several times that the ‘outcome figures’ were very “noisy”and one had to be “very careful in interpreting them”.  A questioner from LSE asked “How do you isolate PBR when a mass of policy effects brought changes?”, to which Dr. Papanicolas again referred to what she called the problem of “noise”.  Another questioner asked Dr. Papanicolas how many patients she had interviewed for her study.  (Dr. Papanicolas did not answer this in the meeting, but, at the end at the informal reception, Dr. Papanicolas confirmed to me that she had interviewed no patients at all, relying instead on ‘headcounts’ from the hospitals themselves or from information from Dr. Foster, the information gathering organisation).

The third speaker, Professor Forder was the easiest to follow and his conclusions least controversial:  standards and prices varied greatly in residential homes; outsourcing of local authority provision had had “an impact on quality” and been a huge experiment; his research tallied with star gradings of homes by the Care and Quality Commission; residential care homes were generally better than nursing homes.  The difference between Health and Social Care was the little data available in Social Care.  He had taken a pragmatic approach, given the cost of research, namely to attempt to measure well being or a quality of life.  Answers showed that feeling of control over one’s life topped even good food, safety, cleanliness,social activity and interest for most people.

One question to the researchers at the meeting was “Do you meet patients or are you in an ivory tower ?”  The fifth floor seminar room tops the tower-like LSE Library. Hundreds of students toiled on every side of a giant spiral staircase in what was yesterday stuffy, stale air and lift failure.  The question was not fanciful.       Roger Gartland