Too often, the debate over the merits of the English Government’s
market-based reforms of the NHS have revolved around anecdotes,
hyperbole and in the best cases, theory. However, now that the reforms
have
been in place for several years, we are in a good position to begin to
analyze
whether the reforms have improved quality, efficiency and equity in the
health service.
The Government’s market-based reforms, which revolve around increased
patient choice and hospital competition cannot be judged without evidence.
To determine how the reforms have performed and to influence future
policy-making in the NHS we need for more quantitative and qualitative
research.
This raises an important point. No research, whether quantitative or
qualitative, is without limitations. There are no perfect data sets,
there are no
fool proof measures of quality and no matter how the reforms are analyzed,
there will always be caveats. However, that does not mean that we should
not continue to try and measure and quantify the impact of policies.
Indeed,
the imperfect nature of research highlights the need for more analysis,
not
less.
Our paper “Equity, Waiting Times and the NHS Reforms: Retrospective
Study” published in the BMJ on September 3rd, looked at one particular
measure of equity: how waiting times were distributed across the
population
in relation to social class over time. We found that based on that
particular
measure, the NHS became more equitable. We certainly agree with Dr.
Katikireddi that more research needs to be done to assess the impact of
the
reforms on other aspects of equity. We are presently in the process of
doing
just that and we encourage others to do so as well.
In their rapid response, Pollock, Godden and Kirkwood question
whether
the incomplete data about Independent Sector Treatment Centre programme
throws our conclusions into doubt; they also the warn against trusting
published waiting times figures.
Our response to Pollock et al has three strands. First, the ISTC
Programme, however dramatic the headlines it has produced, is responsible
for a small sliver of NHS care. The ISTC program is far less than 10% of
total
NHS spending and accounts for less than 3% of total NHS volume. In fact,
the
ISTC programme has not actually cost £5bn as Pollock et al suggested.
Instead, the 5bn pound figure was an estimate of what the program might
spend eventually. To date, since the ISTC programme was introduced
several
years ago, the actual sum is closer to £3.5bn – 1.5bn for Wave 1 and £2bn
or
less for Wave II.
Second, our data, derived from the NHS Clearing Service, did have
data on
Independent Sector Treatment providers, although there was certainly not
data on every case that the ISTCs performed. For knee replacements, in
our
data 3% of procedures performed in 2005, 3.2% or procedures performed in
2006 and 7% of procedures performed in 2007 were marked as having been
performed at ISTCs. Likewise, for hip replacements, in our data 2.5% of
procedures performed in 2005, 2.9% or procedures performed in 2006 and
5.9% of procedures performed in 2007 were marked as having been
performed at ISTCs. The cataract data clearly had a lower percentage of
recorded private cases, with a negligible number of cases recorded each
year.
However, even if we excluded every private sector case and assumed that
they accounted for a larger share of overall care than they did, this
would not
have influenced the patterns we see in our results.
Third, most NHS analysts routinely use HES data for analysis. HES
data is a
rich source of information. Ignoring HES data because of its limitations
is
cutting off your nose to spite your face. We agree that HES data, like
all
administrative data has its problems, as indeed we discuss at the end of
our
paper, but it would be very hard to claim that they are of sufficient
magnitiude to invalidate our results. In many ways, it seems like Pollock
et
al’s motivation to dismiss HES data has more to do with our findings than
the
data itself.
The NHS is facing increasing pressure to do more with less. This
type of
pressure requires creative policies and a realistic analysis of what works
and
what does not. Our paper was not definitive proof that the Government’s
reforms were a success. What our results suggest is that the NHS market-
based reforms did not harm the equity of waiting times. This is good news
for everyone. While we can appreciate some of the skepticism towards a
greater role of the market in the NHS, we would hope that analysts are
driven
by peer review evidence, not by ideology.
Competing interests:
ZC, AJ, and SJ have no
conflicting interests to declare.
JLG worked part time in the
Policy Directorate at No 10
Downing Street from October
2003 to June 2004 and full time
from June 2004 until August
2005.
Rapid Response:
A response from the authors
Too often, the debate over the merits of the English Government’s
market-based reforms of the NHS have revolved around anecdotes,
hyperbole and in the best cases, theory. However, now that the reforms
have
been in place for several years, we are in a good position to begin to
analyze
whether the reforms have improved quality, efficiency and equity in the
health service.
The Government’s market-based reforms, which revolve around increased
patient choice and hospital competition cannot be judged without evidence.
To determine how the reforms have performed and to influence future
policy-making in the NHS we need for more quantitative and qualitative
research.
This raises an important point. No research, whether quantitative or
qualitative, is without limitations. There are no perfect data sets,
there are no
fool proof measures of quality and no matter how the reforms are analyzed,
there will always be caveats. However, that does not mean that we should
not continue to try and measure and quantify the impact of policies.
Indeed,
the imperfect nature of research highlights the need for more analysis,
not
less.
Our paper “Equity, Waiting Times and the NHS Reforms: Retrospective
Study” published in the BMJ on September 3rd, looked at one particular
measure of equity: how waiting times were distributed across the
population
in relation to social class over time. We found that based on that
particular
measure, the NHS became more equitable. We certainly agree with Dr.
Katikireddi that more research needs to be done to assess the impact of
the
reforms on other aspects of equity. We are presently in the process of
doing
just that and we encourage others to do so as well.
In their rapid response, Pollock, Godden and Kirkwood question
whether
the incomplete data about Independent Sector Treatment Centre programme
throws our conclusions into doubt; they also the warn against trusting
published waiting times figures.
Our response to Pollock et al has three strands. First, the ISTC
Programme, however dramatic the headlines it has produced, is responsible
for a small sliver of NHS care. The ISTC program is far less than 10% of
total
NHS spending and accounts for less than 3% of total NHS volume. In fact,
the
ISTC programme has not actually cost £5bn as Pollock et al suggested.
Instead, the 5bn pound figure was an estimate of what the program might
spend eventually. To date, since the ISTC programme was introduced
several
years ago, the actual sum is closer to £3.5bn – 1.5bn for Wave 1 and £2bn
or
less for Wave II.
Second, our data, derived from the NHS Clearing Service, did have
data on
Independent Sector Treatment providers, although there was certainly not
data on every case that the ISTCs performed. For knee replacements, in
our
data 3% of procedures performed in 2005, 3.2% or procedures performed in
2006 and 7% of procedures performed in 2007 were marked as having been
performed at ISTCs. Likewise, for hip replacements, in our data 2.5% of
procedures performed in 2005, 2.9% or procedures performed in 2006 and
5.9% of procedures performed in 2007 were marked as having been
performed at ISTCs. The cataract data clearly had a lower percentage of
recorded private cases, with a negligible number of cases recorded each
year.
However, even if we excluded every private sector case and assumed that
they accounted for a larger share of overall care than they did, this
would not
have influenced the patterns we see in our results.
Third, most NHS analysts routinely use HES data for analysis. HES
data is a
rich source of information. Ignoring HES data because of its limitations
is
cutting off your nose to spite your face. We agree that HES data, like
all
administrative data has its problems, as indeed we discuss at the end of
our
paper, but it would be very hard to claim that they are of sufficient
magnitiude to invalidate our results. In many ways, it seems like Pollock
et
al’s motivation to dismiss HES data has more to do with our findings than
the
data itself.
The NHS is facing increasing pressure to do more with less. This
type of
pressure requires creative policies and a realistic analysis of what works
and
what does not. Our paper was not definitive proof that the Government’s
reforms were a success. What our results suggest is that the NHS market-
based reforms did not harm the equity of waiting times. This is good news
for everyone. While we can appreciate some of the skepticism towards a
greater role of the market in the NHS, we would hope that analysts are
driven
by peer review evidence, not by ideology.
Competing interests:
ZC, AJ, and SJ have no
conflicting interests to declare.
JLG worked part time in the
Policy Directorate at No 10
Downing Street from October
2003 to June 2004 and full time
from June 2004 until August
2005.
Competing interests: No competing interests