Andrew Lansley and his imaginary evidence

February 5th, 2011 by Ben Goldacre in bad science, politics | 50 Comments »

Ben Goldacre, The Guardian, Saturday 5 February 2011

I have never heard one politician use the word “evidence” so persistently, and so misleadingly, as Andrew Lansley defending his NHS reforms. Since he repeatedly claims that the evidence supports his plan, let’s skim through what we can find on whether GP consortiums work, the benefits of competition, and the failures of the NHS.

Are GP consortiums better than PCTs for commissioning? There have been 15 major reorganisations of the NHS in 30 years. We’ve had GP fundholders, GP multifunds, primary care groups, primary care trusts, family practitioner committees, purchasing consortiums, and more. After all this change, lots of data should have been gathered on the impact of specific strategies.

In reality, few were properly studied. Here are 4 papers on GP fundholding, which is broadly similar to Lansley’s GP Consortiums. Kay in 2002 found it was introduced and then abolished without any evidence of its effects. In 2006 Greener and Mannion found a mix of good and bad but no evidence that it improved patient care. In 1995 Coulter found nothing but gaps in the evidence and no evidence of any improvement in efficiency, responsiveness, or quality.  Petchley found there was insufficient data to make any judgement. Lansley says he is following the evidence. I see no evidence to follow here.

Next, competition. Andrew Lansley has repeatedly denied that he is introducing competition on price. This is disturbing behaviour: his bill explicitly introduces price-based competition, it’s in paragraph 5:43 of his NHS Operating Framework.

Does variable-price competition work in healthcare markets? It’s hard to measure, but the evidence even on fixed-price competition – where you compete on quality – is mixed. There are various ways to assess it: often people choose an outcome – like the number of people who survive a heart attack – and compare this outcome in areas of more intense or less intense competition. Sometimes competition makes things worse, sometimes better.

Working from first principles, markets where people compete on price as well as quality will probably make quality worse, because prices are easy to measure, while quality is not. The evidence seems to support this theory. The introduction of variable price competition in New Jersey in the 1990s was associated with a worsening death rate from heart attacks, while in the UK, stopping variable price competition was associated with improvement. It’s hard to measure either way, but despite his using the word repeatedly, again, the “evidence” does not support Lansley here.

Lastly, there is the justification for reform. Both Lansley and Cameron overstate our mortality figures to claim that the NHS is failing. Everyone wants more improvement, but money does not produce an immediate and visible reduction in mortality from one thing. Interventions take time to have an impact, especially on things that kill you slowly, and treatment isn’t the only factor affecting how many people die of something. But to take just two things, mortality from cancer has fallen every year since 1995, and heart attack deaths have halved since 1997.

The government claims that our rate of death from heart attacks is double that in France, even though we spend the same on health. Health economist John Appleby instantly debunked this claim in the BMJ, and his piece will become a citation classic. From static 2006 figures in isolation the government is right: but the trajectory of improvement in the UK is so phenomenal that if the straight line continues – as it has done for 30 years – we will be better than France by 2012.

I’m not in favour of, or against, anything here: all health service administrative models bore me equally. But when Andrew Lansley says all the evidence supports his interventions, as he has done repeatedly, he is simply wrong. His wrongness is not a matter of opinion, it is a fact, and his pretence at data-driven faux neutrality is not just irritating, it’s also hard to admire. There’s no need to hide behind a cloak of scientific authority, murmuring the word “evidence” into microphones. If your reforms are a matter of ideology, legacy, whim, and faith, then like many of your predecessors, you could simply say so, and leave “evidence” to people who mean it.


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50 Responses



  1. EnglishAtheist said,

    February 5, 2011 at 12:54 am

    I wish there could be a law in Parliament that, when an MP mentions the word evidence, they have to actually show/reference it.

  2. MrNick said,

    February 5, 2011 at 1:53 am

    Oh, deary me. Could Andrew Lansley be proposing this
    because he is a Conservative by any chance rather than because
    there is any supporting evidence? I can’t help feeling that it’s
    going to get worse before it gets better. It reminds me of an old
    formulation of the three laws of themodynamics: 1. You can’t win.
    2. Things will get worse before they get better. 3. Who said things
    would get better? Before the election we were in 1. Now we are in
    2. Nick

  3. sgp said,

    February 5, 2011 at 2:48 am

    Politics 101: State something is a fact often enough and people will start to believe that it is.

  4. DrMathewJC said,

    February 5, 2011 at 3:03 am

    Some evidence potential exists here:
    factcheck.org/2011/01/factchecking-dodgy-british-claims/

  5. twaza said,

    February 5, 2011 at 7:30 am

    “I have said it twice: That alone should encourage the crew. Just the place for a Snark! I have said it thrice: What I tell you three times is true.” Lewis Carroll

  6. Dr Grumble said,

    February 5, 2011 at 9:01 am

    One can only assume that Lansley has become aware that doctors, unlike politicians, like to base their decisions on evidence and so has decided to produce some. He must have been desperate to have chosen the example of heart attacks in France which has been puzzling people for decades and cannot conceivably be accounted for by differences in the health services of the two nations.

  7. Ravi said,

    February 5, 2011 at 10:54 am

    Good to see some debunking of the spin put about by the Tories. Have put a link to the Guardian article on my union’s blog (which in true Bad Science tries to be evidence based)

    unisoneastmids.blogspot.com/2011/02/evidence-supporting-your-nhs-reforms.html

  8. Geoff332 said,

    February 5, 2011 at 11:12 am

    There was a study by The Nuffield Institute that looked at the efficacy of similar GP Commissioning in California. They found that GP Commissioning could work, but it required significant investment in administration – things like good, experienced managers, IT systems and the like. Without this sort of investment, it was more likely that the commissioning groups would fail (ie run out of money to provide adequate healthcare to their ‘memebers’). Obviously, to find people experiences in healthcare commissioning in the UK, you’re going to be hiring the people that have just lost jobs with the PCTs (and probably been paid a reasonable amount).

    To interpret those findings somewhat, if GP Commissioning is going to be effective, it will require a fair amount of investment. It will not be a cheaper approach, at least not in the short-term. It’s also unlikely to be more effective – some GP Consorita will, no doubt, be very effective; others will not be. Much the same as the current PCTs are.

    www.nuffieldtrust.org.uk/pressarea/index.aspx?id=1142

  9. jimmy said,

    February 5, 2011 at 12:18 pm

    I think of it as Cargo Cult science. Woo-merchants do it too.

    There have heard that there is this thing called evidence and they think they can bring it into existence by using the word.

  10. geodoc said,

    February 5, 2011 at 12:43 pm

    Likewise, I don’t find health care administration policy intrinsically interesting. But I’m getting increasingly worried that Lansley et al are relying on this natural eyelid-closing response to rush through measures that are potentially dangerous to patients, clinicians and public health generally. Certainly when it comes to GP commissioning:

    www.rcgp.org.uk/brjgenpract/current_issues/free_content/this_months_free_content.aspx

  11. Riffler said,

    February 5, 2011 at 1:07 pm

    They need to extend the list of unparliamentary language to include the word “evidence”. Politicians always fabricate, misrepresent, sex up, distort, invent or ignore it.

  12. loggedintocomment said,

    February 5, 2011 at 1:07 pm

    “Working from first principles, markets where people compete on price as well as quality will probably make quality worse, because prices are easy to measure, while quality is not.”

    I wonder what kind of ideological blinkers are necessary to make that statement (never mind blindly accept the swiss cheese of a paper that purports to back it up – note that the heart attack death rate fell the entire period the care level was allegedly declining).

  13. loggedintocomment said,

    February 5, 2011 at 1:08 pm

    And I should stress for those who did not check the paper, that heart attack death rate WAS the indicator used to measure care.

  14. misterjohn said,

    February 5, 2011 at 1:16 pm

    As the BMJ article points out, every time there’s a rearrangement or restructuring, people are made redundant, as geoff332 says, causing extra costs.
    I’ve had a similar experience recently, being made redundant from one post and getting a lump sum, only to be appointed to a similar post, within a week, by the same organisation, at slightly higher pay.
    Repeating that on the scale of the NHS will not be cheap, and will not help pay the enormous costs of the PFI incurred by many trusts.
    I don’t think anyone has done a great deal to help improve the NHS by restructuring, but employing competent staff at decent pay seems to work wonders.

  15. amedicalstatistician said,

    February 5, 2011 at 1:24 pm

    With a myriad of providers who is going to run the quality assurance schemes? These will be needed to ensure that the providers are working to the same standards and protocols across the country – mind you that assumes that the commissioners have commissioned the same level of service in the first place.

  16. jwm said,

    February 5, 2011 at 1:50 pm

    ‘loggedintocoment’

    ‘never mind blindly accept the swiss cheese of a paper that purports to back it up – note that the heart attack death rate fell the entire period the care level was allegedly declining.’

    While the quality of the paper can be argued – and I would be interested to hear which aspects of the paper and its statistical analysis you feel most strongly about – your statement is massively misinformative and flies in the face of the conclusion of the paper:

    “There were no significant differences in AMI mortality among insured patients in New Jersey relative to New York or the NIS. However, there was a relative increase in mortality of 41 to 57 percent among uninsured New Jersey patients post-reform, and their rates of expensive cardiac procedures decreased concomitantly.”

    The mortality in people did indeed fall: In the INSURED they fell at the same rates as the control state where no reform had been implemented thereby showing no improvement from the reform – the changes merely reflected medical advances in treating acute coronary syndrome and better preventative measures. The mortality in the UNINSURED rose in comparison to the control state thereby showing a deleterious effect from the reform in the most vulnerable of society – eg the elderly for whom insurance becomes crippilingly expensive.

    However, your ability to misread and distort evidence to serve an ideological purpose puts you in an ideal position to serve Mr Lansley, or if you don’t particularly support tories, whichever uninformed incumbent replaces him in 4 years.

  17. loggedintocomment said,

    February 5, 2011 at 2:03 pm

    jwm,
    Are you talking about a different paper ?
    I’m talking about the “Working from first principles” one:
    www.niesr.ac.uk/event/propper.pdf
    which was examining the effects of the change in policy in the UK 1991 to 1997 (so USA data not really relevent).

    I don’t think I have distorted the evidence, certainly not deliberately, it’s entirely possible i’m wrong. Their graph on page 32 however shows AMI death rates dropping 25% over 1991 to 1997 (unless my eyes are deceiving me).

  18. Alan Bird said,

    February 5, 2011 at 2:46 pm

    Do politicians mindlessly (or maliciously) parrot phrases such as “evidence based decision making” while pursuing other, more nefarious, interests? See a telling example on Majikthyse’e blog at majikthyse.wordpress.com/2010/12/15/are-politicians-really-stupid/

    The issue in this case couldn’t be simpler: Majikthyse asks the government why “The Department of Health will not be withdrawing funding for homeopathy on the NHS, nor will the licensing of homeopathic products be stopped.” The evidence, as you’re all well aware, is overwhelming that homeopathy is utter rubbish. He analyses the response of the minister responsible, Ann Milton. One of his conclusions is that “Either Anne Milton is very very stupid, or she is not taking the debate seriously…”

    So she is another minister who claims to be following the evidence but who is doing no such thing.

    Incidentally, I can see where a government can be backed into a position where (in their eyes) the cost of implementing a useless policy is outweighed by the potential humiliation of a u-turn or climb down. After all, the former could be measured over years while the latter will flare up within hours of them doing it, and what government ever considered the long term? But what stops an incoming new government from immediately ditching all this sort of rubbish, to which they have no possible ideological commitment? (Although that’s not quite Lansley’s case – he’s invested his political career in this upheaval.)

  19. Bewildered said,

    February 5, 2011 at 2:58 pm

    @loggedintocoimment I think that paper link is probably a mistake (or in the wrong place) since an empirical study doesn’t fit phrase “Working from first principles” that links to it and I intially logged on to point that out. I don’t know how to interpret the graph you mention w/o reading the paper in more detail than i have time to do, but I’d be careful about jumping to conclusions.

  20. beta2011 said,

    February 5, 2011 at 3:54 pm

    bad science indeed – ben’s providing his own misleading evidence when he asserts that there’s mixed evidence on the effect of fixed price competition benefiting patients.

    the truth is that the evidence that exists shows that fixed price competition unambiguously improves outcomes for patients. take a look at the work of propper (opinion.publicfinance.co.uk/2011/01/unhealthy-competition-by-carol-propper/) and cooper (eprints.lse.ac.uk/28584/)

    however he is right that the evidence on the effect of variable price competition on quality is mixed. that’s the difference to note between these reforms and those that blair and milburn introduced which have had considerable success.

    nevertheless landsley is on solid ground when he asks labour if they oppose price competition why they introduced the scope for price competition in the 2009 operating framework (another of andy burnham’s strange decisions).

  21. nigel said,

    February 5, 2011 at 5:29 pm

    Loggedintocomment – you dismiss Propper’s multiply cited and peer review published work which also reviews a wide range of peer reviewed research with an airy put down. Yet you clearly don’t seem to have understood the very simple concept underpinning it.

    Of course the AMI rate fell – this is a secular trend driven by improvemnts in medicine, the study is a difference in difference estimate so the fact that there is a general fall is irelevant. I could try and explain but its all in the paper and quite simple really.

    There are some reasons to be cautious about using AMI as a quality proxy but your failure to grasp the basic underpinning idea in this research makes the rest of your views irrelevant.

  22. loggedintocomment said,

    February 5, 2011 at 6:09 pm

    Nigel,
    I did not miss that at all; the point was people incorrectly perceive these results (even if correct) as saying quality of service fell when in fact it continued to improve.

    “but your failure to grasp the basic underpinning idea in this research makes the rest of your views irrelevant”

    Does your failure to grasp my basic point make the rest of your views irrelevant ?

  23. nigel said,

    February 5, 2011 at 9:14 pm

    Loggedintocomment
    I am not expressing a view just commenting on the facts in the research. But if you want one then I would say that if you claim that your point was because some people are making incorrect claims then that is what you should have said. What you did say was:

    >>I wonder what kind of ideological blinkers are necessary to make that statement (never mind blindly accept the swiss cheese of a paper that purports to back it up – note that the heart attack death rate fell the entire period the care level was allegedly declining).

    Who are these people who you are putting straight? You don’t say in your post.

    Generally, if people don’t get your point its wise to ask first whether you might have failed to communicate it peoperly. A minor technical correction to Ben’s text might be to say that the differential between areas for AMI survival improved. This doesn’t change the thrust of the argument and doesn’t justify your response.

    No more troll feeding available.

  24. AndrewKoster said,

    February 5, 2011 at 10:26 pm

    @loggedintocomment

    Lets start with the abstract of the paper you link: “Using data on mortality as a measure of hospital quality and exploiting the policy change during the 1990s, we find that the relationship between competition and quality of care appears to be negative.”

    In other words, EXACTLY what Ben said. Not that quality of care didn’t improve during the 90s (in fact, in the bit about the comparison with France you could read between the lines and see that he said the exact opposite). Ben said that there is evidence that the QoC and market-based competition are unrelated, or, working from first principles (insofar as I can see these are his own deductions, not from the paper), QoC should realistically decrease through market-competition. In any case there is no evidence SUPPORTING a link between QoC and market-based competition.

  25. ajh1980 said,

    February 5, 2011 at 11:03 pm

    Let’s wake up to the reality of what Lansley and the Tories are up to here.

    They know that if they if they announced the wholesale privatisation of the NHS that they would have riots on their hands – who knows, possibly a revolution. Taking away the NHS is unthinkable.

    So rather than announcing that that is what they want to do, they are selling GP commissioning as a means of improving efficiency and improving ‘patient choice’ (as though medical care was something that people browsed a catalogue for). When GP commissioning fails… and fail it will, it will be deemed to difficult to revert back to the current system. They will label this as a ‘return to wasteful bureaucracy’. This will pave they way for private companies such as in the USA to take over healthcare in order to assist the overstretched GPs.

    Before you know it, we have a privatised system and the Tories will be able to say that they this will lead to better quality patient care. In reality we will have a system based on profit rather than clinical outcomes.

    These reforms are designed to fail so that the private sector can come in and sweep up the pieces.

  26. paddyfool said,

    February 5, 2011 at 11:04 pm

    @Loggedintocomment,

    I think I see the misunderstanding here.

    You say based on Figure 2 on page 32 that the rates fell over that period, and you’re right. Advances in treatment, decline in smoking etc. has seen an improvement here generally. But if you look at Figure 3 on the next page, you’ll see they fell first and fastest among those hospitals facing the least competition (the “bottom quantile of comp1″), as described in the text on page 19.

    Personally, I’d be careful about reading too much into this sort of analysis. Also, I’m no health economist, and I haven’t checked their methods in depth. But their findings as published definitely don’t support competition for improved outcomes.

  27. ajh1980 said,

    February 5, 2011 at 11:05 pm

    God my spelling and syntax are awful after too little sleep and too much wine! Must do better!

  28. jwm said,

    February 6, 2011 at 12:33 am

    Loggedintocomment

    It seems we are indeed. My apologies.

  29. agibb2 said,

    February 6, 2011 at 2:01 am

    Ben- when you call out politicians for using the term ‘evidence’, you have hit the nail on the head. However, the real question here is who decides how the money is spent. We are not happy with it being allocated centrally, that much is clear. Who then should spend it? I would suggest anyone except the DoH/PCTs, and to see what happens. If it’s good, then great, if not, do something different. But the status quo is not sustainable if we wish to top the survival tables.

  30. TwentyMuleTeam said,

    February 6, 2011 at 1:17 pm

    Mark Twain: Figures often beguile me, particularly when I have the arranging of them myself; in which case the remark attributed to Disraeli [error] would often apply with justice and force: “There are three kinds of lies: lies, damned lies, and statistics.” Let us not be mulcted by that which merely shimmers as true.

  31. loggedintocomment said,

    February 6, 2011 at 4:05 pm

    Paddyfool
    “But if you look at Figure 3 on the next page, you’ll see they fell first and fastest among those hospitals facing the least competition (the “bottom quantile of comp1″), as described in the text on page 19.”

    Yes and after 5 years of “more competition” the gap had all but disappeared again. If it was the introduction of competition that caused the gap in the first place the assumption must be that the persistence of competition caused the rapid improvement afterwards.

  32. Marcus Hill said,

    February 6, 2011 at 8:05 pm

    This reminds me of an email I sent Michael Gove when he published the education White Paper in December, the day after the publication of a major report from Ofsted showing that the quality of teacher education in higher education institutions is significantly better than that in school based settings. I knew his reasons for deciding to move ITE out of universities and into schools had nothing to do with evidence and everything with ideology, which no evidence will budge, so I merely suggested he stop wasting public money on things like that Ofsted report and be up front about the reasons for his decisions.

    Also, now I’ve read this article, every time I hear a politician utter the word “evidence” I’ll hear Inigo Montoya: “You keep using that word. I do not think it means what you think it means”.

  33. jodyaberdein said,

    February 7, 2011 at 12:26 pm

    One of my favuorite papers:

    jrsm.rsmjournals.com/cgi/content/full/98/12/563

    Strangely, when I asked Lansley about the DOH’s attitude toward evidence in another context there was a much more laissez-faire approach:

    Dear Mr Lansley,

    I am writing to you in your capacity as Secretary of State for Health, as I am not a South Cambridgeshire constituent.

    I read with interest the recent Science and Technology Select Committee report, and the Department of Health Government response, on homeopathy.

    Does the current government support the provision, by the NHS, of treatments which have been shown, to the current best available standard, to be no more efficacious than placebo, in any other context than when they are explicitly stated to be placebo?

    Yours faithfully,

    Reply:

    Dear Dr Aberdein,

    Thank you for your email of 29 July to Andrew Lansley about homeopathy. I have been asked to reply.
    As you are, the House of Commons Science and Technology Committee recently carried out an examination of the evidence to support the provision of homeopathy on the NHS.
    The Committee’s report was published on 22 February. The new Government considered its findings and recommendations and has published a full response.
    The Department of Health will not be withdrawing funding for homeopathy on the NHS, nor will the licensing of homeopathic products be stopped. Decisions on the provision and funding of any treatment will remain the responsibility of the NHS locally.
    A patient who wants homeopathic treatment on the NHS should speak to his or her GP. If the GP is satisfied this would be the most appropriate and effective treatment then, subject to any local commissioning policies, he or she can refer them to a practitioner or one of the NHS homeopathic hospitals.
    In deciding whether homeopathy is appropriate for a patient, the treating clinician would be expected to take into account safety, clinical and cost-effectiveness as well as the availability of suitably qualified and regulated practitioners. The Department of Health would not intervene in such decisions.
    The Department’s response to the Science and Technology Committee report explains the reasons behind its decisions in more detail. The response can be found on the Department’s website: www.dh.gov.uk, by typing ‘Government Response to the Science and Technology Committee report’ into the search bar and following the links.
    Yours sincerely,

    Bilal Ghafoor
    Customer Service Centre
    Department of Health

  34. richard.blogger said,

    February 7, 2011 at 2:33 pm

    What about Lansley’s plan to allow patients to register with any GP? (OK, it was a Labour plan, but they only half heartedly promoted it, Lansley is gungho.) On the surface it sounds great, but as my GP friend Jonathon points out getting rid of practice boundaries may have serious effects on patient care:

    abetternhs.wordpress.com/2010/12/12/what-is-the-point-of-practice-boundaries/

    So surely someone has done a study to see what evidence there is to dispel any fears of the effects of this policy? Nah, that would mean that we have a government who believe in evidence. Have a look at the email exchanges this GP had with Lansley over this issue:

    onegpprotest.org/2011/01/22/an-attempt-at-transparency-from-andrew-lansley/

  35. skyesteve said,

    February 7, 2011 at 4:23 pm

    The English NHS reforms? That’s why I live in Scotland :-)

  36. onegpprotest said,

    February 7, 2011 at 11:03 pm

    I am a GP with concerns about abolishing practice areas; I asked Andrew Lansley for his evidence for this policy, but there was none. onegpprotest.org/2011/01/22/an-attempt-at-transparency-from-andrew-lansley/

  37. damianpeterson said,

    February 8, 2011 at 12:03 am

    Hi, completely off topic here but does anyone know whether there are the same lack of restrictions on the title ‘nutritionist’ in New Zealand as in the UK? (In other words, can anyone willy nilly call themselves a ‘nutritionist’ in NZ?)

  38. Tavistocker said,

    February 8, 2011 at 10:33 am

    There has been some interesting research done looking at what happened to the quality of healthcare when the NHS introduced the internal market and price competition in the early nineties.

    The researchers found that increased competition actually resulted in a reduction in the quality of healthcare. Not the sort of evidence Andrew Lansley is looking for but interesting nevertheless.

    Carol Propper, Simon Burgess, Denise Gossage
    The Economic Journal
    Volume 118, Issue 525, pages 138–170, January 2008
    Competition and Quality: Evidence from the NHS Internal Market 1991–9
    onlinelibrary.wiley.com/doi/10.1111/j.1468-0297.2007.02107.x/full

  39. msjhaffey said,

    February 8, 2011 at 12:55 pm

    Big disclaimer up front: No, I have not read the details of the proposed reforms.

    However, I do wonder about the statement “markets where people compete on price as well as quality will probably make quality worse”. I can think of plenty of markets where quite the opposite has occurred – cars are just one, passenger aircraft another.

    In the area of health, do we find in the UK that BUPA and PPP compete and make quality worse?

    I’d be interested to know.

  40. jonathon tomlinson said,

    February 8, 2011 at 1:01 pm

    Dear Ben, Well done on another excellent contribution to the debate about evidence. Let’s not forget that health outcomes are a post-hoc justification for the reforms. Last year, when the health white paper was published, I pointed out that extraordinary change requires extraordinary justification backed up by extraordinary evidence, but there was none. Only when others such as Paul Corrigan, Nigel Edwards and Andy Cowper made a fuss about it, did the government come up with this imaginary evidence. Now we need to go beyond the trees and look at the woods to see that the pronouncements on the NHS from politicians of all parties are absurd, and whilst we mock, they hide like Berlusconi behind a façade of buffoonery while the savage process of dismantling the NHS goes on. abetternhs.wordpress.com/2011/02/07/lansley-cameron-zizek-and-marx/

  41. jodyaberdein said,

    February 8, 2011 at 6:44 pm

    Re39: msjhaffey

    ‘In the area of health, do we find in the UK that BUPA and PPP compete and make quality worse?’

    Given that this article is about the evidence I’m not sure you’ll find what you’re after. I might add that a lack of evidence for harm is not the same as evidence of a lack of harm.

    Interestingly, since 2001, NHS acute trusts have been required by law to report MRSA blood stream infections, and to do something about reducing the number of them. Pleasingly they are now much much rarer than they were.

    It would be interesting to know if the same problem, or proportionate reduction, had occurred in the ‘independent sector’, but as there has only been a voluntary agreement to self report such infections in the independent sector, and since 2008 a ‘code of practice’ which they ‘must have regard to’ in ‘deciding how they will comply with registration requirements’. The answer must remain elusive.

    The Health Protection Agency (destined to be abolished with some or all functions transferred to elsewhere, along with the DOH advisory committee on healthcare associated infections) thus have had ‘interest’ from 250 independent hospitals and raw incomplete data from 210 only since 2009. Surprisingly for a venture related to blood stream infection as of 2009 the independent dialysis centres were still discussing the issue.

    Dialysis is in some ways a health economist’s dream – neatly defined sessions and treatments, mostly automated with often real time data collection on stuff like blood pressure and biochemical parameters for which there are national standards. Now I would never suggest you might make the numbers look good but the quality less so by tweaking a few parameters here or there, oh no. Hence the profit / non profit discussion about dialysis in the USA.

    Neither have I heard tell of junior colleagues in independent (not dialysis as it happens) settings being asked to go easy on the sterile gloves, or having trouble getting hold of a culture bottle.

    jama.ama-assn.org/content/288/19/2449.long

    From which a citation search on pubmed gets you:

    www.bmj.com/content/339/bmj.b2732.long

  42. jwm said,

    February 8, 2011 at 11:43 pm

    msjhaffey

    “However, I do wonder about the statement “markets where people compete on price as well as quality will probably make quality worse”. I can think of plenty of markets where quite the opposite has occurred – cars are just one, passenger aircraft another.”

    We cannot state this. As far as Im aware, there is no situation where the airline industry have been forced to compete only on price or only on quality to allow comparison. Therefore all we can conclude is that continued scientific improvements has led to a better situation that may or may not have been better if price or quality competition was removed.

    “In the area of health, do we find in the UK that BUPA and PPP compete and make quality worse?”

    Currently in the UK we have the NHS setting the price and quality standard. No one is going to pay money out of pocket to see a private doctor if it is worse quality than they’d get for free, therefore we do not see your hypothesised decline. However if we remove the current standards this may reverse. Although as Ben says, evidence in this region is minimal.

  43. msjhaffey said,

    February 9, 2011 at 7:50 am

    jodyaberdein , jwm

    Thank you – that’s helpful.

    >jdm. You write ” there is no situation where the airline industry have been forced to compete only on price or only on quality “. Of course that’s true. It’s true in every case where competition is allowed. For example, delivery time may be critical. That doesn’t lead to your following statement.

    I am afraid I disagree with you final paragraph. Let’s assume that the NHS sets a floor standard. Someone might happily pay for a medical service in preference to the NHS for all kinds of reasons. Again, speed of delivery might be one. False belief might be another: know anyone who pays for homeopathic medicines or nutritionist consultations?

    I get the feeling from many of the comments that whatever the question, the answer is the NHS, preferably unchanged. I absolutely agree with the thrust of Ben’s article that policy in this (and other) government areas should be wherever possible based on evidence. However, on occasion a proposed change may not have evidence for or against it and may, if the arguments in favour have force, be worth trying.

    The NHS is excellent in many ways, but that should not stop us from looking for ways to improve it.

  44. irishaxeman said,

    February 9, 2011 at 1:03 pm

    Sadly we are indeed arguing over the corpse I suspect. Lansley has – and needs – no other justification than clearing the ground for free market intervention. This is the government policy across the board – ‘shock and awe’ preceding free market chaos and subsequent shattering of communities and living standards. There is a 40 year track record of this. I personally hope so see some of these villains miss out on their Galtieri-style peace in retirement, but won’t hold my breath!

  45. jodyaberdein said,

    February 9, 2011 at 1:34 pm

    re:43 msjhaffey

    Should a change be proposed for which there is minimal or contradictory evidence, yet forceful (presumably logic rather than volume) argument in favour, doesn’t that just constitute a stong argument to study the benefit and disbenefit of said changes scientifically? Should the said change be a large and potentially expensive one, say on a system that costs £100bn annually, would you think that better evidence would be the first order of the day?

  46. jwm said,

    February 10, 2011 at 12:25 am

    In case people are still following-

    Here is a governmental response to the article:

    www.guardian.co.uk/society/2011/feb/08/deconstruction-of-the-nhs-bill?INTCMP=SRCH

    Rapidly followed by a brilliant response by the author whos data the minister was misquoting:

    www.guardian.co.uk/society/2011/feb/09/research-on-the-nhs?INTCMP=SRCH

    A better demonstration of political misunderstanding/deliberate ignoring of evidence one could hardly construct.

  47. adamk said,

    February 11, 2011 at 12:19 pm

    David cameron has said the NHS has to change , and he’s right. Aging population , more expensive treatments , idealistic guidelines – it doesn’t add up financially.
    I feel that this whole scheme is being set up to fail. hand the responsibility to GPs , a widely maligned profession in the press recently , and they can take the blame for failure , and the inevitable difficult decisions that are going to have to be made (who is the money going to be spent on? who is not going to get treatment? etc)

  48. davidmam said,

    February 13, 2011 at 9:15 pm

    The John Appelby ‘debunking’ needs itself to be debunked.

    We’ll ignore the fact that it is an opinion piece (not peer reviewed) commissioned from a charity whose remit is health care policy and look at the data.

    Appelby publishes a graph which he claims shows such a dramatic decline in UK MI rates that they will overtake France in two years. This is based on data from OECD. However, if you take the OECD data and plot UK vs France for each year you get an almost perfect correlation (98%). They are the same curve, just scaled differently. This indicates that there will be no predicted convergence, not until you reach the level of reporting errors in the data.

    I’m surprised the BMJ let this through (with a graph that would be returned to a first year undegraduate to draw properly). The figures and analysis are easy to check, once you have access to the OECD figures.

    As ben says, it will become a citation classic, but not for the reasons he thinks.

  49. jodyaberdein said,

    February 18, 2011 at 4:45 pm

    er,

    Y=x and y=2×-5 are perfectly correlated, have different slopes and intercept at x=5.

    The OECD data is unfortunately behind a paywall for me.

  50. AgentR said,

    February 18, 2011 at 6:00 pm

    Hello Dr. Ben,

    Speaking of “evidence” which the minister might find suited to his tastes, are you planning an article on the recent PACE trial on treatments for CFS/ME I wonder? Lots of questions are being raised about how the trial was conducted. And (you won’t be surprised to hear) it’s being reported rather sloppily.

    For example the Guardian headline: “Study finds therapy and exercise best for ME” Best? Not ‘helpful’ or ‘somewhat more effective than…xyz’ but BEST!
    The closing paragraph of said article: “One of the trial participants …said the trial had changed his life.” And this would be relevant how, exactly, in a ‘science’ article?
    Smacks of an uncritically regurgitated press release.

    What’s the real story hear, Dr Ben. We need you laser intellect to get to the FACTS.

    Thanks,
    Agent R.