I’d expect this from UKIP, or the Daily Mail. Not from a government leaflet.

April 16th, 2011 by Ben Goldacre in bad science, politics | 37 Comments »

Ben Goldacre, The Guardian, 15 April 2011

HM Government have issued a new leaflet to justify their NHS reforms: Working Together For A Stronger NHS. It was produced by Number 10, appears on the Department of Health website, and many of the figures it contains are misleading, out of date, or flatly incorrect.

It begins, like much pseudoscience, with uncontroversial truths: the number of people over 85 will double, and the cost of drugs is rising.

Then the trouble starts. In large letters, alone on one entire page, you see: “If the NHS was performing at truly world-class levels we would save an extra 5,000 lives from cancer every year.” The reference for this is a paper in the British Journal of Cancer called “What if cancer survival in Britain were the same as in Europe: how many deaths are avoidable?”

This study does not aim to predict the future: in fact, it looks at data from 1985 to 1999 (seriously) which is a very long time ago. It finds that if we’d had the mean EU cancer survival rates, in the 80s and 90s, then we’d have had 7,000 fewer deaths then. Not 5,000 fewer. And to put the big number in context, by this study’s calculation, that means 6-7% of UK cancer deaths were avoidable in the 1990s. Since then, we’ve seen the massive 2000 NHS Cancer Plan, a new decade, and a new century. This paper says nothing about the number of lives we “would save” each year in 2011, and citing it in that context is bizarre.

The next interesting figure misleads about a trend (we’ve seen this a lot from health ministers recently). The leaflet says: “since May 2010 the NHS has gained 2,550 more doctors and has 3,000 fewer managers”. This is correct: full-time equivalent figures (my favourite) from NHS workforce data show 97,720 doctors in May 2010, and 100,197 in December. Meanwhile NHS Information Centre figures show that the total number of doctors increased from 88,693 to 132,683 between 1999 and 2009; GPs have gone from 28,354 to 36,085; consultants from 21,410 to 34,654. Doctors take a while to grow.

Then we have choice: “95% want more choice over their healthcare”. The source given is the British Social Attitudes Survey. Interestingly, the government have just announced that they’re going to abolish stop funding the health questions on the British Social Attitudes Survey. The data was collected in 2007, and if you download it yourself you’ll see they didn’t ask about “more choice”. Question 583 asks how much choice do you think NHS patients currently have, and 584 asks how much choice do you think they should have.

How they aggregated those responses to get 95% for “more choice” – a key justification for reform – is a mystery: many people will have said they have “a little” and they should have “a little” (we can’t see how many, without respondent-level data). I asked how they produced their figure, since BSA25 doesn’t have data on “would you like more choice”. They told me the source was table 3.1 in Chapter 3 of a book that costs £52, called “Do people want more choice and diversity of provision in public services”.

I got that book: it’s the same old BSA25 data, it doesn’t contain anything on “more choice”, and the title is not: “Do people want more choice…”. It’s: “Do people want choice…” This stuff matters, especially if you waste my time going to a library, but more importantly: the facts in this plainly political pamphlet should be clean, correct, transparent, and justified. As the government defies all reason by claiming that NHS staff support their reforms, I can only fear the results of their listening exercise.

More: See comment below for an attempt to calculate these figures from individual respondent-level data in the BSA. The BSA funding was cancelled, the survey itself was not abolished, correction here!


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37 Responses



  1. amcunningham said,

    April 16, 2011 at 12:34 am

    hi Ben,
    @markhawher found and analysed the choice data here: markhawker.tumblr.com/post/4421202662/playing-with-department-of-health-statistics he downloaded I from here: www.data-archive.ac.uk/
    I tweeted you a link o his work during the week but you must have missed it. The short story is “13% actually have choice that exceeds what they think they should have; 46% actually have choice that matches what they think they should have; and, 41% actually have choice that does not match what they think they should have.”

  2. don_pedro said,

    April 16, 2011 at 2:46 am

    What did you expect? Cameron is a PR man: the facts are irrelevant. The name of the game is getting people to believe what you want them to believe, disregarding the truth, unless that ever happens to coincide with your purpose.
    “Oh, we’re listening …”
    Almost everyone stops listening when they hear a politician come out with statistics anyway. It’s not that they are accepted, far from it, but the overall effect is something like the media’s warped idea of balanced coverage.
    “We’re just going over here now for crackpot view, and the truth will turn out to be somewhere in the middle, won’t it?”

    All in all, it makes me think of starting a campaign to make Marketing and PR capital offences – aiming for the compromise position of one or the other.

  3. keristor said,

    April 16, 2011 at 4:11 am

    Er, I think you may have missed some key things about the material under review. There are words which are instant triggers for suspicion — “government” for instance, and “Number 10″. I think most people now know that if a politician says it then it is less likely to be true (by 87.2%) than a TV advertisement for cat food.

    And of course that 97.36% of quoted statistics are made up on the spot.

    It would surprise me far more if they actually managed to use any statistics in context and relevantly.

  4. deevybee said,

    April 16, 2011 at 6:41 am

    All this stuff about ‘choice’ is a bit of a red herring. If you have a rubbish local hospital, you’d like the choice to go elsewhere. If you know you can get stellar and timely treatment locally, why would you want to go further afield? It would be v. interesting to look at the geographical location of respondents to the survey – my guess is that those who want more choice come from regions with poorly performing hospitals. What is needed is to ensure all NHS provision is of highest standard, rather than shuffling people around between hospitals and adding to everyone’s fuel bills.

  5. Dr Grumble said,

    April 16, 2011 at 7:20 am

    There is quite a lot of data out there which shows the NHS in a very good light compared with other countries. For the government to go to such lengths to bad mouth the NHS shows they have an agenda. I too fear the results of the listening exercise.

    www.commonwealthfund.org/~/media/Files/Publications/Chartbook/2010/PDF_2010_IHP_Survey_Chartpack_FULL_12022010.pdf

  6. jodyaberdein said,

    April 16, 2011 at 9:30 am

    So fairly similar to the sort of stuff you might find, say on page 44 of the Conservative Party 2010 manifesto:

    media.conservatives.s3.amazonaws.com/manifesto/cpmanifesto2010_lowres.pdf

    Could have beem straight out of Huff’s book.

    Also, re: 4, I would expect that those who want more choice are likely to be the ones nearest to the better performing hospitals, GPs, social services etc etc. Inverse care law and all that. On this note the BMJ had a really good issue on practice variation recently, and I would heartily recommend J E Wennberg BMJ 26/03/11 342:687 (paywalled I’m afraid), or alternatively take a lok at the Dartmouth atlas.

    Quoting from the above:

    ‘Supply sensitive care comprises clinical activities such as doctor visits, diagnostic tests, and hospital admissions, for which the frequency of use relates to the capacity of the local healthcare system. Among older Americans, most of these services are used in caring for chronic illness. However, regions with high rates of use of supply sensitive care do not have better overall outcomes as measured by mortality and indicators of the quality of care, suggesting that the problem in the US is overuse of this category of care.’

  7. gpprotest said,

    April 16, 2011 at 9:38 am

    Many thanks for this. I am a GP and one of my (many) concerns about this question of ‘choice’ is the promise that people in England can choose any GP practice they wish, anywhere in England (!). Of course almost everyone would say, ‘Hey, that sounds great.’ But when you look at the implications and the practicalities, it is monstrously stupid, destabilising, and unworkable. For my attempt to question Andrew Lansley about this bit.ly/f4iTA1 My blod concerns this issue mainly www.onegpprotest.org

  8. reprehensible said,

    April 16, 2011 at 11:04 am

    @ deevybee

    actually you’d probably find they’d make the choice based on if they could park easily or not. Even when given data on heath outcomes patients don’t really use it, prefering the anecdotal ‘evidence’ of their friends (particularly in middle class areas).

    See www.kingsfund.org.uk/publications/patient_choice.html

    or

    www.informaworld.com/smpp/content~content=a908469703~db=all~jumptype=rss

    having said that though, I can hardly blame them, my anecdotal evidence from back rep’ing all around the north atm would testify parking is a nightmare in most hospitals around clinic time!!!

  9. Riffler said,

    April 16, 2011 at 12:33 pm

    Choice is the politicians con-trick de jour. It’s far easier to provide 5 mediocre services than one that’s actually good, but more than that – give people a choice, and they end up with a crap srvice, they blame themselves for choosing the wrong one. They can’t be sure that the other options were equally bad or worse, so are convinced that it’s their fault they ended up with a crap school/hospital/whatever. Choice is just a cheap way of politicians avoiding the blame for the crap they serve up.
    Lansley strikes me as a fanatical fundamentalist loony. You’ve as much chance of convincing him that his reforms are bad for the NHS as convincing a suicide bomber he’s not going to pop up in paradise with 72 virgins. He’s not merely unwilling to listen to criticism, he’s psychologically incapable of listening.

  10. ferguskane said,

    April 16, 2011 at 1:00 pm

    Thanks Ben. Thanks also gpprotest for sharing.

    Having done a four year PhD. I feel more confused than ever, so if I was to change things in my small field, I’d do it slowly and with caution. Having done a few months of talking to GPs, Andrew Lansley feels certain that he understands the NHS, is doing the right thing and that he should do it as fast as possible.

    On choice. As Riffler says, it’s mostly a con-trick. For a start, it assumes that we have the facts, the ability and the time to do the analysis of where is best for us to be. Then it relies on us having the ability to put the choice into action (often meaning having a car, being able bodied and having some spare cash to make things easier).

    If the government seriously wanted choice for all, it would work towards equalising some of these things in the latter category (education, wealth) and providing advocates for the needy. But of course, choice means: ‘choice for the rich’.

    Now I see myself as relatively well off, relatively intelligent, relatively well educated, relatively footloose and with a little time on my hands (no children etc). But when I came to choose among my local dentists, I had no idea which way to go. I looked for all the facts I could (easily) lay my hand on, and still had to make a guess.

    Choice would be nice (but I’d rather have a rise in across the board quality). Honesty and humility would be nicer, Mr Cameron.

  11. emen said,

    April 16, 2011 at 6:24 pm

    @ gpprotest

    Thank you for sharing this.

    I am interested to find out how exactly this free choice of GPs will create a disaster. Yes, I understand from you posts, the main argument is that it is easier for the patient to see the GP or for the GP to see the patient if it’s a 2-minute-walk rather than 20.
    But

    1. patients are grown-ups, who UNDERSTAND that, and I presume distance will be on their list of reasons to choose one surgery over the other

    2. if this is the main concern, you should be campaigning for an extra “rule”, that GPs should not be required to do home visits if the patient lives further away than x miles.

    Some GPs are better than others, in one way or another, as you must surely know, and I as a patient, am strongly in favour of patients’ choice.
    Why should a patient be forced to be stuck with a GP they don’t get on with (whatever the reason) if there is nobody else in the area?

    Of course, it means there will be a reputation-based market of GPs, and some GPs will have to compete for their patients and might have to compete for their income.
    That will soon improve the quality of care, which can only be a good thing.
    I wonder whether that is worrying you at all?

  12. emen said,

    April 16, 2011 at 6:44 pm

    @ ferguskane

    You are right, when your GP says you need to see a specialist, would you like to go to hospital x or z? you often haven’t got a clue. But even then, you will probably decide based on the length of the waiting list and that is already a choice that you made to get a better service.

    On the whole I disagree with you when you say
    “it’s a con-trick. For a start, it assumes that we have the facts, the ability and the time to do the analysis of where is best for us to be.”

    …you wouldn’t say that about a supermarket, would you? and you wouldn’t like supermarkets to be allocated to people so you can use only one supermarket chain, happy or not? I know that hopefully people don’t use hospital consultants as often as a supermarket, but I have seen this kind of competition and choice happen abroad and believe me it works!
    Even at our local GP surgery, where there are three doctors, we all talk about who is the nicest, the most thorough etc, (not to mention making friends with the local chemist, who will know much more about the GPs’ clinical skills than you would think).

  13. Sili said,

    April 16, 2011 at 10:29 pm

    Oh, don’t be so serious. I’m sure this “wasn’t intended to be a factual statement”.

  14. kml234 said,

    April 16, 2011 at 11:31 pm

    I agree in principle with choice, but the public in general have only a minute amount of information upon which to base their choice; as an NHS info analyst I’m in the privileged position of being able to see huge amounts of data that I use to make my own choices about the services myself and my family access. For spurious ‘information governance’ reasons very little of this is released in a format useful for the average punter. Until it is, ‘choice’ will remain just a buzzword.
    By the way, the government leaflet inquestion was widely regarded in my office as one of the worst examples of info graphics we have ever seen.

  15. ferguskane said,

    April 17, 2011 at 1:45 am

    Emen

    It does not have to be a con-trick, but as used by politicians I think it generally is. The standard example is schools (under labour). Labour promised choice, but as there were only a certain number of places for each school, clearly there could not be real choice. Obviously, growing one school at the expense of another would be a solution, although not without its problems.

    As it happens, I do actually have choice at my local GP surgery, as you mention, and it does work to an extent, I can choose to see the GP I think is best. Whether the GP is the best, I can’t say for certain – but I guess I’d know if they were bad!

    I love the example of the supermarket. The perfect example of a mixture of real and illusory choice. The whole supermarket is designed to try and make you buy stuff you don’t need, and to pay more than you should. As you may be aware, expensive items are placed at eye level, with cheaper (and often identical, eg ibuprofen) products at a lower level. Then there are so many almost identical products, that choosing becomes a chore (could segue here onto food labelling).

    Taking this further, we’re being sold a lie at many levels. Most people have absorbed the lie that supermarkets provide good value (as the result of endless advertising). They don’t. My local grocers and my localish butcher provide far better value. I’m lucky enough to have some that have not been forced out of business. The local market (East Street, London), provides deals which you’d never get at the supermarket. Further, money I spend in local shops goes into the local community. When I spend money at the supermarket, extra gets syphoned off to management and shareholders. Does this sound like a familiar situation? If not, just wait for the reforms.

    It’s your choice to go to the supermarket, but it’s not necessarily the best choice for you. It’s almost certainly not the best choice for your community. (Also, After a while you might not have any choice, because there will be only the supermarket).

    Now all that said, I’m not anti choice. But first we need to be told how it will work, shown it can work, shown it can be replicated, and then we can apply it further. That takes time and careful analysis.

    By the way, there is a choice that many of my continental friends tell me that they like. That is the choice to not see the GP, but to go straight to the specialist when they think they know what’s wrong with them. I quite like the sound of that choice. Rather than have the GP refer me to the physio, I can go direct. This should work nicely for the NHS, as physios get paid far less than GPs, so their triage could be cheaper. I know this is being considered/implemented for psychology services, and I’d welcome it. I’m not sure how it would work with GP consortia?

  16. Jut said,

    April 17, 2011 at 10:54 am

    So the Government lie to the electorate to try and gain support for a policy which will end up screwing the electorate. Great.

  17. nwinton said,

    April 17, 2011 at 8:03 pm

    With regards the Cancer deaths figures that form the basis of their assertions, I would be questioning the government who was overseeing the NHS during this time. Now remind me, who was in power from 1985 to 1999 again?

  18. SimonW said,

    April 17, 2011 at 11:49 pm

    I have a GP in the nearest City as a GP in the practice whose area I am in failed me badly in tasks that should be routine for a GP.

    There is already de-facto choice in GP for reasons like I describe. Anyone who has ever gone looking for a better GP knows good GPs are already over subscribed.

    Many GPs presumably know this because they typically pick their doctor, since they wouldn’t usually be treated by their immediate colleagues (or themselves) presuming that many of them live in their own area.

    Even within my local GP practice other patients have clearly noticed which GP is better than the other, and book appointments accordingly.

    Ultimately there needs to be sanction for under-performing GPs, allowing more patient freedom is one way. Though I know some very popular doctors whose critical thinking skills are not well developed, people’s choices aren’t always rational, but if we want to enforce rational choice we probably should start with banning homeopathy rather than the gradations of GPs.

    Cancer deaths – begs the obvious question how many more in that age group of not dying now. i.e. is it more than 7,000?

  19. Jackeline B said,

    April 18, 2011 at 12:05 am

    People don’t want more choice they want good quality local services. If you think your GP has not treated you well you should complain and you are already entitled to see someone else. All that will happen with choice is that educated well off people will take over all the GPs they think are good leaving poorer people with the less good ones and increasing health inequality.

    Why is competition always seen as the answer to everything? Go back to supermarkets – a market economy means a small town might have 2 or 3 different ones giving people choice. Do we need 2 or 3 hospitals at vast cost so we have a choice or do we just want 1 good one? OK this probably won’t happen but you could end up with several providers of a particular service in one area all costing money that could be better spent on 1 decent provider.

    The NHS is not a business like a supermarket, it is a public service. Its job is not actually to court ‘customer’ satisfaction its job is to save lives, reduce pain and try to improve peoples health (among other things) and yes hopefully people will be happy with this. Competition and choice are not the cure for all ills.

  20. PlasticManc said,

    April 18, 2011 at 9:49 am

    But Lansley continues to repeat the same old line. If people don’t like the reforms it can only be because they don’t really understand and he needs to explain it again. He’s been saying that for months and I’m slightly gob-smacked by the arrogance of it.

    Especially since straight afterwards he starts on about the importance of giving people choice.

    When will understand that he’s done enough explaining and the people that understand the changes best are the ones complaining the loudest?

  21. Jackeline B said,

    April 18, 2011 at 5:21 pm

    Yes he’s in favour of all choice except the choice not to have these reforms. Also the conservatives say they want frontline staff more involved in decision making but won’t listen to their criticisms of these reforms.

  22. emen said,

    April 18, 2011 at 8:24 pm

    @ ferguskane 15

    By “supermarket choice” I didn’t mean you can choose between identical bottles of milk in one supermarket. I meant you can choose between ASDA, Tesco, Aldi, and Waitrose, AND local grocers, butchers, farmer markets, ethnic shops.

    Having in mind that healthcare of course is never exactly the same as buying food, imagine the following. The food shopping equivalent of the NHS would be a National Food Service: identical medium-sized outlets, where you get your Tesco value quality food from behind the counter from staff. You don’t have to pay, but you don’t have a say in what you have either. If the government guidelines ration a bag of apples for fruits per week, you can’t get more and you can’t have oranges. Arguments like you prefer oranges to apples would not count. Furthermore, there would regularly be a shortage of food, so even if you qualify for apples, they might not have them – and you would find it out after standing in the queue for 10 hours. Or they migth send you over to another outlet, with no guarantee that they will have any.

    If you complain that this is one of the richest countries of the world, could we perhaps have more choice, more variety, shorter queues, staff would get offended that they are doing their best, they are underfunded and overworked. When in fact you are not blaming them personally…
    I’m sorry, but this is what the NHS looks like to someone from the EU. Terribly reaassuring that whatever happens, there will be SOME healthcare. But the quality is quite dreadful.
    After all, if you have no income, the governmnet doesn’t give you bags of apples, potatoes and cabbages – it gives you money (benefits) that you can spend on food. You choose where and on what.

  23. emen said,

    April 18, 2011 at 8:54 pm

    @ ferguskane 15

    “By the way, there is a choice that many of my continental friends tell me that they like. That is the choice to not see the GP, but to go straight to the specialist when they think they know what’s wrong with them. I quite like the sound of that choice. Rather than have the GP refer me to the physio, I can go direct. This should work nicely for the NHS.”

    I think it depends on the country. In France the state will reimburse a higher percentage of the specialist’s bill if you are referred by the GP. In Germany (in state healthcare) you need to get referred by the GP, but the referral is quicker, almost automatic. You don’t have to beg your GP to refer you for a scan if you have some bad abdominal pain. But, as you say, in some countries (Spain eg), as far as I know, they are looking to abolish GP care altogether.
    And in a lot of countries, including Eastern-Europe, children see paediatricians in primary care, not “adult” GPs, which is much better.

    Also, in England there is a whole level of healthcare provision missing: the specialist care between GP and hospital specialists. In other words, instead of having one hospital with ENT doctors or gynaecologists in it, you get individual specialists working from rented flats, small (or big) clinics etc. That is one type of choice: you see one when you are referred, if you are not happy with her, next time you choose to see another one.

    You have to have SOME level of competition in healthcare, to reduce price, increase quality, innovation and patients’ RIGHTS.

    By the way, when you say, “it should work nicely for the NHS”, I wish it was true. But the main reason why we have GPs at all is that they function as gatekeepers to expensive good quality specialist care. They need to keep you in primary care as long as it is possible (and longer…) – without having the time, the access to scans, tests OR the skills to treat the conditions they are trying to sort out (not their fault, I must add).

    Trust me – competition in healthcare has been tried and tested in many countries (I’m NOT talking about the US) and it works well. Well, better than what we have here now.

  24. emen said,

    April 18, 2011 at 9:04 pm

    @ Jackeline B 19

    “All that will happen with choice is that educated well off people will take over all the GPs they think are good leaving poorer people with the less good ones and increasing health inequality.”

    I disagree.
    It’s not just educated and/or well-off people who can be unhappy with their GP. It’s people who have had bad experiences, educated or not.

  25. danfaller said,

    April 18, 2011 at 9:33 pm

    Hi Emem

    as a GP i am glad you see GPs as gatekeepers – but worried you see our primary role is to stop people getting to expensive tests and consultants.

    Actually, as a GP I see our role within the NHS as hugely valuable. It keeps us in budget, and comparing us to an american system that costs considerably more (as a proportion of GDP) is disingenious.

    I see 30 – 40 patients a day – and of those patients many do NOT need to see a consultant. The holistic care i can hopefully offer them means that the *anxiety* of illness and the psychosocial causes of their illness behaviour can be properly accounted for and actively managed. Specialists are great – but you must remember that they apply their expensive tests and scans to a selected population. Have a read of Bens excellent book if you want to see what happens to specificity and sensitivity of tests when you start applying them to unselected populations. They stop working properly. And who does the selecting? GPs.

    As for children, i see something like 4 to 6 a day, more in the winter with viral illnesses. I probably refer 1 a month (at most); I understand their families and their social situation (because i look after mum and/or dad too). This advantages of this are palpable, and i genuinely believe i am offering good care (i have the diploma in child health).

    The real problem with the health care reforms is that we are NOT offering true choice in this. What is being offered is the opportunity for me to choose on your behalf a service which will deliver a service. If you don’t like it, unlike with true competition, you cannot simply ‘go somewhere else’ (incidently in the USA if you don’t have insurance you can’t just ‘go somewhere else’ either – and even if you do the insurance company actually limits your choices).

    So…what will happen if the service is poor? I will have signed a contract with a provider – so to get out of this i will need to provide evidence that they are underperforming. The measures used to decide on performance are not yet clear, and the degree to which underperformance is likely to need to be ‘proven’ before i can terminate a contract is likely to be high. This definitely concerns me, and financially having to engage legal counsel to argue with private providers when there is disagreement seems not only crazy, but likely….

    as to the particular issue of choosing the GP of your choice – why not? home visits are a pain but not insurmountable. BUT thought does need to be given to how one maintains a service to some rural GPs though (big communter group move to city practices for work and the money follows, making the service unaffordable, so who looks after the old/infirm/immobile in the rural community)

  26. danfaller said,

    April 18, 2011 at 9:38 pm

    having reread your comment i have of course realised you did distance yourself from the US model – apologies for focusing on that! My thoughts on the value of the UK GP system still apply though….

    dan

  27. AdamJacobs said,

    April 19, 2011 at 8:38 am

    Seriously, Ben, you wouldn’t expect dodgy statistics from a government leaflet? Seriously?

  28. sciencerocks said,

    April 20, 2011 at 8:09 pm

    Once again, thanks for your efforts on this sort of thing Ben. Alas, we are probably all reminded of various episodes of Yes Prime Minister. Groan…

  29. p.allmark@shu.ac.uk said,

    April 21, 2011 at 8:46 am

    Most of the material below comes from something I wrote for Roy Lilley’s blog, NHSmanager.Net.

    The DoH claim that the 95% figure comes from a different Chapter of the NatCen report to the one we all looked at first. Chapter 2 is on Health which is where we looked; Chapter 3 is on Choice in Public Services, which is where they claim the 95% figure comes from. But this remains ludicrous.

    In Chapter 3, table 3.1, it asks: “How much choice should users of public services have about …” followed by six areas of public service, two of which are health related. The answers are as follows:

    How much choice should users of public service have about ……
    which hospital to go to if they need treatment

    None A little Quite a lot A great deal
    4 21 49 26

    …what kinds of treatment they receive
    3 22 52 21

    So the accurate report of this is that around 96-7% want more than no choice at all in relation to two areas of health treatment. There is nothing here to imply that this proportion of people want more choice, only that they want some choice.

    We could look at the rest of the survey to get a better sense of what people think about the place of choice in health care.

    Table 2.6 asks whether people thought they should have a say over various aspects of care (hospital, appointment and treatment). Here the crucial figure is those who believe patients should have a say but do not. In relation to the three aspects of care the figures are: which hospital, 57%; outpatient appointment time, 44%; and kind of treatment, 50%.

    In other words, the very highest figure for the amount of people who think they should have more say is 57%, and that is in relation to which hospital to go to.
    This is nowhere near the 95% figure on page 11. And this is leaving aside the fact that “having a say” conveys a different meaning to “having a choice”, something the authors of the chapter state explicitly on page 40. In fact, when asked about choice, the survey is clear.

    To quote from page 60,
    “we asked our respondents to state which of four possible priorities for the NHS was ‘most important for the NHS to achieve’. No less than 78 percent chose ‘make sure people who are ill get treatment quickly’. In contrast, just six percent say ‘make sure people have a lot of choice about their treatment and care’…

    So, 94% rated choice as a lower priority than i) getting treatment quickly, and ii) making sure people on low incomes are as healthy as people on high incomes.
    Page 11 of Working together … makes this 95% claim. There is no data in the NatCen report to back it up and some which clearly conflicts with it. Furthermore, the last two NatCen reports have shown clearly that satisfaction with the NHS is, or was, at an all time high.

  30. JHvW said,

    April 21, 2011 at 1:12 pm

    Just to let you know that I greatly enjoy reading your work, although I do not always find the time (so many things to do, so little time).

    In the Netherlands there is an association named the “Vereniging tegen de Kwalkzalverij”, you may be familiar with it. Loosely translated it is the “Association against Quackery”. It is not very popular with those who engage in the practices you frown upon.

    There seems to be a tendency to try and bankrupt the Association by drawing them into expensive courtcases.

    You may be amused that a recent professor in homeopathy (he is actually a professor at a liberal university) who stated that homeopathy works although there is no proof. His argument was that people fall in love and there is no scientific basis or proof!

    My personal opinion is probably among the lines of regression to the mean. I have definitly fallen out of love with alternative medicine. In the Netherlands I have often heard people saying that it can do no harm. Recently there have been a number of courtcases where “alternative” healers waited too long before sending those they care for to regular care, often resulting in death. It is a sad state of affairs, especially as the treatments are often paid for by healthcare insurers as they are a cheap alternative to regular care.

    On a final note: I saw an advertisement for an alternative healer who claimed he could help insulin dependend diabetics to overcome their insulin dependency. Yet the government will do nothing.

    The mind boggles.

  31. ferguskane said,

    April 22, 2011 at 12:41 pm

    @ danfaller 25.

    I’m not quite sure I get the point about specificity/sensitivity in unselected samples. Is the selection of the sample not part of the screening process itself and therefore subject to the same problems? As a GP you are essentially part of the test, and you also sensitivity and selectivity issues.

  32. ferguskane said,

    April 22, 2011 at 2:24 pm

    @ emen

    “By “supermarket choice” I didn’t mean you can choose between identical bottles of milk in one supermarket. I meant you can choose between ASDA, Tesco, Aldi, and Waitrose, AND local grocers, butchers, farmer markets, ethnic shops.”

    Choice can happen, or appear to happen, at many levels. If the above was what we got, we could be happy. My worry is that we’d start off with that, and then large companies and consortia would use Starbucks/Tesco tactics to shut down competition. We’d end up with just Tesco. Hence we need to be cautious. We need to run pilots before we make changes, not just makes changes based on ideology.

    Competition can be useful, but to quote (probably misquote) Stiglitz, the reason the invisible hand seems invisible, is because it is often not there. Or, alternatively, there are various invisible hands, most of them dirty and with their fingers in too many pies.

    “If you complain that this is one of the richest countries of the world, could we perhaps have more choice, more variety, shorter queues, staff would get offended that they are doing their best, they are underfunded and overworked. When in fact you are not blaming them personally”

    Yes, institutional inertia can be a problem. But if a good manager really takes the time to build their business (and social) case, then this can be overcome. I’m over in Ireland at the moment, where the cuts are really beginning to bite, but I’ve just seen a CEO do a really god job of explaining to staff the rationale behind all the changes he’s putting in place. Makes a big difference.

    I’ve not seen a sensible rationale from our government yet.

  33. danfaller said,

    April 26, 2011 at 1:52 pm

    @ ferguskan 31

    I think the point i am trying to make is this:

    a test gets developed by secondary care that, when applied to the patient population they see, gives a sensitivity and specificity which is acceptable for what they are looking for. That is fine provided they continue to apply the test to the same population.

    The point i was trying to make is that the population they are applying it to is already defined by GPs and their knowledge of what to refer and when. Our secondary care colleagues, excellent as they are, will often apply the same set of tests to their patient population because their job is different from ours. But if we change referral patterns (e.g. by GPs not existing) then when those same tests are applied to the now undifferentiated population, they will get different results.

    You could train secondary care consultants to begin doing the differentiation process of course, and only doing their tests on certain people. This sounds simple but the mental processes involved are quite different; it is a totally different way of thinking, and of course the numbers of people presenting to primary care are huge. When you have a group of doctors specifically trained in risk stratification and differentiation (when done well) why not persevere with that and let the secondary care doctors get on doing what they like doing best?

  34. parasura said,

    April 26, 2011 at 6:23 pm

    When my GP referred me to an Othopaedic specialist, the practice manager asked me which hospital I wanted to be seen at. As far as I could see at the time, the choices available to me were to pick one at random, go home and learn enough about the subject to be able to determine what a “good” othopaedic surgeon looks like (however long that would take) or finally to ask someone with some specialist knowledge what to do. My GP reccomended Mr Hyphenated Such and Such and that’s who I saw. Illusionary choice is no choice at all, as most people surveyed seem to be fully aware.

    So what about the online data on sugeons success rates? Well for starters, I know my way around the Interweb and the best I can find is this: www.nhs.uk/Scorecard/Pages/Results.aspx?OrgType=5&Coords=3911%2c3486&TreatmentID=0&PageNumber=1&PageSize=0&TabId=0&SortType=1&LookupType=1&LocationType=1&SearchTerm=l35+9lh&DistanceFrom=50&SortByMetric=0&TrustCode=&TrustName=&DisambiguatedSearchTerm=&LookupTypeWasSwitched=False&MatchedOrganisationPostcode=&MatchedOrganisationCoords=&ServiceIDs=&ScorecardTypeCode=&NoneEnglishCountry=&HasMultipleNames=False&OriginalLookupType=1&ServiceLaunchFrom=HomePage which is about as reliable as the equivalent sites for hotels as far as I can see. More importantly, I suspect that surgeons with high success rates could in fact be cherry picking patients whereas those with high mortality rates could in fact be extremely good surgeons who are prepared to handle high risk patients. Again, I don’t know enough to be sure. Like most people I reckon.

  35. CaptainHaddock said,

    April 27, 2011 at 1:48 pm

    @Emen
    “All that will happen with choice is that educated well off people will take over all the GPs they think are good leaving poorer people with the less good ones and increasing health inequality.”

    “I disagree.
    It’s not just educated and/or well-off people who can be unhappy with their GP. It’s people who have had bad experiences, educated or not.”

    Less well off people may be unhappy with their GP, but they may not feel able to change to another practice. They may not drive, or can’t afford the increased travel costs to further clinics. Whereas better off people won’t have that worry.

  36. heavens said,

    April 30, 2011 at 5:16 pm

    Patients want to choose what they believe is the best hospital… but I agree that the actual quality of the health care provided isn’t what they’re making the decisions on. Parking, decor, private lavatories — these are the things that the typical patient/consumer cares about. I’m aware of a pair of American hospitals, literally across the street from each other, that advertise themselves like this to pregnant women:

    #1: Full-service hospital. Only NICU for thirty miles. Full emergency department, top-rated intensive care unit, cardiac care unit, full range of diagnostic and procedure services available around the clock, with physicians on duty/on site 24×7.

    #2: Plush terry cloth robe for the mum, ‘free’ champagne, hotel-style room service, king-size bed, plenty of ‘free’ parking, recently remodeled, 100% private rooms and 100% private lavatories.

    All the obstetricians work in both hospitals, and much of the nursing staff has worked at both facilities.

    Most of the typical-risk pregnant women choose the robes, champagne, room service, large beds, ample parking, and private rooms over the full-service facility with night-duty physicians.

    Also: “best” depends on what you need. Even a world-renowned place like the Mayo Clinic isn’t “best” if they don’t know any more than the typical hospital about your particular condition. If you have an extremely rare condition, “best” has more to do with where the individual subject-matter experts happen to be than with the common-disease quality measurements.

  37. Majikthyse said,

    March 5, 2012 at 3:11 pm

    Here is what I got from my MP John Glen, when I asked about releasing the Risk Register:

    “I appreciate the principle behind the blog post; we have a duty to ensure all the facts we present are correct. However, I take the stance that statistics are always malleable, and can generally be manipulated to say what the user wants.

    “The first point about cancer death rates seems to question the validity of the study simply because it uses data from 1985 to 1999. I appreciate that times have changed since then, but I still believe it is a fair statement to make; the data source was the same for all countries. Perhaps it was too strong to use the qualifier ‘would’ rather than ‘could’.

    “I do not accept the second point at all: we are in a time of relative economic austerity, and it remarkable in my mind that the growth rate of doctors has continued at all when many other professions are deteriorating substantially.

    “The analysis on choice seems dependent on using increased patient choice as the basis for reform. This is not true. The central reason we are reforming the NHS is because it is completely unsustainable and not suited to manage the healthcare required of it in the future. In ten years time, 53% of people will be using the NHS to manage a long term chronic condition. The PCT system accounts for 69% of the NHS deficit, and bureaucratic middle management has got in the way of delivering health care, which is the priority of the NHS.

    “Having already mentioned that statistics are easily distorted, I would nonetheless like to offer you some concrete figures that I have been provided with. The real benefits of these reforms are now starting to materialise: one Clinical Commissioning Group has seen a 33% reduction in admissions from care home patients over the past six months; a second has seen a 40% reduction in hospital visits through a new team to deal exclusively with care home visits; a third has redesigned stroke services and reduced the average hospital stay for patients from 56 days to 12 days, saving £700,000 annually.

    “In my mind, this is what matters; we are delivering real benefits already. If the disclosure of the Risk Register prevents this, as it undoubtedly would because it is so easy to misrepresent, either for political purposes or otherwise, then I cannot support its release.”

    Any thoughts?