The NHS is a World Unto Itself

My position when writing: unclear, but I’m not particularly a fan of Jeremy Hunt.

Apparent argument: some things are going wrong in the NHS.

What’s right with this? Well, I assume the claims are factually correct

What’s wrong with this? Two main things – it’s context free, and it doesn’t tell me why I should care about those particular measures.

As the NHS changes, facts and figures about it will change. Without knowing the story behind a change, it’s difficult to know if the facts are part of good news or bad news. The facts given by David Lammy’s tweet could be be part of good or neutral changes. I don’t know that they are, but consider:

  • “the number of people waiting over two weeks for urgent cancer treatment has more than doubled” – this depends on how the number of those people is measured. How do we decide who has an urgent need for cancer treatment? If our detection systems are better now, but our treatment capacity hasn’t changed, then the queue could be longer without any decrease in the amount of treatment.
  • “the NHS has lost 7000 beds” – this would be fine, if the need for beds had also decreased. So if treatment was better, and patients had shorter stays in hospital, or if more conditions were being treated without a hospital admission, then the number of beds could decrease without any negative consequences.
  • “the number of people waiting more than four hours in A&E is up 842%” – okay, it’s difficult to see how this could be a good thing! But perhaps this is partly explained by there being more patients overall. If the number of patients has doubled, then that cuts in half the size of the increase that needs to be explained by something else, such as incompetence or relative underfunding.

Similarly, for some of the items in the StandwithNHS tweet:

  • “72 NHS Walk In Centres Closed/Downgraded”, “61 Ambulance Stations Closed” – the number of closures or downgradings are not that useful by themselves, because it’s not clear that the numbers are net (effective) or total. It’s possible that 100 new ambulance stations were opened, 61 were closed, and we now have 39 more overall. Maybe only 50 were opened, but that still means there are only 11 less than there were before, rather than the 61 mentioned.
  • “9.1% NHS funding cut per patient” – maybe drugs are cheaper, or more effective. Maybe we treat more patients without admitting them. Maybe we treat more patients with drugs than with surgery. Maybe this includes patients who called NHS Direct. There are all kinds of ways that funding levels could be lower without anything being worse.

Now look at the good news, according to the Conservatives’ own web site:

This looks like good news, but it can still hide poor service:

  • “We have increased health funding to a record level – so people get the care they need.” – it could still be falling when inflation is taken into account.
  • “We are investing more in mental health than ever before – transforming mental health services.” – this isn’t inflation-adjusted either. It’s impossible to know what is meant by “transforming”.
  • “There are more doctors and nurses looking after patients.” – there could still be less than are needed.
  • “Our healthcare system has been ranked the best healthcare system of 11 wealthy countries by The Commonwealth Fund.” – the Fund’s criteria may not be the same as British people’s criteria. The NHS’s current performance could be worse than it was in the past.
  • “Cancer survival rates at a record high.” – performance may simply have moved from “very bad” to “bad”. It may still be possible to do much better.

There are thousands of possible ways of describing the NHS’s performance. Most of them don’t tell you much, unless you understand their context. Because the NHS is such a large organisation, and is constantly changing, it’s perfectly possible for some parts of it to get better while other parts get worse.

The NHS is supposed to keep people healthy. It is effective if the people it treats are healthier than they would have been otherwise, and it is efficient if it doesn’t cost too much to do that. (That cost can be in cash, time, or something else).

Discussion about the number of hospital beds, the number of nurses, or the number of ambulance stations, is beside the point. Changes to those numbers can help or hurt. But we don’t care how many ambulance stations there are, we care about how many people are saved by ambulances arriving quickly. We don’t care how many nurses there are, we care about how many patients don’t get good enough nursing care.

The questions we should be asking are about outcomes, not resource levels. Are patients are receiving high-quality care? Is the NHS saving the highest possible number of Quality-Adjusted Life Years? Is this being done for the lowest cost consistent with high quality?

Most of the points raised above are about resource levels, not outcomes, so any discussion they prompt is likely to be about means, not ends. We should focus on ends.


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