A bland euphemism which hides a dangerous lack of planning

One of the finest euphemisms in management speak is “right-sizing”. It’s as bland a euphemism for sacking people and shutting things as you could hope to find.

There are several problem with right-sizing healthcare provision in the way that the new failure clauses being debated in today’s Care Bill reading would permit if they pass.

These clauses have emerged in response to the defeat in law of the secretary of state’s efforts to back the trust special administrator’s attempts to cut services at Lewisham Hospitals Trust to try to bolster other parts of the south London provider economy, following the dissolution of South London Healthcare Trust.

Lacking evidence

While there is clear evidence of quality improvements with certain volumes of clinical procedures – a fine summary of which was given at the Nuffield Trust’s Health Policy Summit last week by Dr Barbro Friden, chief executive of Sahlgrenska University Hospital in Sweden – we lack convincing evidence of the secretary of state’s or the Department of Health’s capacity and capability to know what the right size for a provider is.

We do have evidence from the London stroke provision reconfiguration.

‘We lack convincing evidence of the secretary of state’s capacity and capability to know what the right size for a provider is’

However, as its overseer Dame Ruth Carnall (then chief executive of NHS London) told the summit that the plan was deeply contested and intensely unpopular with almost everyone at the time and indeed, until research evidence proving its benefits emerged.

Strategic health authorities such as NHS London were of course abolished with the Health And Social Care Act 2012.

Philosophically, the act’s reforms sought to abolish the mechanisms of planning health economies, replacing them with the Liberating the NHS white paper using commissioning (whose evidence base in the NHS is waif-like), choice and competition.

Market like mechanisms

Of course, more market like mechanisms had been put in place for the provider sector under the new Labour health reforms.

“Contestability” was Simon Stevens’ neat euphemism for competition, yet it is too easily forgotten that he plotted that on one low-high axis of a chart, and on the other low-high axis put “measurability”.

It’s worth remembering his view was that market mechanisms would be appropriate where services were both highly contestable and highly measurable.

To many this remains a reasonable taxonomy. In 2000 the NHS wanted more of stuff: more doctors and nurses, and particularly more activity in the acute sector.

‘This year the problems and financial climate are quite different’

The mechanisms put in place were broadly the right ones to achieve that in an era of sustained financial growth: a national tariff preventing price competition, which Carol Propper and colleagues’ research showed to be damaging to safety; fee-for-service (almost fraudulently mislabelled “payment by results”); waiting time measurements; freedoms from central control for high performing providers; and patient choice.

The new health economy

This year the problems and financial climate are quite different. And where a health economy has what some see as an oversupply of troubled providers, then the logic of the act – which also brought in a clear failure regime – tells us that the market should decide.

The strongest providers should thrive and the weakest go to the wall. Unless Jeremy Hunt is a closet socialist (which seems unlikely), surely there should be no planning fixes?

Had Lewisham been a foundation trust the option to intervene in its provision would not have been available in law to the secretary of state. Providers have the economic and legal incentives that they have, and respond to them accordingly.

To borrow from Russell Hoban’s wonderful allegory The Mouse and his Child, which tells the story of some broken clockwork toys’ quest to become self-winding, “one does what one is wound to do”.

Tax-funded, single-payer healthcare is different. It is in its very nature planning.

There are reasoned arguments that provider diversity and competition at the margins for elective care have useful roles to play in providing some challenge to major incumbents.

Yet we see in the desire for clause 119 that even those like the secretary of state – who voted for the act – have since recognised that a system without planning faces a whole new range of problems that may waste public money without improving the quality of patient care.

Andy Cowper is HSJ’s comment editor