Why the NHS debate needs an independent voice

There is an urgent need to pull the current health debate back into an evidence based space away from political and personal blame games to ensure the viability of the core principles of the NHS. Two seemingly unrelated issues sparked this idea.

Axel Heitmueller

‘Which “evidence” to believe, and where even to obtain it?’

First, I almost got myself confused watching the news. Politicians from all sides reassured me that accident and emergency departments would not be closed under their watch. At the same time, we had senior current and former NHS officials warning publicly that unless significant reconfiguration and consolidation was going to happen, the very future of the health service was under threat.

What was going on? Either politicians were promoting potentially unsustainable services, or NHS officials had been besotted by a collective depression. Which “evidence” to believe, and where even to obtain it?

Second, I felt my few remaining econometric brain cells tickled by the publication of yet another research paper on patient choice. The paper by researchers at York University, while raising some relevant and interesting questions, seemed rather overconfident in its conclusion (that quality drives patient choice) given the methodological and conceptual shortcomings the paper suffers from, in my opinion.

Why do I worry? Because bold statements in the area of choice and competition find grateful customers on either side of the argument, yet most people will not read beyond the executive summary.

Make meaning of it all

What links these two issues is the absence of any meaningful debate, challenge and, at least in the A&E case, the ability to obtain evidence to form an independent and informed opinion.

Much of these issues have integrity, trust, and transparency at their heart. Surely it is a wonderful thing that we have access to research results much earlier than even 10 years ago thanks to the internet and availability of discussion papers?

‘There is hardly any other domestic policy area with such a strong independent voice as the IFS’

Of course, the flipside is that readers (including policymakers) have to conduct their own peer review to judge whether the findings are sound unless they are prepared to wait often several years before publications appear in reputable journals. Reputation helps, but as the Rogoff-Reinhart debacle on optimal levels of public debt has so powerfully shown, even the best get it wrong sometimes.

I hold my hands up; I have been there. As an academic, I had all the incentives to sell research to a broader audience by pushing the interpretation of data to its maximum. As a policymaker, I had ministers pushing me to find definite answers, even in the heyday of evidence based policymaking. I therefore understand that overconfident conclusions in research are a demand side and supply side problem, driven by a set of entrenched and often complex incentives.

In my view, part of the solution lies with the internet and social media. Institutions publishing discussion papers should enable readers to actually comment on them on their websites, introducing instant peer review. And social media platforms, such as Twitter, offer even more interactive opportunities to engage with a broad and often random set of people, though I appreciate that nuances are sometimes hard to get across in 140 characters.

All of this may contribute to greater transparency and trust, and is easily achieved. But there is a more fundamental point here when contemplating transparency and trust.

Unrivalled reputation

Those following government spending reviews and budgets will know that the real insights and translation often do not come from the Treasury but the independent Institute for Fiscal Studies. Over the years, the IFS has built up an internationally unrivalled reputation for economic and fiscal expertise, and there are few media outfits that would not turn to it on the eve of the annual budget. That is not to say the IFS gets it right all the time or that it is the only institute (the National Institute of Economic and Social Research did an excellent job demystifying recent welfare-to-work claims), but its independence enables a more informed public debate.

There is nothing quite like it in health. In fact, there is hardly any other domestic policy area with such a strong independent voice.

‘Health has one of the largest budgets of all but the public at large finds it very hard to make sense of it all’

By that I don’t mean there aren’t very good health thinktanks which play a vital role in facilitating debate and, arguably more importantly, conduct evaluations and disseminating knowledge. People like John Appleby at the King’s Fund, who has shown great skill in informing the recent debate about A&E figures or media claims about the failings of the NHS are doing are already in this space.

However, my concern is about scale (not enough of these trusted voices), consistency (often debates take place on selected items on blogs, not in the mass media) and level of independence (controversial, I know).

Having been close to both the fiscal and health debates, there is a perceptible difference compared with the way the IFS is acting consistently and on the full range of fiscal issues as an independent clearing house.

Public information

In contrast, many think tanks have, for understandable reasons, chosen a collegial style. This enables them to access information and keep communication channels open. But it affects heir perceived independence, rightly or wrongly.

And yet, health has one of the largest budgets of all − and has just seen the biggest structural reorganisation in its history − but the public at large finds it very hard to make sense of it all, and even informed commentators seem to struggle with the facts some times. 

There is clearly a need to pull the health debate back into an evidence based space away from political and personal blame games, to ensure the viability of the core principles of the NHS.

We may therefore want to consider the merits of an “Institute for Health Studies” (most certainly not under this name, but possibly building on an existing think tank infrastructure) that is fiercely independent; grant funded (though some genuinely unconditional government seed funding may be necessary); staffed by more of our best clinical, academic and policy minds; and with access to all health data, reconfiguration modelling tools and other relevant evidence by default (which would go beyond the current IFS toolkit and reduce the need for a collegial approach).

It would act as an independent clearing house, and might just take the heat out of the current health debate, and help inform the views of the public at large.

Axel Heitmueller is director of strategy and commerce at Imperial College Health Partners