How much management does the NHS need?

Andrew Lansley (he's the health secretary, in case you haven't learned all the names yet) is playing an old political trick on TV this morning. He claims to have found £1 billion of "bureaucracy" to cut - money which will be redirected to the "front line".

Of course everybody would support that...wouldn't they?

But what if he decided to fire 30,000 essential support staff and shift their workload onto hard-pressed GPs? Doesn't that sound like a terrible idea?

Of course it might be exactly the same thing. It's all in the framing. Frank Luntz wrote a revealing - and cynical - book, Words That Work, about how he and the politicians he advises control voter's emotional responses with the language they choose. "Bureaucracy" is a classic choice of word for conservatives; while those on the left might choose "public investment", "social spending", "public healthcare" or "efficiency improvements" to describe exactly the same thing.

Indeed, with that phrase "efficiency improvements" I'm revealing a little of my own thoughts about the subject. I was taken aback by Lansley's suggestion that bureaucrats were "standing in the way of doctors providing care". Surely not?

There are two kinds of non-clinical resource in the health service. One is the straightforward support resource: the people who make your appointments, clean the floor, publish the leaflets which give you public health advice, order new drugs or bandages, and administer the payroll of nurses and doctors. These people are all taking unproductive work away from clinically trained staff. That is, other things being equal, a good thing. There is an optimal level for this support resource which generates the maximum amount of healthcare for a given budget. In most industries, support resources of this kind are at least 25% of the total cost of production. In some high-tech, high-knowledge industries with strong network effects (such as software development) the optimal level of support resource may be as high as 90% of the total, with only 10% of people working on "pure" productive outputs.

I don't think this is what Lansley is complaining about - though he might think the proportion of support resources is too high. It's hard to get a figure because these resources are managed at PCT (primary care trust) or hospital level, not centrally. Presumably the Department of Health has some idea of the numbers, and Lansley will be attending to those in due course.

But the reference to "standing in the way of" indicates he's really talking about the other kind of non-clinical resource - what we might call "meta-clinical" staff. The job of these people is to influence, improve or control the decisions of individual medical workers.

From the context of the interview, it seems that this is what Lansley wants to cut. This desire links two separate concerns.

The first is how much money the central resource costs. In this document we get some clues as to how much that might be. 83% of revenue expenditure goes on primary care trusts. Thus 17% of resources (excluding capital) are spent centrally - and much of the control, coordination and prioritisation will happen here. That is a lot of money - about £11 billion - but is it worth it? What does it achieve?

This is at the heart of the second concern: Lansley does not want individual doctors' decisions to be restricted by central influence or control.

But why does this happen? It's not just a power grab by a bureaucracy which has been created for its own sake. This central influence includes:

  • education of doctors in the latest discoveries
  • distributing information to doctors to make them more effective - partly through IT infrastructure, partly through internal and external publications
  • tests of the effectiveness of different treatments
  • allocating limited resources among different treatments, different regions and different people
  • quality assurance and upholding patients' rights (for example through litigation)
  • and, controversially, deciding which drugs or treatments doctors are allowed to provide
Do these improvements and knowledge transfer improve the quality of outcomes for patients by more than spending the same 17% on more doctors and drugs? Or more precisely, would more or less central spending at the margin bring a net improvement? That question's hard to answer, but name-calling and stereotyping doesn't help.

The new government is more and more clearly drawing a distinction between modern right-wing and left-wing politics. The right focuses on the value of local and individual knowledge; while the left believes in the value of universal, central knowledge. Perhaps this is why people in the social sciences tend to be left wing: the whole project of social science is to provide universal explanations of how people are. Does the right believe that people are really more different from each other than the left does? Or do they, perhaps, fear that they are no longer in the majority - and will therefore fight more strongly for the freedom to follow a different path? Just as the left did in earlier years when their lifestyles were the ones at threat from majority rule.

Maybe I'm pushing a simple debate on healthcare efficiency a little too far...

Update: The FT has more details of Lansley's proposals.


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