Anyone who has had the joy of working with Sir Muir Gray will know that his genius extends in many directions. But I think it’s his ability to communicate that really marks him out. His knack of condensing complex phenomena is deeply impressive.
According to Muir, how does the NHS decide what services to provide?
“Charisma is probably the main determining factor that has given us the shape of health service that we’ve got at the moment”.
This came 21 minutes into Episode 2 of Professor Al Mulley’s excellent podcast ‘The Choice: securing the NHS for the next 75 years’. I replayed it, convinced I’d misheard. I hadn’t.
Both Al and Muir have given me much to think about. Each of them has fundamentally changed my understanding of multiple topics, and I’d need more than this lifetime to do their insights justice. But - even for them - this looks like a strong claim.
So how does ‘charisma’ explain the current pattern of NHS services?
According to Al and Muir, it is because persuasive and well-meaning (this is not a cynical theory) clinicians want to offer the best care to patients. Equipped with a promising innovation in treatment, they seek to persuade managerial colleagues and commissioners to fund this potential breakthrough and improve outcomes for patients.
These decisions combine over time. Consequences ripple and aggregate into patterns of care that would never be planned. Procedures are done at many times the rate in one area compared to another. ‘Population need’ explains little of the gap; and no-one can be found to defend the decision to allocate resources in the way they are.
This is deeply challenging. Anyone with a background in disciplines such as commissioning, policy making or health economics will be looking on in horror.
These disciplines are careful and rational. They produce accounts of how resources ‘should’ be allocated, which tend to go something like: understand population needs; know what health gains you can achieve with your resources; (re)allocate resources to maximise gains. These accounts provide very weak explanations for what actually happens. The rational are left baffled.
In the podcast, Al and Muir take their argument down many interesting lanes; readers really should listen from start to finish in order to follow them.
But I see an implication that seems both unexplored and important: if charisma is ‘the main determining factor’, then the desired ‘shift from hospital to community’ is swimming uphill to an incredible degree. And if charisma determines investment, then (ahem) ‘simply’ improving community-based services will not change patterns of care. The NHS will remain hospital centric.
Why?
One thing to notice is that Muir and Al aren’t suggesting charisma as the sole explanation. They are also showing how persuasive new treatments are. Advances in medical technology, in the hands of clinicians who want to use them, is also doing the work here. Lives can be saved using new drugs, procedures and equipment; we admire and support the people that want to save them.
Accuracy would have ruined Muir’s line, but it is innovation in the hands of the charismatic that gives us the services we have.
Multiple studies support this view. Estimates, of course, vary. But they vary around enormous numbers - with a very rough consensus being that around half of the growth in healthcare spending is attributable to advances in medical technology. Half. Other factors, such as the ageing population, are trivial relative to this.
Where has this growth concentrated? Hospitals. Despite the stable policy goal of shifting care to primary and community settings, investments have gone in the opposite direction.
This is illustrated with stunning clarity by the Nuffield Trust in their analysis ‘Where does the NHS money go?’. And the Kings Fund argues that:
“The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years”.
The Health Foundation’s report ‘The bigger picture’ shows and scales this brilliantly (Figure 12 is a neat summary). And a forthcoming Strategy Unit paper looking at changes in planned hospital activity between 2006 and 2019 concludes that:
“Having controlled for changes in population size and age profile, we estimate that half of all growth in elective admissions and two thirds of the growth in outpatient attendances is attributable to the emergence and adoption of new medical procedures”.
Policy on community services has not done the work here. Technology has. The specialities, located in hospitals, not in the relatively low-tech community sector, have provided enticing breakthroughs. Funding has followed, smoothed by charisma. This explains the shape of our services in a way that accounts based on NHS policy and implementation cannot.
And so, when it comes to explaining the failure to shift care, have policy analysts – perhaps prone to belief in rationality and the power of policy - been looking in the wrong place? If so, what does that mean for the policy mix needed to really shift care?
At a very broad level, it would mean that action to bolster and invest in primary and community services is necessary - but far from sufficient. Related steps to stem the flow of investments towards innovations in treatment would also be needed. Nothing says ‘politically unpalatable’ like denying new treatments to patients who believe they will benefit.
And yet, in a recent - and stunning - paper in the Lancet it seems that investing in new drugs, rather than services, has actually cost lives.
“Overall, the cumulative population-health impact of drugs recommended by NICE was negative, with a net loss of approximately 1·25 million QALYs.”
Are we spending more and achieving less because of this kind of innovation?
If the argument in this article is right, then shifting care will need much more than changes to primary and community services. It will also require wide-ranging policy imagination, astonishing political boldness, and a very healthy dose of charisma.
