The Hateful Eight: An Exploration of the evidence presented for Jeremy Hunt’s ‘Weekend Effect’ – UPDATED 13/1/15 with Stroke data

“We now have seven independent studies showing mortality is higher for patients admitted at weekends.”
JEREMY HUNT, ALL THE TIME.

You can view these seven (or rather eight) ‘studies’ here:

On the basis of this evidence Jeremy Hunt and the Department of Health have put forward the argument for sweeping changes to the NHS to create ‘Seven-Day’ services.

Juniordoctorblog deconstructs the Hateful Eight.


DISCLAIMER: this is written for a lay person. Further details on all the papers available on request.

1. Increased mortality associated with weekend hospital admission: a case for expanded 7 day services?  by Freemantle and Sir Bruce Keogh, published in the BMJ in 2015.

This is the most recent and most quoted paper, and where the soundbites “11,000 excess deaths” and “16% increased probability of death” come from. The study was performed by a group of researchers which included Sir Bruce Keogh, and was commissioned on his request, which makes the claim “independent” rather dubious. The study was an update of a 2012 paper (see below) and therefore 2 of the Hateful Eight are actually the same paper for different years.

This study pulled numbers from Hospital Episode Statistics, which records patient information from the discharge summaries written by junior doctors when you are discharged from hospital. If you have ever been to hospital you would know this is not always 100% accurate. The study identified the day of admission for every patient admitted to hospital in 2013/4, and then counted how many patients had died at 30 days after admission.

Overall just over 1.5 in 100 patients died in the study. They found patient deaths were LOWEST on Sunday, and HIGHEST on Wednesday, but for those ADMITTED on a Sunday or a Saturday they found a small increase in the risk of death at 30 days, an absolute increased risk of 0.07%* for admissions between Friday and Monday, compared to those admitted on a Wednesday.
The study also found 1/3 of patients died after being discharged from hospital, and the majority died after 7-8 days in hospital. For the first time the study tried to work out how sick patients were and found a higher proportion of the very sickest patients were entering the hospital on Saturday and Sunday compared to the weekdays. The authors conclude ‘to assume these excess deaths are avoidable would be rash and misleading’. At no point did this study measure staffing levels, rota cover or hospital resources, and the figure “11,000 excess deaths” is a statistical guess based on the numbers the study cranked out – they are NOT real identifiable cases.

BOTTOM LINE: Patients admitted at weekends are sicker, and they have a very tiny increased risk of death compared to the weekday admissions. “To assume this is avoidable is rash and misleading.”

2. Weekend hospitalisation and additional risk of death: an analysis of inpatient data by Freemantle/Sir Bruce Keogh published in 2012

This was the original paper as described above, by the same group from the same data using broadly the same methods. The only thing to add for this paper is it actually found patients in hospital on a Sunday were 8% less likely to die than those on a Wednesday.

BOTTOM LINE: 2 papers from the ‘Eight’ are written by Bruce Keogh of NHS England and are actually the same paper repeated.

3. The Global Comparators Project: international comparison of 30 day in-hospital mortality by day of the week by Ruiz, published in BMJ Quality and Safety 2015

The authors for this paper work for the Dr Foster Unit, sponsored by Dr Foster Intelligence: a former Department of Health co-owned patient safety monitoring company. They looked at the same data as the above from the Hospital Episode Statistics warehouse, and compared this to other countries: USA, Australia, the Netherlands and several more. This study looked at emergencies and routine surgery only for 2.8 million patients, 1.3 million of which came from the UK. For surgery, the UK had the lowest risk of death at 30 days. Emergency admissions were sicker than planned admissions. The results were similar for all countries studied, suggesting that this is an international phenomenon. UK planned surgery patients who had procedures on a Sunday, before adjustment**, were 0.7% more likely to die than those on a Monday. For emergency admissions the risk was 0.4% higher on a Sunday compared with a Monday. The effect was seen in nearly every country. Again this study performed no measurement of staffing levels on each day and the authors conclude themselves “we are not able to determine the reason for these findings.”
BOTTOM LINE: The ‘weekend effect’ is seen across the world in varying health systems.

Now is a good time to pause and discuss mortality. Imagine if you will two hospitals. Hospital A has a 90% mortality rate at 30 days – 90 in 100 people die within 30 days of admission, while at Hospital B the rate is only 2%, or only 2 in 100. Which would you rather be treated at? On the face of it, the answer would be Hospital B, because the obvious logic is: all illness should be curable, therefore I go to hospital to get better, therefore I choose the hospital where I have the greatest likelihood of getting better, ie not dying. Which makes sense: except if I told you Hospital A is a hospice, for end-of-life terminal cancer patients, and Hospital B is a community minor treatment unit for children, for scrapes and bruises and runny noses. Now this changes your perception of the figures: Hospital A has a surprisingly low mortality rate, considering everyone admitted is there to die peacefully, and Hospital B has a worringly high rate – considering no one should be dying at all. Now what if I told you Hospital C had a 1% chance of death for a procedure, and Hospital D had a 1.1% chance? Would you be bothered which hospital you went to? I wouldn’t. But if I told you that Hospital D had a 10% higher probability of death than Hospital C, you might change your mind. This illustrates the problem with superficially accepting statistics and why it’s so important to properly scrutinise the figures. Anyway, back to the papers.

4. East Midlands Clinical Senate (2014), 7 Day Services Project: Acute Collaborative Report

This is not a scientific report at all, but a consulting report from ATOS. The same ATOS that the Department for Work and Pensions recently dropped for the ‘poor quality of their work’. The report is from a group of executives from the East Midlands. It’s really dull, and not scientific at all – all of the numbers come from the other ‘studies’ here in regards to weekend and weekday working. Of 10 clinical standards for ‘seven-day’ services it found all were already being met 50-60% of the time. The biggest fail areas were ‘mental health’ and ‘transfer, discharge to social care’. Both budgets of which have been cut in the last ten years. However, here are some favourite quotes

“It is likely unsustainable and unnecessary for all trusts to provide all services 7 days a week”.

“There may be a need to drive funding for the whole system to deliver 7 day services”.

Here is a good time to remind readers the last eight years have been the worst funded decade for the NHS in its history (including the recently announced ‘extra’ £3 billion). Again no measure of staffing levels and no mention of junior doctors.

BOTTOM LINE: 7 day a week routine services require proper funding and are not necessary or sustainable in all areas. A good proportion of 7-day emergency services are already available.

5. NHS Services, 7 days a week report by NHS England/Sir Bruce Keogh

This is a policy document from NHS England and, again, Sir Bruce Keogh’s office. Also, again, not a scientific ‘study’ at all. Interestingly the focus is nearly entirely on emergency services – no mention of ‘routine’ care at all. The review notes that doctors and nurses are present on the acute medical unit 100% of the time weekday or weekend, the importance of diagnostic services being available 24/7, and lots of case studies- all of which achieved better cover without changing work conditions for staff. Interestingly in the annex it notes that many more weekend admissions are end-of-life patients compared to the weekdays- suggesting an increased need for community hospice and palliative care services.

BOTTOM LINE: Bruce Keogh and friends re-hash other research in this list- but importantly define the need for seven-day services as emergency care improvements, not routine services.

6. Academy of Medical Royal Colleges Report: 7 day consultant present care published in 2012

Again, not a unique scientific study but a review of many other studies. Produced by the Academy of Medical Royal Colleges to look into the necessity and feasibility of increasing consultant presence on the wards for emergency unscheduled patients. Again, not routine services and again, nothing about junior doctors or staffing levels.

BOTTOM LINE: Consultant presence is important for emergency admissions, not routine services.

 7. Weekend mortality for emergency admissions: a large multicentre study, BMJ Quality and Safety by Aylin published in 2010

Here is an ACTUAL scientific study, another from the Dr Foster Unit at Imperial College London (which was 50% part owned by the Dept of Health at the time of writing). This is the fourth study in this list that uses the Hospital Episode Statistics warehouse: again discharge letter information. This paper focused only on emergencies. They reached the same conclusion as the papers above, with an absolute increased risk of death at the weekend vs the weekday to be 0.12%*. They didn’t take into account how sick patients were, or their method of admission, and again no explicit measure of staffing levels were made.

BOTTOM LINE: A fourth study from the same data, showing a very small increased risk of death in weekend vs weekday emergency admissions, and no accounting for how sick patients were or staffing levels.

8. Time for training Report by Professor Sir John Temple from the Department of Health published in 2010.

Unfortunately this the original report has disappeared but in summary this was another policy document from the Dept of Health looking at the issue of training doctors under the European Working Time Directive. It’s main conclusions was that shift work is anti-social and has had an impact on training, and that consultants should be more involved in 24/7 work to support trainees.

BOTTOM LINE: Another non-study, suggesting a larger consultant presence day-to-day would help training. Nothing to do with the ‘weekend effect’.

I’d be remiss for not mentioning the latest papers in the ‘weekend effect’ argument, which haven’t quite made it onto the gov.uk website yet but are already in the briefs and interviews of Mr Hunt and the spin machine.

9. Association between day of delivery and obstetric outcomes: observational study by Palmer, published in BMJ 2015

A fifth paper looking at Hospital Episode Statistics, and the third from the Dr Foster Unit. It is remarkable actually that no single paper has tried to analyse ‘the weekend effect’ in any other way than use the same source. This group tried to identify a weekend effect on seven different measurements associated with giving birth. Overall the stillbirth rate was 0.7%, or 7 in 1000. It actually finds that the stillbirth rate is significantly lower on Monday and Tuesday, which had

‘no association with staffing’.

BOTTOM LINE: No  link between mortality and staffing, and no obvious ‘weekend effect’ (Thursday had the highest rate of perinatal mortality.)

10. Mortality of emergency general surgical patients and associations with hospital structures and processes by Ozdemir published in the British Journal of Anaesthesia in 2016

This study unsurprisingly also used the Hospital Episode Statistics database, looking at all emergency admissions undergoing surgical procedures or admitted with pancreatitis over five years. The study then cross-referenced these numbers with data about the hospitals it was collected from – e.g. staffing levels, number of beds etc. The methodology in this paper was actually quite good, and they show a very strong association with the number of doctors, nurses and beds and the association with better surgical outcomes- of course this does generally reflect the amount of money a hospital has, and how well-resourced it is overall. The weekend data shows the same bump in mortality at the weekend as all the other studies that looked at the HES data, but didn’t measure weekend vs weekday staffing levels, as many media stories wrongly reported.

BOTTOM LINE: Increasing resources improves outcomes from emergency surgery, regardless of the day of the week.

UPDATE: Following the strike announcement Jeremy Hunt began quoting ‘you are 20% more likely to die from a stroke at the weekend’. Given how stupendously dangerous delaying presentation to hospital is for a stroke I’ve updated this post to add in the following; (Full credit to Prof David Curtis and Ben White for drawing this to public attention.)

11. Mortality following Stroke, the Weekend Effect and Related Factors: Record Linkage Study published on PloSOne in June 2015 by Roberts.

This was a study that took the Welsh equivalent Hospital Episode Statistics and looked specifically at patients who were admitted to hospital for a stroke between 2004-2012 and counted how many died at 7 days, 30 days and 1 year. They found less patients were admitted on a weekend for strokes (88) and patients admitted during the week (111), and a small increase in mortality of 1.8% at 7 days between weekend and weekday admissions. There are three really important things to say about this:

  • 1) The study notes – stroke mortality fell by 3.1% every year for the 8 years of the study. This reflects the radical improvement in stroke care that has occurred over the last twenty years with the introduction of ’emergency’ stroke pathways and hyperacute stroke units. Here is a nice graph. This study doesn’t really factor in this massive improvement in overall care, and isn’t relevant to today. Also – this improvement was done without changing working conditions for staff.Stroke trends
  • 2) Stroke occurs on any day with equal frequency except mondays– where it is slightly higher. Stroke can range from transient weakness or loss of vision which resolves after 24 hours, to permanent loss of power to limbs and face and even death. The authors note that the effect ‘may be influenced by a higher stroke severity threshold for admission on weekends’. If you look at day of stroke, regardless of admission, there is NO WEEKEND EFFECT, as seen here in a study from Japan.
  • 3) Stroke is defined as ‘maximal at onset’ – it represents sudden and complete blood loss to an area of the brain. There is only one main treatment, which is to give clot-busting medication. However- this is very dangerous and the list of situations where the risk of the treatment outweighs the benefit is very long. Having worked on-call in a stroke unit and ICU previously I have only seen one patient who met the criteria. Only 15% of strokes were treated this way in 2014. 60% of patients came to hospital too late for treatment. Stroke is now treated as an emergency – the ambulance calls a stroke-centre hospital before the patient arrives, and a specalist team sees the patient as soon as they come in to the door. The limiting factor now is when the patient dials 999.
  • 4) Lastly, a recent study found the presence of a consultant or doctor had no effect on a patients survival after stroke, whatever day of the week they were admitted. However, the presence of adequate nurses had a huge impact: increasing nursing numbers from 1.5 nurses/10 beds to 3 nurses/10 beds reduced mortality by 4%. This reflects the fact that stroke patients are very vulnerable in the immediate period after the event, and it’s good nursing care, not junior doctors, that directly influence this. However – Jeremy Hunt has so far suppressed the NICE recommended safe staffing levels for nurses- and the NHS student bursary to incentivise nursing training has been cut.

BOTTOM LINE: This study took place 12 years ago, in Wales, during a time of rapid improvement in stroke care overall. It shows a reduced number of strokes admitted on the weekend – and likely increased severity of those admissions resulting in a small 1.8% bump in mortality overall. Jeremy Hunt’s scaremongering has previously led patients to delay coming to hospital – in this particular case this could lead to devastating loss of function and even life. Time is the single biggest factor in survival in stroke, and has nothing to do with  weekend doctor staffing or junior contracts.

Now time to look at things differently. You hear a lot about the studies showing a ‘weekend effect’. But did you know there are many studies that show no effect? The fact that you don’t is an example of something called publication bias – the government only wishes you to think the ‘body’ of evidence all points one way. It doesn’t.

Here are some studies that show NO WEEKEND EFFECT.

Weekend mortality in paediatric patients in Scotland – published by the Royal College of Paediatrics, Turner 2015. [1]
Byun 2012 (small study compared to the others) [2]
Kazley 2010 (US study) [3]
Kevin 2010  (Canada) [4]
Myers 2009 (USA) [5]

Overall: 

  • Of the ‘Hateful Eight’ studies only four represent actual research
  • Two are the same paper and co-authored by Sir Bruce Keogh,
  • The other two are from Dr Foster, formerly owned by the Dept of Health.
  • All of the studies come from a single source of data.
  • None of them show any link to staffing levels, and none of them show any link to junior doctors working patterns.
  • Much research exists disputing the weekend effect
  • Research shows that increasing resources improves outcomes. Which is obvious.

And here is the pièce de résistance. When there is a finite amount of money the logical management of resource is to put money where it will do the most good. The National Institute for Health and Care Excellence, NICE, have a recommended money spent vs benefit formula for approving treatments. The cut off is currently about £20,000 to buy a year of quality life. This is how all new medications are decided if they are value for money or not.

Meacock in 2015 sat down and worked out the cost of a ‘seven day NHS’ and then tried to work out if NICE would approve if it were a medicine. Needless to say the money spent (estimated for emergency services to be £1-1.4 billion) is 2x-3x as much as the ‘recommended’ cut off.

BOTTOM LINE: This isn’t even good value for money.

Finally – some context. Every year in the UK 25,000 people will die of a blood clot to the lungs, 60,000 people will die of a heart attack, 30,000 people will die from chronic lung diseases, mostly smoking related. Improving research and treatment pathways for any of those conditions would save more lives than this endless politically driven ‘seven day’ debacle. I dread to think how much money has already been spent on the ‘seven-day’ services problem – but if it is real, it is a tiny relative problem and a problem no country anywhere has been able to solve.


All doctors would want to have the entire gamut of services on hand every day of the week – but the first lesson of practicing medicine is learning to prioritise. So far, the ‘studies’, simply don’t add anything useful to the debate – we need to know where and how to spend our money, whether that’s in the community, in social care, in improving hospice care, or in expanding emergency departments or increasing perioperative care. The list goes on. It’s not clear there is a truly avoidable ‘weekend effect’, but more importantly it’s not clear if it’s worth the vast amounts of money, damaging publicity, time and general consternation being spent on it.

This is a classic situation of political meddling in the NHS creating harm. We have a government and media who prefer soundbites to sound decision-making and spin doctors to actual doctors. THIS is the true threat to the safety of patients.

juniordoctorblog.com

 

It’s The Spin that Wins

The strike is back on and Jeremy is straight out in front with claims of committing ‘extra funds’ to the NHS. Unsurprisingly this is rubbish.

juniordoctorblog explains how the funding spin is constructed and how they are getting away with it.


 

NHS Funding: Who’s telling the truth?

The funding situation of the NHS can be a tricky thing to get your head around, so it’s no wonder the British media struggle to report it accurately. As such, we often hear statements from the Government and leading health economists that seem diametrically opposite to each other, leaving media reporters, and by extension the general public, confused and unsure of what to believe.

For example, George Osborne in his latest Spending Review can announce a “half trillion pound settlement, the biggest commitment to the NHS since it’s creation”[1]. Meanwhile, the chief economist of the King’s Fund, states the NHS is facing the “largest sustained fall in spending as a share of GDP”[2]. David Cameron can say he’s invested “£10bn more into the NHS” while the chief executive of the NHS is aiming for “£22bn in savings” [3].

Surely these widely varying statements aren’t compatible? So who’s telling the truth?

In fact, all of these statements are correct. No one is lying…technically. To understand how, we first need to explore the concept of healthcare inflation, and how it has affected the NHS budget over its 67-year history. Healthcare inflation describes the long running trend for healthcare needs and costs to rise above the rate of general inflation, and above the average rate of growth in the economy.

One of the most important drivers of increasing healthcare costs is an ageing population. This isn’t a new phenomenon; throughout the last hundred years we have been progressively living longer and longer [4]. We’re also spending a greater proportion of our lives in ill health [5], requiring greater medical care. Another cause of healthcare inflation is new technology – new medical discoveries, drugs and devices – and again, this is nothing new; research and innovation has always been a feature of medicine. So spending on healthcare has always had to increase to ‘keep up’ with these drivers. Before 2010, the annual NHS budget increased by 4% on average, in real terms, year on year since the NHS was created [6]. In 1948, 3.6% of GDP was spent on health, and by 2010 that had climbed to 7.8%[7].

Historically, successive governments have justified these increases because health is important to the British public: a fundamental right, a key part of our wellbeing, an economic necessity for our productivity, and the bedrock of a fair and just society. So actually, increasing expenditure on health is appropriate if we as a nation feel that health is a priority to our wellbeing, and we’re willing to devote a greater proportion of our economy towards it. Nor is this pattern unique to the UK; healthcare costs have increased over time in all developed countries regardless of the type of health system [8]. In fact, we spend less than most developed countries on healthcare [7], with better outcomes [9].

Returning to the present day, the NHS is clearly under pressure. But the Government would have you believe that these pressures exist despite robust investment in the NHS, and that’s where the real deception lies. Rather than being inevitable, the pressures are largely self-created as a result of funding decisions by the Government since 2010.

Yes, technically, there has been a funding increase, and yes, technically, the NHS is a ‘protected department’, ‘ring-fenced’ from cuts. But this increase has been negligible and far far below the demands of healthcare inflation. Over the last 5 years, the health budget grew by 0.8% per year [7], far short of the historical trend of 4%. Extrapolating this difference for a further 5 years works out as a 17% gap (£22bn per year) between needs and funding by 2020. So despite seeming like a ‘protected’ department, the NHS is actually having to make severe cuts, and that pressure is being felt by the overworked and under-appreciated staff of frontline services.

These realities are being hidden from the public, conned by effective spin to believe the NHS has been shielded from austerity. Osbourne’s recent boast of a “half trillion pound settlement” can simply be explained by multiplying by 5 a budget of over £100bn, for the 5 years of the parliament. “Biggest ever commitment to the NHS?” Yes, it is the largest absolute monetary spend, but then, every successive parliament has spent more on the NHS than the previous one [7], so this is meaningless. Cameron’s “£10bn investment” is a paltry sum when spread over 5 years. Yet for all these mistruths, the Prime Minister and his Chancellor are so skilled in PR and careful phrasing, they come out sounding like champions of the NHS, and it’s difficult for the media and the Opposition to challenge their over-simplified sound bites.

The lesson here is that using absolute monetary terms to describe health spending is flawed, because the issue is complicated so much by healthcare inflation. Perhaps a more meaningful way of assessing relative spending priorities is to look at health spending as a proportion of GDP: as a nation, how much of our economy are we prepared to devote to our health? On this measure, the NHS has been falling consistently since 2010 [7], and it wasn’t that high in the first place compared to other countries. With an economy that looks set to grow over the next 5 years [10], and austere NHS spending plans already laid out, the health service looks set to lose out further. Hospital trusts are already running deficits [11] in attempts to maintain current standards of care, but it won’t be long before the impact is felt with longer waiting times and poorer quality of care.

Is this what the British people want? Did the electorate vote for this? In 2010, one of Cameron’s defining campaign slogans was “I’ll cut the deficit, not the NHS”[12]. Similar statements were made before the 2015 election. Given the highly persuasive Government spin, many simply aren’t aware of how the NHS is being starved. This systematic defunding of the health service would be democratically acceptable if, following honest debate, it truly reflected the views of British people. But that public debate never took place, and it’s one that our Government would rather avoid. In politics, it’s the spin that wins.

 

image

Image source: The Health Foundation

1. https://www.gov.uk/government/news/unprecedented-investment-in-the-nhs

2. http://www.kingsfund.org.uk/blog/2015/10/nhs-spending-squeezed-never

3. https://www.england.nhs.uk/2015/05/18/fit-for-future/

4. http://visual.ons.gov.uk/how-has-life-expectancy-changed-over-time/

5. https://publichealthmatters.blog.gov.uk/2015/09/15/the-burden-of-disease-and-what-it-means-in-england/

6. https://www.england.nhs.uk/wp-content/uploads/2013/07/nhs-belongs.pdf

7. http://www.health.org.uk/health-and-care-funding-nutshell

8. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS

9. http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

10. http://cdn.budgetresponsibility.independent.gov.uk/EFO_November__2015.pdf

11. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/478860/Quarterly_report_on_the_performance_of_the_NHS_foundation_trusts_and_NHS_trusts_-_6_months_ended_30_September_2015_-_Overview_paper__2_.pdf

12. http://conservative-speeches.sayit.mysociety.org/speech/601556

 

contributed to JDB by DrWJ

How To Sell Off The NHS: A Users Guide

So you want to sell off the NHS? A 65-year old behemoth, part of a raft of reforms that radically improved the quality of life of working people for nearly a century? It won’t be easy, but with this handy step by step guide you too can privatise your health service.

Step One
Know your enemy. In 2010 a Kings Fund poll put NHS satisfaction at above 70% [1]- the highest ever recorded approval rating. The United Kingdom has low child mortality outcomes globally; 5 per 1000 live births, (compared with world number 1 – Iceland at 2 per 1000 and the U.S. At 8 per 1000), long average life expectancy (male); 79 (compared with world number 1 Iceland at 82 and the U.S. at 76) and for maternal mortality the UK has an estimated 8 deaths per 100,000 pregnancies (compared with 1 per 100,000 in Belarus and 28 per 100,000 in the US). As a system the UK was ranked the best in the world for health access, efficiency, effective, safe and coordinated care (Commonwealth fund, Mirror,Mirror 2014). However, it currently spends only 9.1% GDP on healthcare or US$3,598 per person, which is free at the point of service. [2] The US spends over twice as much (17.1% of GDP or US$9,146) and was ranked dead last in the same Commonwealth Fund study. [3]
So, to sum up, you’re faced with a well-liked, efficient, life saving machine. So you won’t be able to try a head-on approach, public opinion will need to be swayed first.

Step Two
Misinformation: the great thing about the NHS is most voters at any given election will not have a vast deal of deep experience of its services. To many people the NHS is for shoulder physiotherapy and antibiotics for a chest infection and maybe the odd stitched wound at A&E. This is to your advantage! Start early on by pervading a helpful message of ‘improvement’ and ‘efficiency’. Steer every news piece towards this same message, regardless of context. Be consistent with this message and quickly this will become the ‘norm’. You will need some national newspapers on side to keep this reinforced. Before you know it the NHS will be percieved as ‘failing’. But that won’t be enough!

Step Three
Divide and conquer! It doesn’t matter what you campaigned on- once you’re elected you only have to apologise occasionally and you can do whatever you want! Push through some major reorganisation as early as you can- use words like ‘transform’, ‘power’ and ‘into the hands’. These will keep everyone in service on the back foot trying to respond. Make sure any change is extremely complex- this has two advantages; A) it makes it difficult for opposition campaigners to create ‘headline’ zingers against you and b) this is your opportunity to lay some legal horcruxes to build your platform!*

Step Four
Wash your hands early! If you want to sell off a national institution you have to make sure it’ll slide away easy. When no one is looking, make sure the government no longer has a legal duty to provide the NHS. But don’t stop there! Now is your chance to plan ahead!

Step Five
Open market! Everyone knows they get a better deal when one supermarket opens next to another one! Despite there being absolutely no evidence this applies in any way to healthcare provision! Use that knowledge to your advantage! Use words like ‘competition’ and ‘drive up performance’ – the more you can paint the NHS like a car the better- people like to sell their cars. Meanwhile once the law has changed,  open up the NHS to private contracts bit by bit. This will mean if anyone kicks up a fuss you can say ‘come on! It’s only 4%! It’s only 8%! Etc’. When the numbers start to get bigger use the relative percentages ‘It’s only increased by 15%!’. Useful phrases here are ‘can we please focus on the bigger picture?’. But then what about the staff on the inside?

Step Six
You do have a problem here: much of the NHS staff will see what’s happening, and people will listen to them if you don’t do something about it! Politicians are the least trusted individuals in the country, while doctors are the most; start early on with subtle denigration of the perception of all NHS staff. Take any news report about A&E or midwives or doctors or nurses and make sure someone high profile gets on a box and sticks it to them. Appoint a health secretary who will regularly inflame the situation- this will create distraction from the sell off! Frequently offer empty re-organisations that both fail to address and belittle any problems. Then get down to business.

Step Seven
The money! Cut it, and cut it hard. People use A&E and the GP the most- keep these areas stripped of cash and drive up demand by demanding people go at any time of day- encourage your health secretary to do exactly this! Once these areas go too far under they’ll sink by themselves- locum agency costs to cover staff gaps will cripple failing departments, and smaller GP closures will domino into bigger ones. Obviously don’t be seen to be thrifty- use words like ‘efficiency savings’ and ‘reform’, and above all ‘austerity! But do cut services away- the more gaps you can create the easier it will be for private companies to fill them! Put pressure on the very front services by cutting departments like a and e and maternity, and sell off the backend like microbiology and biochemistry, because no one really understands this stuff anyway.
Make sure you use this opportunity to crush the spirit of the staff- cut their pay, at least in as boring way as possible, e.g by pay freezes and under inflation changes. In the meantime try to award yourself a huge pay rise- this sell off is hard work you know! Doctors and nurses will leave, temporary agency staff will come, the service will worsen and the People will suffer! Now it’s time!

Step Eight
It’s showtime! If you’ve followed the above steps then this last will be a doddle. You’ve got a demoralised and depleted workforce, an unhappy electorate and you aren’t even spending very much on it all! You’ll need to do some hand-wringing, some lamenting, some explaining away. You will find these phrases useful; It’s ‘an ageing generation’, 21st century demand is too much, and ‘the burden to the taxpayer’. And then roll them in- hopefully by this time you should’ve got private companies into at least 20% of services.

Step Nine
Sit back and relax! All your hard work no doubt has been a lot of stress. And those long hours of drinking and smoking and missing the gym have really taken their toll. You deserve some time off! Don’t worry about the newspaper backlash- it’ll come eventually, and there won’t be a hint of apology as the same papers that supported you will hypocritically tear you down. And don’t worry about that chest pain you’ve been having! You’re insured right? Oh you lost your job? But what about the end game- the cushy seat on the board of the health companies? Oh, you’re politically toxic now and all those backroom offers disappeared? And you didn’t save anything?

Oh.

Goodbye.

Re-printed with kind permission @ juniordoctorblog.wordpress.com

*if you have to bridge an election with this still hanging over you just apologise for it! Say it was a big mistake. Then once you’re re-elected you don’t have to do anything about it!
[1] http://www.kingsfund.org.uk/projects/bsa-survey-2013
[2] http://data.worldbank.org/indicator/SH.DYN.MORT?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=asc
[3] http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror