“The Department of Health would never tell doctors how to do surgery”
This week, the DfE announced its new Curriculum Fund, whereby schools who teach a “knowledge rich” curriculum will be eligible to bid for up to £150k to further develop these proposals and create shareable materials. Leaving alone the truly terrible timing of such an announcement and bid schedule, the response was largely one of weary scepticism that the DfE’s favoured schools and MATs would inevitably be the ones who get the grant, coupled with a fervent objection from some that it isn’t right as a point of principle for government to prescribe a preferred way of teaching – after all, so ran the argument, the Department of Health would never tell doctors how to do medicine.
Cards on the table time – I don’t care *that* much about curriculum and ways of teaching. It’s my main departure from the Evil Neoliberal Orthodoxy and it’s always the blockage to my annual renewal of my Hydra membership. I have a reasonable-ish personal preference for a certain method of teaching which happens to accord with that of Nick Gibb and the traditionalist philosophy. But if a school wants to teach another way, and they’re getting good results with it, I find it hard to summon up sufficient outrage to demand a change. I think there are bigger battles to fight in education. That said, I also think it’s perfectly reasonable for a government of any stripe to try and encourage their preferred method – even if I disagree with said method I think it’s well within the democratic legitimacy of a government to do, and I’d be equally relaxed about a future government funding projects to try and grow, say Project Based Learning. Government can incentivise, schools can decide whether or not to take the incentive, everyone remains being measured on outcomes, all happy.
But the thing which does irritate me is the slightly lazy comparison to health. I’ve written before about how “teachers should always run schools, you’d never have non medical professionals running hospitals” doesn’t actually hold up to scrutiny. And it turns out, neither does “the DH wouldn’t prescribe the right type of surgery”
Since 2002, hospitals have been paid for much of their work – what are called episodes of healthcare – via a tariff system – £x for a hip op, £y for a cataract op and so on. The idea is this standardises spending and encourages efficiency, because if the hospital can do the operation for less than the tariff, they get to keep the difference.
But in 2008, the Brown government had a problem. Despite six years of tariffs, which ought to have brought about greater consistency, a lot of hospitals simply weren’t doing what was generally considered best practice for episodes of medical care. Ara Darzi, the world famous surgeon from Imperial College, was commissioned to review this as part of his broader look at the future of healthcare in England. His conclusion was very clear. Although the DH has very few levers to mandate hospitals and doctors to do anything, one major one that they did have was funding. So he proposed that alongside the normal tariff structure, something called Best Practice Tariffs be introduced. This is a method of reimbursing providers based not on average cost like normal tariffs, but by the cost of best practice. In the review’s words:
To support local efforts to address unexplained variation in quality and universalise best practice, we will start to pay prices that reflect the cost of best practice rather than average cost. This will be enabled through the Best Practice Tariffs programme, which we will introduce where the evidence of what is best practice is clear and compelling.
Best Practice Tarrifs work in two ways. Sometimes, they pay more than the standard tariff – in other words, hospitals are rewarded for following the best practice method. And sometimes they pay less – and in this instance, hospitals are only paid the amount that best practice would cost. If you want to do it another way, you essentially pay a fine, because you need as a doctor to have your hospital subsidise that inefficient method because the tariff isn’t enough to cover it on its own.
BPTs have been in existence for 8 years now. And every year since they were introduced, as the evidence has grown, more procedures have been turned into BPTs and the costs have been more and more accurately calculated. The change in tariff pricing every year is one of the most effective tools that DH and now NHS England have in pushing doctors to do precisely what DfE is so often accused of. Because as health funding gets tighter, it becomes more and more important to move to best practice ways of doing surgery to either receive the top up payment or deliver the operation without needing a subsidy.
And so, it turns out that the DH *do* tell doctors how to carry out surgery after all – and in fact, using a much stronger lever than Nick Gibb has ever tried. Maybe he shouldn’t read this blog….
