Terrible adult maths - attrition rates in the NHS

There's a great article on the BBC News website today stating that many adults' maths ability is worse than the level expected of 9-year-olds. I can certainly testify to that. And, in fact, I'm going to, right now.

If someone studies to become a nurse, allied health professional, dentist, etc. then their course fees are usually paid by the NHS. Naturally not everyone that starts a course finishes it, so something that's monitored carefully is the attrition rate for each course.

I used to work for one of the NHS organisations that commissioned education and monitored the activity on each of the courses we had paid for. Different regions used slightly different calculations for their attrition rates, which caused problems when you tried to look at attrition across the country as a whole (which I later did, when I moved onto a national NHS workforce organisation).

Of course everyone agreed that it would make sense to have one single attrition calculation across the country. Indeed the now defunct National Audit Office had commented on exactly this, and suggested a single definition to be used nationwide, which the Department of Health tried to get everyone to adopt. Some areas adopted it, but I'm pleased to say my area refused to (mainly on my own recommendation, if I may say so myself) - because yes indeed, this definition contained errors a 9-year-old would be ashamed of.

Let's get to the detail. Don't worry, none of this is at all hard to understand, but there are some definitions to get to grips with. Basically there are two ways you can join a course - you either start at the beginning (making you a starter), or you join it mid-way through, having already started a course that brings you up to the relevant level (making you a transfer in). Conversely there are two ways you can leave a cohort - by transferring out to another cohort or by discontinuing (due to academic failure, ill health or whatever).

If you start or transfer in to a course and don't transfer out or discontinue, then either you are still on the course or you have successfully completed it. In other words, the number of students on a course (if the course is still running) is the same as the number of successful completers (if the course has finished) and this is wholly dependent on the other variables:

N = s + t(in) - d - t(out)

With me so far? Great. So on to the NAO definition of attrition. Remember, these were proposed by the National Audit Office - the Government's chief maths-checkers - and were pushed hard by the Department of Health. There had been much discussion leading to this point, including recognising the importance of including transfers in the formula.

The NAO and DH published their attrition definition as two formulae, one for completed courses (with a reference to "numbers completing") and one for "cohorts not yet completed" with a reference to "numbers in training". But as we've already shown, these two things are the same, so really there was only one formula, and here it is:

Attrition = s + t(in) - t(out) - N

              s

So far so good - it's a definition that looks straightforward, and, crucially, includes some mention of transfers in and out. Which is all very well until we remember that our numbers of completers / numbers on course (N) is in fact defined by some of these terms too. So the definition in fact is....

Attrition = s + t(in) - t(out) - (s + t(in) - d - t(out))

              s

Oh. Can you see what's happening yet? Any decent nine-year-old mathematician would now collect like terms:

Attrition = s - s + t(in) - t(in) + t(out) - t(out) + d

              s

Which of course means...

Attrition = d

                   s

Oops. So that definition is pretty rubbish after all. Thanks for nothing, National Audit Office.

The really annoying thing here is that we raised that issue with the Department of Health in 2003 and kept pushing it. We also explained it to the other NHS regions - some of whom agreed with us and used the definition we were using, and some of whom pressed on with the DoH definition. Eventually, once I was working for that national organisation several years later, we managed to persuade all the NHS education commissioners to adopt our recommended definition and drop the one above. It was still a year or two later that the DoH finally cottoned on, and even then it took a shouty email to a senior civil servant with the words "PLEASE READ THIS" splashed over the top for them to acknowledge that yes, actually, their proposed definition doesn't take account of transfers between courses and is therefore incorrect.

The BBC article begins with the words "A quarter of adults in some parts of England have maths skills below those of nine-year olds." Too right. I know where some of them work.

It's all gone quiet over there

It's been a few weeks now since the Cabinet reshuffle at which Andrew Lansley lost his job as health secretary, to be replaced by Jeremy Hunt. The feeling inside the NHS was very much one of "out of the frying pan, into the fire" and this was pretty much confirmed a couple of days ago when Hunt lined up Christine Lineen to be one of his policy advisors.

But apart from that and a couple of hospital visits, Hunt has stayed quiet. It remains to be seen what impact he'll have on Lansley's plans for a complete top-down reorganisation of the NHS - the very thing the Coalition Agreement (and the Tories' pre-election pledges) promised would not happen.

It's worth pondering where it went wrong for Lansley. Was it that broken promise, going against the very fabric upon which the current government was built? Or was it his final throw of the dice - his plans to market the NHS abroad? Or perhaps it was his failure to communicate openly and honestly about what he was really planning to do - or maybe, on the other hand, he gave too much away.

That "marketing abroad" thing is a good example of the lack of joined up thinking on the NHS from the Tories. One thing it gets right is that the NHS is a brand, shared by lots of different organisations, not one big organisation. So it wasn't "the NHS" that Lansley suggested should be marketed abroad, but individual NHS trusts.

Now the key thing to remember here is that the NHS is, rightly or wrongly, a competitive marketplace. Just like in other businesses, NHS trusts work together in some areas and compete in others. And just like in other industries, NHS trusts will try to leverage any competitive advantage they can find to out-do their rivals. So it's vital that any new innovation applied to this marketplace is done so fairly and doesn't unfairly hand an advantage to some trusts while disadvantaging others.

This is where the NHS as a marketplace is already institutionally unfair. Because while informed healthcare commissioners will judge trusts based on their performance, many will simply opt for the big brand names. So no matter how hard other children's hospitals work, no matter how much they achieve, they'd never be able to match the Great Ormond Street brand, even if GOSH performed really really badly. This skewing of the marketplace is constantly reinforced by the likes of Lord Sugar and Piers Morgan constantly trumpeting GOSH and ignoring their hard-working competitors and other children's hospitals up and down the country who do just as good a job.

The big hospital brands are already the richest. They are not the ones that need help.

This is where Lansley's suggestion is typical of the Tories. It allows the rich to get richer and keeps the poor poor. Lansley was adamant that any money raised from the "marketing abroad" exercise would be ploughed back into the NHS. What he neglected to say very clearly was which parts of the NHS would receive that money: the answer is that the rich trusts that can afford to market themselves abroad would be allowed to keep the proceeds. The rest of the NHS would not gain a penny from the initiative.

One of the criticisms of Lansley's plan was that Labour had already announced something similar when they were in government. But the stark difference was that Andy Burnham's plan involved marketing the NHS as a whole, with the NHS as a whole reaping the benefits. Lansley's plan was simply yet another way of making the rich richer and the poor poorer. Further unbalancing the NHS marketplace in such away offers no hope at all for lower profile trusts, no matter how well they perform.

The NHS was intended to be a single, united, national health service not a brand war battlefield. I sincerely hope Jeremy Hunt catches hold of that original vision and stops the pointless fragmentation and wasteful inter-hospital rivalry that his predecessor was so keen to exacerbate.

Do the proposed NHS reforms amount to privitisation?

Privitisation is difficult to define. Our railway system is privitised, yet receives a certain amount of public funding. Our roads are public, but almost all the work done on them is delivered by private contractors. So it's not who delivers the services that makes it public or private, but who commissions the services and whether the service user has to pay up front or not.

With prescription, opticians' and dental charges the NHS can no longer be said to be free at the point of delivery. With private businesses (GP practices) instead of publicly owned primary care trusts doing the commissioning, the fundng can no longer be said to be under public control. Which makes the NHS under reforms more akin to the rail system, where service users pay some up-front fees and the state provides a subsidy to the private operators, than to the road system, where although the providers are mainly private, the commissioning is done by national and local government organisations and the service user pays through taxation, not up-front fees.

Those in favour of the reforms will cry foul at this point, pointing out that the GP commissioning consortia won't have complete free reign but will be accountable to the central NHS Commissioning Board, and providers of NHS services will be accountable to the regulator, Monitor. However, that's no different to the train operating companies being accountable to the Office of the Rail Regulator. The only real difference between the two systems is that the trains are privately owned whereas some, but not all by any means, of the hospitals and other clinical buildings are publicly owned. The owner of the title deeds doesn't really matter to the service user; what makes the difference is how the service runs operationally, and who calls the shots. Under the proposed reforms, the organisations choosing what services are available and being given the cash to spend on them will be private businesses. It is privitisation in everything but name.

Gordon Brown's NHS Plan

Now that Tony Blair has announced that he'll be standing down within the year, his probable successor, Gordon Brown, has started making noises about what he intends to do when (and if) he becomes Prime Minister. Recently he declared his plans for the management of the NHS, namely taking control away from the politicians and setting up an independent body to oversee the health service. Here's what I think of that idea, and the British Medical Association (BMA)'s reaction to it.

As a workforce planner in the NHS, I know that one of the biggest barriers to creating accurate plans is the fact that it takes around a decade to train a doctor, yet the standard parliamentary term is five years. Therefore we've been constrained, wanting to plan decades in advance but knowing that the policies on which we're basing those plans might change at a moment's notice. A politics-free governing body for the NHS would enable the genuine long term planning that the health service so desperately needs.

Another problem with the current arrangement is that policies are often drawn up based on perceptions of the NHS rather than the real situation. You often hear people talking about doctors and nurses as if they are the only people that are required to run a hospital. But that ignores the thousands of therapists, scientists, cleaners, porters, caterers, information technology staff, human resources advisers, planners, secretaries, receptionists, accountants and so on that are all equally essential. The BMA have criticised Gordon Brown's plans, which is not surprising. With new technologies, better training and imrpoved ways of working, the role of doctors carries less emphasis than it did a few years ago. Jobs that only doctors could once do can now be carried out by other staff, with much smaller salaries, therefore providing much greater value for money. An independent governing body for the NHS would recognise the value in this reassessment of skill mix, and would be able to make tough decisions (like cutting the numbers of highly paid doctors and replacing them with cheaper staff who can do the same job just as well) without fear of the publicity backlash that politicians are so scared of. This is the reason the BMA are critical of Brown's plan.

General practitioners in the UK are now the highest paid in Europe, yet work fewer hours than their European counterparts. This is due to organisations like the BMA holding the government to ransom when negotiating contracts and making key decisions about the NHS. Without the politicians involved, the BMA would have less influence over the direction of travel of the NHS, and the interests of patients would trully come first. Unfortunately the reaction of the BMA to Brown's announcement indicates that they are more interested in looking after number one than looking after their patients.