Body name Department of Health and Social Security (DHSC)
Place in the wiring diagram: National Body
The DHSC’s function is to “support ministers in leading the nation’s health and social care to help people live more independent, healthier lives for longer.”
Their Annual Report and Accounts for 2022-23 dedicates 96 pages to performance, so we thought we’d take a look.
Performance is based on five priority outcomes. We’ll start with Priority 1: “Protect the public’s health through the health and social care system’s response to COVID-19.” We find this priority bizarre: What about all the other agents? Should the public not be protected from the DHSC’s evidence-free measures?
This is a perplexing document; TTE wonders whether anyone has read it. Many process measures are reported, such as distributing vaccines, surveillance, running clinical trials, and stuff about PPE stocks that have pride of place. But there’s nothing about patient outcomes.
We are told the government gave £25 million of UK aid to the World Bank’s Pandemic Fund—Fantastic, but what does this have to do with performance?
Protecting the vulnerable comes down to a risk score: QCOVID, which doesn’t tell us whether folks were protected. The number of accesses is something you'd expect in an Altmetric Score; it has nothing to do with quality and whether it was used and affected care.
Moving onto priority 2: improving healthcare outcomes by providing high-quality and sustainable care at the right time and place. Perhaps some performance measures might be found here.
The section starts with the growth of the NHS waiting list to a record high of over 7 million. Perhaps the section should be renamed to underperformance. However, you'll be glad to know that the Government “remains committed to ensuring people get the right care at the right time.”
In March 2023, roughly 360,000 people waited more than a year for treatment. How is this compatible with ensuring people get care at the right time?
We’re also told, "Cancer remains a top priority as services recover.”
Another DHSC Oxymoron: “In February 2023, 75% of patients were diagnosed with cancer, or had it ruled out, within 28 days of referral.” TTE suspects that no one with any clinical knowledge put these reports together. One in four waited longer than 28 days, which is unacceptable.
Figure 11 tells you all you need to know about cancer performance. So, while some on the waiting lists could wait a little longer, that shouldn't be the case for cancer treatments, which should occur within weeks, not months; the standard should be 100%, yet despite the low bar for performance, it is a complete failure of care.
We were told critical actions in 2022-23 were to improve A&E performance. These included increasing bed capacity, creating new innovative virtual wards, and establishing System Control Centres to help manage demand (whatever that means).
Yet, all the while, A&E's performance has deteriorated. As far as TTE can tell, if there’s a problem in the NHS, the solution is to ignore it—then create a distraction such as virtual wards to keep the media off our backs. And let’s not forget the F word flu and Covid.
The performance moves from one lousy scenario to another. In December 2022, Category 2 response times for ambulances took an average of 1 hour and 33 minutes when they should be 18 minutes. Pre-pandemic, they were terrible at 27 minutes and 57 seconds. The DHSC considers a range of factors contributed, including the fact that more patients need an ambulance.
Priority outcome 3 says the DHSC will improve healthcare outcomes through a well-supported workforce. The plan is to hand it over to NHS England to develop a Long-Term Workforce Plan for the next 15 years. We're told there are more doctors (4,500 more), nurses (12,900 more), GPs (400 doctors), and vacancies (112,500) than a year ago. Oh, and more strikes than ever. We have yet to be told how this translates in improved patient outcomes.
Outcome 4 seeks to improve, protect, and level up the nation’s health by reducing health disparities. Here, they refer to the Office for Health Improvements and Disparities (OHID), which became fully operational in October 2021 (we’ll look into them and their funding later). The can is kicked further down the road due to the announcement that the government would publish a Major Conditions Strategy in 2024.
The ubiquitous solution to all health evils is stated in paragraph 259 - health checks.
Finally, in priority outcome 5, we are told how the DHSC will Improve social care outcomes through an affordable, high-quality, and sustainable adult social care system.
We are led to yet more documents: the BCF Policy Framework, the Adult Social Care Winter Statement, Care Data Matters: a roadmap for better data for adult social care, updated Infection Prevention Control (IPC) Guidance for the social care sector, and a consultation on ‘adult social care charging reform: distribution of funding 2023 to 2024’. Not a shred of evidence is presented about performance or outcomes.
We’re not sure the DHSC know what their role is. The DHSC performance report shows that, if anything, care is often late and not in place.
Grey areas: everywhere you look
Recommendation
The DHSC requires performance indicators for which it is held accountable.
By setting specific time-limited outcomes, the DHSC would have to report performance based on these measures.
For example, you might target 100% of cancer patients seen and treated in a month. The public and patients should be given input to prioritise those performance measures for which they want the DHSC to be accountable.
Two old geezers who like to be in the right place and on time wrote this post.
Gents - as much as I hate to add even more uncertainty to the question of where all the money goes, as a chartered accountant the first thing I turn to is the audit opinion, and the one in these accounts is not good. If you look at page 204, the auditor says he has had to qualify his opinion (translation: can't guarantee the numbers are basically correct) for two reasons.
The first one is a belter - he says he has been unable to obtain evidence for the opening balances, closing balances, or the transactions in the year. That's like someone trying to audit your bank account and you telling them that you didn't know how much you had at the start of the year or the end of the year, and you've lost all your bank statements. But you think you spent £3.1 billion.
The second qualification relates to the £1.36 billion of PPE the department said it had at the year end. Basically, the auditor couldn't find it.
So, if you're trying to use these accounts to work out where the money goes, bear in mind that the auditor is saying that the figures may well be/probably are wrong.
Whilst terrifying, this doesn't appear to be unusual. I looked at the UKHSA accounts for 2021/22 when you commented on them. There, on page 95, the auditor comments: "The audit work that I have performed has identified significant shortcomings in financial control and governance which are pervasive to UKHSA’s financial statements. The uncertainties that I have encountered mean that I am not able to report quantifiable adjustments which UKHSA could make to correct the financial statements." Translation: the figures are wrong but I can't tell you by how much, because the financial controls are so bad no one can work out what the accounts should really say.
Obviously, for a commercial company, this type of audit opinion would be a major issue. For government departments and agencies, no one seems to take any notice.
This post has touched a few raw nerves for me.
The paragraph on the QCOVID risk calculator is particularly inflammatory, as it states that the calculator helped clinicians identify other adults with risk factors making them vulnerable to Covid-19. Though I seem to recall the tool did highlight an increased risk for adults with Downs syndrome and liver disease, the sentence on how many times the tool was downloaded implies that this was a useful clinical tool for assessing and communicating risk.
We were sorely in need of better risk communication tools from the outset of the pandemic as risk was being so poorly and indiscriminately communicated across the board, including to NHS staff who were the very people whose responsibility it was to communicate risk to patients/the wider public. Even SIGN got it wrong through their infographic which they declined to update in the face of real world evidence to the contrary.
As such I was delighted when the QCOVID calculator was announced as it looked perfect for us as was based on UK data. Within a very short timeframe of its launch however we were told not to use it for clinical communication. The website explicitly stated 'This implementation of the QCovid calculator is NOT intended for use supporting or informing clinical decision-making. It is ONLY to be used for academic research, peer review and validation purposes and it must NOT be used with data or information relating to any individual.' Today it states 'The QCovid® tool below may be used for academic research or for peer review in Great Britain only. Before using the tool, please make sure your organisation has a Data Protection Impact Assessment (DPIA) in place that covers your use of the tool.'
I did wonder at the time whether this was because the first iteration of the calculator accurately informed people of their risk. My own risk of a Covid related death in Feb 21 on QCovid was calculated at 1 in 62500 (updated to 1 in 71500 before vaccination status included in the tool), risk of hospitalisation 1 in 2532 (updated to 1 in 4200). I thought these favourable odds given that it was 3.5 lower than my risk of death from a car accident in the UK.
When news emerged about AZ induced VITT I was able to see that the risk to a 25y old woman of dying from Covid-19 was about 1 in 1000,000, whether she was vaccinated or not. Her risk of catching and being admitted to hospital with Covid-19 was apparently, if unvaccinated*, 1 in 4237 compared with 1 in 19231 if vaccinated..This was an absolute risk reduction of hospitalisation of 0.018% (or NNT to prevent one such hospitalisation from Covid-19 = 5555). Her risk of VITT from the Astra-Zeneca vaccine was put at about 1 in 47393. If she did get VITT, the case fatality rate was as high as 23%. So a risk of getting and dying from VITT was about 1 in 206056 versus a risk of getting and dying from Covid-19 of 1 in 1000000. And that was only one of a number of risks. And that was before the human challenge studies were published which confirmed even when the virus was squirted up the nose only a minority experienced clinical infection.
Imagine if we had been allowed to use the qcovid tool officially to communicate risk from the infection at the time people were making decisions about vaccination? Many low risk people may have made different choices, potentially including some who came to harm from their decision.
*I did later become suspicious about the QCOVID data after the calculator was updated to include vaccination status, as in comparison to earlier versions I found that my own risk of hospitalisation and death had significantly statistically increased if I entered unvaccinated into the calculator. This suggested to me some bias in the way data had been recorded on vaccination.