The NHS: Torpedoes Locked and Loaded

The NHS is, as I went into in a previous post a highly efficient service.  It is much loved (see for instance (#welovethenhs on twitter or the Olympic Opening Ceremony).  That isn’t to say it’s a perfect service, and there were definitely some challenges facing the NHS even before the government introduced the Health and Social Care Act 2012 (opposed by the BMA almost from the outset, with the Royal College of Nursing, the Royal College of Midwives, and the Royal College of General Practitioners all becoming opposed after things clarified).

There are major challenges ahead for the NHS, and for every other healthcare system in the world.  And even without “help” they would be pretty big ones.  Some of the main ones are below:

1: An ageing population.  You spend more on healthcare for the elderly than the young.  Period.  And this is only going to get worse.

2: Medical development.  Much is now curable.  But cures are expensive, especially modern high tech ones.  A robot to assist surgery can run to a million pounds – and there was no equivalent when the NHS was set up.

3: Pharmaceutical companies.  Partly costs are increasing as a subset of medical research and development, partly as Ben Goldacre extensively documents pharmaceutical research is incredibly corrupt.  And of the two screens parallel imports are still there but NICE has been stripped of its powers.

4: PFI.  Hideously expensive and a bad idea almost from the start.  Private Finance Initiatives is the main cause behind first the creation of South London Healthcare (to merge three near-bankrupt trusts into one), then its recent bankruptcy.  Note that as of writing it is likely that the recommendations will involve closing Lewisham A&E (Lewisham being the nearest hospital) which is going to spread the financial mess all round the reason.

These problems were already there without the help of the current government (other than the stripping NICE of its powers).  And would be more than enough of a challenge for almost any service, all causing costs to escalate rapidly.  Other than PFI, all these are problems facing almost every comparable service in the world.  It’s a challenge, undoubtedly.  It’s a ship trying to pass between the Scylla of not providing adequate care and the Chrybdis of getting monstrously bloated spending – the last thing it needs is to have someone start launching torpedoes at it.

A common answer to challenges is that “We must do something.  This is something.  Therefore we should do this.”  But what “this” does in the case of the Health and Social Care Bill is drops at least half a dozen torpedoes into the water.  I’d spotted several even before hearing John Lister on the subject last week, but really hadn’t worked out the Any Qualified Provider issues.

This isn’t meant to criticise GPs in general or the ones who will end up implementing this set of changes.  But they are trained as doctors, not administrators.  Different skillset.  They are merely the people who will end up carrying the can.  But without further ado, the issues from the Health and Social Care bill include:

1: De-skilling.  The Primary Care Trusts (PCTs) work.  Not always perfectly, but they more or less know what they are doing.  The GP Consortia need to build the whole structure up almost from scratch – and reinvent the PCTs while losing expertise.

2: Isolating risks.  At present the NHS is responsible for the UK.  Care Commissioning Groups (CCGs) are only responsible for their own area of patients, and there is nothing saying they have to work together.  It’s like dividing the number of people in an insurance scheme by 300 or so.  Much higher risk.

3: Isolating negotiations.  At present when an NHS provider negotiates with its local PCTs, that negotiation is binding on all PCTs.  Keeps things much fairer, restricts the postcode lottery, and lowers administrative overheads because everyone should receive the same care for any given condition.  This not necessarily being binding is a vast administrative overhead and Postcode lottery.  (The CCGs can decide to team up but they no longer have to).

4: Destroying oversight. Unlike the PCTs the Strategic Health Authorities (SHAs) are being destroyed and not replaced.  And their job is oversight – few can watch themselves truly effectively, and PCTs are huge organisations.  The SHAs are imperfect and don’t catch everything but their role is needed.

5: Forcing everyone to become Foundation Trusts by April 2014.  Foundation Trusts have a purpose.  Freeing high performing and specialist centres from standard oversight (instead they are overseen by Monitor).  And even Monitor think there are too many foundation trusts.  Foundation Trusts tend to get better performance  than standard hospitals but if they hadn’t been performing well they wouldn’t have become Foundation Trusts.  Monitor itself says that it shouldn’t have allowed a number of the Foundation Trusts we already have to become Foundation Trusts.

6: Raising the cap on private work at Foundation Trusts to 49%.  Remember that’s meant to be all hospitals.   Private work has higher administrative overheads than state work and is inherently far more bureaucratic; you need to deal with multiple possible payers. Also it messes up streamlined pathways – but hospitals will not only want to do it but almost be forced to because of the higher profit margins. That’s 49% private care possible at all hospitals.  Almost the definition of a two tier health system.  (Of course this will mean that private work takes place in a hospital that can cope if it goes wrong – at present if something goes wrong in private care the NHS sorts it out).

7: Any Qualified Provider.  At least this is slightly improved from the initial draft of “Any Willing Provider” so setting qualifications is possible.  But this doesn’t come with a strict definition of qualified providers, so e.g. Virgin can bid to run A&E (as they do in Croydon). If trains don’t go all the way, that’s one thing. But if A&E doesn’t, that gets bloody. Any bunch of clowns can bid for services (and as is normal with the private sector in Britain, hand all their failures off to the NHS). This not means that we might again put healthcare provision in the hands of people who will trouser the money and run (Croydoc) or again put on only one Out of Hours GP for the whole of Cornwall (Serco), you can plan better if you know what’s coming. So hospital overheads are going to increase due to the risk of not getting activity.  And without definitions as to what counts as qualified, there’s a vast junket train possible for companies to have themselves classed as “qualified”.

There are almost certainly more torpedoes in the water. Those are just the ones I’m aware of that are the responsibility of this one bill.  And these changes aren’t easily reversible.

Singing the songs of angry men?

A followup to the previous post, I’ve been musing for a while about political songs.  And their seeming absence – last weekend the musicians (insert drummer joke here) thought that drumming while shouting buzzwords like Unity and Solidarity would work.  And when that didn’t fire the crowd they put on the worst performance of ‘We Will Rock You’ I think I’ve ever heard.  (It might have helped if they’d gone for clap/clap/arms rather than stamp/stamp/clap given the slightly waterlogged ground.  But you don’t get anything back if you don’t even attempt the verses).

Yes, there is protest music still around.  The Folk Song Army is still there, and the Red Leicester Choir at Saturday’s march brought out pieces including There is Power in the Union (something I found ironic). Bruce Springsteen is still touring.  As is Billy Bragg.  And others.  But it’s a matter of “still there”.  The last new protest group breaking through I recall were Chumbawumba, although Pulp probably also qualify.  And Rage Against the Machine had the Christmas Number 1 only a few years ago in an anti-corporate protest.  Come to think of it, of all unlikely artists, Nick Clegg has been widely played although with only moderate chart success.

But this is nothing compared to the seventies.  The Clash spring to mind, as do the far more nihilistic Sex Pistols (who were banned from number 1), Dylan, and many people mentioned above.  Before that we have Woodie Guthrie, Sixteen Tons, et al.

So what happened?  I have four theories.

1: I’m missing things.  Entirely possible.  I’m not paying that much attention.  But looking at the Top 40, I don’t think so.

2: I have a … distorted view of the past.  I wasn’t there.  And the music that lasts isn’t that which was acclaimed at the time.  Possible, but I doubt it especially given the attempt to keep the Sex Pistols off the number one spot.

3: Things aren’t as bad as they used to be.  There hasn’t been anything like the Red Lion Square Disorders in a long time; by comparison to the National Front, even the EDL/Casuals United are a storm in a tea cup.  Despite the best efforts of Osbourne and co, we’re a lot better off than we were under the three day week (and I do mean best efforts – the government is trying to privatise the NHS and break up the planning committees – both huge changes).

4: Corporate media caught on.  And are blocking the avenues – I believe Woody Guthrie et al sang to children because they were banned from singing to adults for being socialists.  Just another example of blowback.  And there’s a block against left wing songs being allowed to break out.  I don’t believe this one, but it’s a hypothesis.


Do you hear the people sing?

I was at the London March for a Future That Works yesterday (October 20).  And my answer to the title question can be best summed up with the fact that I considered titling this post ‘The People’s Flag is Palest Pink’.  The march was … a big march.  I’ve been on them before and because you are all marching in the same direction you don’t get to see much of what is going on.

I arrived in Hyde Park to be greeted by a Green activist telling me I’d just missed Mr Millibean being booed for saying he’d be implementing cuts. Or more accurately telling us that Ed Miliband had been terrible.  He did not, contrary to Twitter, arrive in a Rolls Royce; that picture was taken in Hull (see the watermark). But from the linked video you can see exactly how bad a speech that was give to that audience.

Of the speeches I saw, little needs saying.  There was plenty of red meat for the crowd (some provided by Osbourne attempting to fare-dodge) including the union leaders and Bob Crow in particular calling for a General Strike.  Hint: This isn’t 1982.  Or even 1926.  There hasn’t been the will or the strength for a general strike in my lifetime – it’s nothing more than seeking one big battle to be crushed in.

And this brings me on to the core of my observations.  I was walking round and looking at the crowd far more than I was the speakers.  They were far more interesting.    And far more of an indication of what sort of unrest there was.  They were claiming 100,000 people at the time and the official claim is over 150,000.  Which is 100,000 down on the march a year ago – a very bad sign.  But worse was looking round the crowd and seeing who wasn’t there.

To quote the Billy Bragg version of The Internationale “Freedom is merely privilege extended,
Unless enjoyed by one and all.”  And the people there?  I’d estimate UNISON were the largest group, followed by the other unions (PCS, RMT, NASUWT, etc.).  The SWP were there, of course.  So were the other various socialist parties.  The Quakers.  Oddball left wing groups like the Red Leicester Choir.  Various local Labour party groups.  The Stop the War Coalition.  In short it was just about all left-wing rent-a-mob.

And who was missing?  My first observation on hitting the rally was that I didn’t think I’d seen a crowd that white in London since I lived in Eltham (the site of the Stephen Lawrence murder).  My second thought was that the students were missing.  There may have been a group of students from Warwick – and the two trolls carrying signs (one asking ‘Haven’t the bankers paid enough’) may have been students.   There were also other students in the crowd – but a distinct lack of students groups.

And this lead me to my second observation.  The overwhelming majority of the crowd were either people who I thought would have marched in the 70s or their children.  It seemed that the crowd was almost entirely a subset of the white upper working/lower middle class.  So much for “International Solidarity” –  they couldn’t even manage to attract outside a specific wedge who will be completely ignored by this government because I believe 99.9% of the crowd that turned up wouldn’t vote Tory if you paid them.  Marches are supposed to show strength.  That showed weakness.  It showed a lack of solidarity and a group that almost can not affect this government.

So no, I don’t hear the people sing.  The group preaching solidarity have turned into a pressure group.

Deconstruction: The Parable of the Prodigal Son

I’ve been reading deconstructions for years, and a discussion on a message board has inspired me to try my hand at deconstruction.  And for various reasons I was reading the Parable of the Prodigal Son and realised how much was missed from the normal descriptions.  The bible being long out of copyright, I can comment scene by scene.  (The Parable of the Prodigal Son is found in Luke 15:11-32 – and I use the KJV because I like the prose)

11 And he said, A certain man had two sons:

12 And the younger of them said to his father, Father, give me the portion of goods that falleth to me. And he divided unto them his living.

What can we see from this?  We see a pair of sons who so dislike their father that the Prodigal declares him dead to him and leaves.  It makes me wonder what was so bad that it led to the relationship being that disastrous?

15 And he went and joined himself to a citizen of that country; and he sent him into his fields to feed swine.

16 And he would fain have filled his belly with the husks that the swine did eat: and no man gave unto him.

17 And when he came to himself, he said, How many hired servants of my father’s have bread enough and to spare, and I perish with hunger!

18 I will arise and go to my father, and will say unto him, Father, I have sinned against heaven, and before thee,

19 And am no more worthy to be called thy son: make me as one of thy hired servants.

So the falling out was so great that the Prodigal Son literally only went home because it was that or starve.  To quote Lois McMaster Bujold “Home is where, when you go there, they have to take you in.”

20 And he arose, and came to his father. But when he was yet a great way off, his father saw him, and had compassion, and ran, and fell on his neck, and kissed him.

21 And the son said unto him, Father, I have sinned against heaven, and in thy sight, and am no more worthy to be called thy son.

22 But the father said to his servants, Bring forth the best robe, and put it on him; and put a ring on his hand, and shoes on his feet:

23 And bring hither the fatted calf, and kill it; and let us eat, and be merry:

24 For this my son was dead, and is alive again; he was lost, and is found. And they began to be merry.

25 Now his elder son was in the field: and as he came and drew nigh to the house, he heard musick and dancing.

26 And he called one of the servants, and asked what these things meant.

27 And he said unto him, Thy brother is come; and thy father hath killed the fatted calf, because he hath received him safe and sound.

And there we see why the Prodigal Son left.  The Father was delighted to see the Prodigal Son return and laid out the welcome mat.  And never once in this whole time did he think to send someone to tell the older brother ‘Hey.  Your brother’s home.  I think this calls for a celebration.

27 And he said unto him, Thy brother is come; and thy father hath killed the fatted calf, because he hath received him safe and sound.

28 And he was angry, and would not go in: therefore came his father out, and intreated him.

29 And he answering said to his father, Lo, these many years do I serve thee, neither transgressed I at any time thy commandment: and yet thou never gavest me a kid, that I might make merry with my friends:

30 But as soon as this thy son was come, which hath devoured thy living with harlots, thou hast killed for him the fatted calf.

So the elder son is angry.  Angry that his father blatantly ignored him and didn’t even bother to have someone tell him that his brother had turned up.  He’s hurt and left out because his father blatantly takes him for granted.  And the ‘thou never gavest me a kid’ to me has the feel of a long running argument

31 And he said unto him, Son, thou art ever with me, and all that I have is thine.

32 It was meet that we should make merry, and be glad: for this thy brother was dead, and is alive again; and was lost, and is found.

So what does the father do?  He doesn’t think to apologise for his behaviour.  Instead he simply lies to the elder son’s face.  He says that ‘all that I have is thine’.  No.  No it isn’t.  If all he had was the elder son’s, and he actually believed that, then he would at least have spoken to the elder son before throwing a lavish party at the cost of something valuable.  All that he has belongs to him.  He has exclusive control over it, not letting the elder son have a party and feed his friends.  And not even bothering to think of the elder amidst the party preparations when the younger comes home.

And to add insult to injury he follows this up with a passive-aggressive guilt trip.

So there you have it.  An unlikeable father who takes his sons for granted, lies to them, and forgets them when the New Shiny comes along.  Is it any wonder the more dutiful son resents this and the less dutiful ran away?

Healthcare: Life, Liberty, and the Pursuit of Happiness

There are many things that can be said about how to provide healthcare.  And how without provision of healthcare your right to life is dubious, your liberty is massively circumscribed every time you get ill, and following from Maslow’s Ladder, the pursuit of happiness requires physical needs to be met before you care about self-actualisation.  Or I could make the moral arguments about under most moral systems responsibility is differentiated, mutual and complementary, not exclusive, binary and competitive.

But I won’t.

Many pixels have been wasted on moral codes from people who do not see eye to eye – and I don’t think that anyone is open to convincing from a single blog post.  What I intend to show is that public provision of healthcare with tight governmental controls is the most efficient model – and the free market is one of the least.  There are healthcare services more financially efficient than the NHS – but not many of them (Japan is the only one that springs to mind and I don’t know enough about their health care system to talk about it).

Financially the NHS has problems – expenditure as a proportion of GDP on healthcare has increased by 25% in 10 years (2001-2010) and as such measures do need to be taken to keep spending under control.  But they need to be ones that work, not ones that simply open us to the problems of the largest and most inefficient healthcare system in the world.  (Figures from the World Bank; the latest iteration of the WHO website is almost impossible to find things in)

  • 9.6% of GDP is spent on healthcare in Britain in 2010, and 17.9% in the United States
  • The US Government spends more on healthcare per head than the British one
  • Life expectancy in Britain is a year longer than the US
  • The NHS was comfortably the most popular system surveyed by the Commonwealth Fund by its users, the US system the most likely to be thought “Fundamentally Broken”

I could go on with figures – and I could compare the UK model with the other big two European models (France and Germany – both of which spend more than 11.6% of their GDP on healthcare, making a difference in outcomes).  But the outcomes from the NHS are good despite the low funding.  So why this difference.

To put things simply, the US Healthcare model is a turducken of bad design, whereas at a strategic level the NHS gets most things right at present.  And the current British government seem to be trying to copy the American model.

Doctor Costs are much much higher under the American model

Lack of free healthcare does horrible things to the insurance rate

When something goes wrong medically then in a public system the damages paid would cover the direct damages inflicted. Future operations would be covered by the state – and many people don’t bother to sue.

In the US, there is no safety net to treat patients, therefore patients need to sue as otherwise they have no future healthcare – and the damages they are suing to cover aren’t just for direct damages, but for all future healthcare to cover those damages. There’s therefore a very good reason Americans are more likely to sue. What this does to doctors’ malpractice insurance rates I leave to your imagination, but last time I checked (a few years ago now – so these numbers will be low), the overheads to just insure the doctor against being sued ranged from $30,000/year to $160,000/year (this latter value for an obstetrician who hasn’t even been sued).

So to employ one single doctor takes that much extra in overheads before lighting, salary, support staff, etc. As European malpractice insurance rates are comparatively trivial, that’s several hundred dollars income every single American doctor must make every single day above and beyond European ones.

As a compounding factor, the insurance rates mean that it’s much, much harder in America to be a nurse practitioner than it is in Britain – you take many of the same risks, so the insurance is as absurdly high. Meaning a lot of minor procedures that don’t actually need a doctor so can be done more cheaply without aren’t.

The very high American education costs are passed on to the patients

The average American med student graduates around $162,000 in debt – and Sally Mae is aggressive (and won’t accept bankruptcies). British ones may have debts of about a third of that amount – but it doesn’t honestly matter because they only have to pay back 9% above £15,000 for standard student loans.  And if you’re earning £15,000 before healthcare you’re already starting to get somewhere.

Say about 6% annual interest (going by the fixed rate amount) or about $10,000 per year after tax the doctor needs to go straight to just paying the interest on the loan. Throw in taxes, payroll and a need to do more than pay off the interest and the cost for the cheapest doctors in America has just risen by another $20,000 – or about $100 per working day. Plus with that much debt there’s a much bigger incentive for greed. And once the loan is paid off the doctors don’t go to lower rates.

So the cost of an American doctor is therefore around $500/day above that of a European equivalent for no appreciable benefit.  Of course by first introducing then raising tuition fees, the last two British governments have been stepping down that path (especially as in London £15,000 doesn’t go that far).

The treatment method is the most financially inefficient possible

In America if you are uninsured you more or less wait until you can go to A&E/the Emergency Room. That’s about the most cost-inefficient method of treatment possible. It means that the condition is worse than it needs to be and makes planning harder and so overheads higher.  Or people don’t go and die.

In Britain there are few people who can’t afford to go to the doctor because the treatment itself is free (other than for dental care – of the British dental system the less said, the better).  But if you think you can’t afford to go to the doctor until an emergency you take the risk.

A “Competitive” model is incredibly bureaucratic

The doctors have separate rules for different patients

In Britain the list of authorised procedures is put out by NICE. A consultant only occasionally needs to look to see what’s changed in what they are allowed to do or they need to see what they want to do as part of their research work. Given that it’s fairly big news when things change, this takes a negligible amount of time.  There is also an agreement that when a hospital negotiates with its local PCTs, that is binding on all PCTs.

In America, you need to know what insurance scheme your patient is on. You need to be up to date with dealing with a dozen separate possible insurance schemes, some of which have … odd exemptions. And for each patient you need to know what treatment you can provide. This is a double overhead – first it means you need to spend some extra time per patient and second the hospital needs to be able to brief the doctors.

Note that this can be mitigated by a NICE-like system controlling what is authorised as they do in e.g. Germany.  Or by private provision under tight control with mandated non-profit healthcare as in Germany or Japan.

Also as no one currently knows how the GP Consortia the government is introducing will work, we have the same risk in Britain of multiple procedure models.

Line by line accounting takes people to produce the lines of ink

In Britain, the cost of your stay is based on very few factors – and it’s assumed that other than some very expensive drugs and a few parts patients average out (if anyone is interested in the exact costs paid by the PCTs for hospital stays, you can find them here (although they will take some unpicking); the quick version is that you take the highest tariff for any one single procedure in the hospital stay, add a modifier based on the admission method, and then possibly something for unusually long staying patients).

In America they can charge $18 for a nurse delivering a baby aspirin. What they do not explicitly charge for is the time taken to write and bill all that crap rather than just put it in the medical notes – but this is another huge overhead.

Legal defensive measures

In addition to malpractice insurance, the legal costs are higher – a further overhead. And this also encourages the doctors to do more diagnostic procedures, protecting themselves from any possible charges of negligance. This costs a significant amount of money – which due to the insurance model is cost-shared to consultations (partly to make consultations cost-effective for the money-hungry junior doctors with their $150,000 debts). Otherwise they’d do fewer of them. So due to the legal system not only is the malpractice insurance rate much higher, but so are other costs. Including administration fees.

Pharmaceutical Companies and advertising

In America, pharmaceutical companies can (and do) advertise directly to patients.  Patients who have no understanding of risk and are likely to be extremely worried – a very receptive audience and not one that normally understands the outcomes.  And they put the doctors under pressure to prescribe drugs which might not be the best treatment available.

In Britain, the drug companies can’t do this.  So there is less unwanted pressure on doctors – the drug companies do still advertise to them.  Also the NHS practices collective bargaining to keep the drug prices down (the NHS, as the world’s fifth largest employer being simply too big a market to ignore).  Also the pharmacists are allowed a system of parallel imports so, for example, if a drug costs a certain amount in France (or anywhere else in the EU) and more in the UK, the pharmacists are allowed to import the French version and keep a small cut – competition and arbitrage in action.  (Needless to say the pharmaceutical companies hate this – and they also hate that NICE makes sure drugs work and are cost-effective before approving them for use).

Of course even these provisions aren’t enough.  Dr. Ben Goldacre has recently written Bad Pharma about how the drug testing system is gamed by pharmaceutical companies.

The insurance companies are almost pure bureaucratic overhead – probably the biggest single issue

One of the things an insurance company does is checks through all the claims to find out reasons to not pay out. They do this to both patients, and to hospitals – on a line item basis. This means that the hospital needs to charge for everything – and it needs an entire team of specialised people whose job is nothing more nor less than wrestling with the various insurance companies. Medical benefits from this team: Nil.  And the costs American doctors charge needs to be inflated because the insurance companies are going to try to avoid paying out whatever they can. (The discounts if you offer American hospitals cash rather than go through the insurance companies can be up to 89% as they don’t have an arm-wrestling match to see any money – and even the linked cash prices are a lot higher than the price for the same procedures in Britain).

People, of course question bills under the British system on behalf of the PCTs.  And I know two people that between them, answer these queries from the PCT for two of the bigger hospitals in the country – as a minor but annoying part of what they do.

So what of the future?  Obamacare and the ConDem Government?

Obamacare first.  Obamacare is definitely a good thing as far as health is concerned.  It cuts down the number of different rules and makes it much easier to get non-emergency treatment.  Further it prevents recission – which means that the insurance companies could accept money then deny the healthcare based on any trivial mistakes.  Of course the really expensive group to treat in America is covered by the government anyway – the over 65s are covered by Medicare (healthcare for over 65s making up 40% of NHS spending) and that at least has a single model.  So it helps, but doesn’t deal with all the points.

Then the ConDems.  Fortunately we start in a much better position.  But GP Consortia are throwing everything into the air and meaning that the rules are changing and the hospitals don’t even know how.  Tuition fees give the new doctors more debt, and the government is intentionally opening up private care, which gives the doctors more direct financial incentive to overuse diagnostic tests and overtreat.  Plus they’ve almost crippled NICE which has given the pharmaceutical companies far more power.