Monday, January 30, 2006

The Tesco Value NHS

Another radical new healthcare initiative! Yep, a new drive to create "care campuses" providing medical services in the community - which is, of course, UTTERLY different to the concept of General Practice, isn't it? They're spewing out crap faster than that kid in The Exorcist these days...

Oh, and apparently "The GP market could also be opened to the... voluntary sector to help fill gaps in under-doctored areas" - even though the reason those areas are "under-doctored" (bloody ridiculous term) is largely because no doctors want to work there. Asking them to do it for no money ain't going to solve the problem, chum - doctors all come out of training these days saddled with upwards of £30,000 debt, so is it any wonder the majority try and stick around the major hospitals, where they've got a chance of becoming an over-paid consultant or getting spotted by a private practice, rather than buggering off to the sticks where they get to be moaned to by little old ladies and threatened by teenage thugs in hodded tops, all for far less pay (in real terms) than their forebears were getting three decades ago.

The report also includes the wonderous news that those "health MOTs" (stupid enough anyway) are going to be called "life checks" ("Right, that's OK MRs Prendergast, you ARE still alive after all..."), and that the government hope to have them available in Tesco. Yes, really...

Much like Tesco Value sausages, Labour's latest healthcare wheeze seems to be made of the discarded offal of fifty years of health policy, hastily re-packaged and flogged to the braindead public at a knock-down price.

Because, children, it has to be at a knock-down price. I can exclusively reveal to you today the real problem at the heart of the NHS - it's simply too bloody expensive to provide free healthcare for all at the point of use in a country with 60 million people and a rapidly aging population.

Every politician in Westminster knows this full well. But the NHS is the sacred cow of British politics - we can't slaughter the bastard even when it does start stomping through the back garden, munching on the geraniums, and costing us far more than it's worth. And so, instead, we'll get the same "new ideas" regurgitated every few years as if they're some brilliant cure-all, while the NHS infrastructure continues to creak under the strain and all the best medics defect to the private sector to earn some real money.

You see, the thing in medicine is that there are no magic potions to cure all ills. Sometimes a body is so racked with disease that little can be done - bits may yet be salvagable, but in order to do so, other parts must be amputated, or the body will be wasting precious energy supplying blood to limbs which no longer have any chance of survival.

This is the modern NHS - a lurgy-racked near-cadaver, covered with a liberal dosing of make-up to disguise the scars of the pox that has been ravaging it for decades; still recognisable, but in need of some major surgery if it is to survive. Adding some extra blusher around the endges to try and give the impression of health is no longer going to do the trick.

The NHS is a great idea, but much like swimming the Channel in lead pyjamas it's also insanely impractical. But no one is going to have the guts to take on the inevitable cries of "murder" that are always hollered when the sheer impracticality of such an insanely expensive drain on government resources is raised.


Blogger strangely rouge said...

So volunteer doctors, schools controlled by the loudest parents. All we require is a clever right wing christian movement, to move in and before we know it we have children declaring 'I'm not a monkey' and being refused treatment if it's derived from 'immoral' research. Perhaps I shouldn't say this out loud?

1/30/2006 10:02:00 am  
Blogger Tim Newman said...

Every politician in Westminster knows this full well. But the NHS is the sacred cow of British politics - we can't slaughter the bastard even when it does start stomping through the back garden, munching on the geraniums, and costing us far more than it's worth.


1/30/2006 10:36:00 am  
Anonymous tom p said...

what could the NHS money better be spent on than ensuring the health of the nation?
Earlier this month you linked to an article showing that in some of the poorest areas of Scotland the life expectancy could be as low as 54. You know full well that without a comprehensive and universally free NHS it'd probably be closer to 34 (the biggest determinant of life expectancy being infant mortality).
If, as you seem to be suggesting some services should be left to the private sector, which ones would you suggest? How should they be chosen for the axe or for retention?
Your analogy of a "lurgy-racked near-cadaver" is far off the mark. The vast majority of the NHS is functioning excellently, but there's a few problems that opponents of the principle of free health care (most of the press) delight in jumping on and always have done (and always will do).

This latest wheeze of the govt is typical half-arsed gimmicky nonsense designed to appear to be reaching out to poorer communities (after all, the richer in society already have free annual health checks either if it's required by their employers or through private medical insurance) to afford them the health benefits of being rich without actually doing anything tangible about the inequality in our society that is at the root of the health divide.
If these annual check-ups were to do anything about peoples' lifestyles and be able to co-ordinate cross-departmental support services to help people who need it but don't realise that it's available, then they would be an excellent idea and save a huge amount of money in the long run. But they won't because then people would get the help they're entitled to which would cost a lot of money in the short term.

1/30/2006 01:54:00 pm  
Blogger Nosemonkey said...

Tom - if I had a workable solution to the NHS problem, I'd be some kind of highly-paid public policy genius rather than some guy ranting incoherently on the interweb. The few ideas I do have all have flaws, aren't properly thought through and would all be rather complicated to introduce in an efficient manner.

A few things, though - I would maintain the principle of free healthcare for the poor, no matter what. The last thing we need is a US-style system where the poorest - and thus usually unhealthiest - members of society can't afford health insurance and avoid essential medical treatment for the excessive costs. But Increasing private medical treatment would only compound the problem of a lack of decent medical staff working within the state healthcare sector, so it's a tricky balance to achieve.

One thing that I do think is a major problem, which could be (in part) solved by some form of national health insurance (meaning there would be some form of deterrant for timewasters), is the overly generalised nature of the current NHS. Why can we go to dentists or optitians straight off if our teeth or eyes are knackered but not go straight to a chiropractor when we put our backs out without going via a GP first? I'm reliably informed that in Japan it's possible to go straight to a specialist, treatment is funded by a national health insurance scheme and that the system works well. Why can't we do something similar over here? It could speed up the process considerably, plus cut down on paperwork.

My only major, semi-practical idea is simple (though at first glance possibly contradictory to the last one) - people get fined for wasting police time, so why not fine them for wasting NHS time? Do people with sore throats really need to go to casualty? Does someone with an earache need to call an ambulance? Should people who have booked NHS appointments with doctors, dentists etc. be able to just not turn up, wasting time and money as well as preventing others from being treated, without having to reimburse the practice for the hassle?

There's always fuss made about wasted resources within the NHS (and I'm always inclined to believe the stories about bureaucrats and managers buggering the thing up with excessive salaries and meaningless paperwork thanks to complaints from my parents, both of whom work on the medical side of the NHS), but a lot of the waste is caused by the public taking advantage of the thing being free. Cut down on that, you could save a good amount of money - especially if we follow Blair's fetish for extrajudicial punishment and make fines for failing to turn up to appointments etc. automatic.

Other than that, on this issue I'd buy the tabloid line on certain procedures being inappropriate or unnecessary to fund via the NHS. Whether the tales are true that that transexual who won Big Brother got her sex change op on the NHS are true or not I have no idea - but personally I'd count that as an unnecessary treatment that should be dealt with privately. Chuck in fertility treatments, cosmetic dentistry, most plastic surgery etc. (the list should doubtless be drawn up by a panel of experts who know far more about these things than I), and the financial resources these take up could be happily transferred to frontline services.

As I say, I'm no expert, and I'm fully aware that all of these suggestions would have major problems. But something needs to be done - the NHS east up 6.6% of national income, some £65.5 billion in 2002-3 - and the strain on the system is only going to increase over the next twenty years as the baby boomers reach retirement age - not least because life expectancy has grown so much over the fifty years since the NHS was introduced. Something major is needed to cope, because we simply can't afford to keep chucking money at the problem.

1/30/2006 03:04:00 pm  
Blogger Rob Jubb said...

Actually, as this excel file - shows - Britain actually spends about the lowest per capita of the established liberal democracies on healthcare. That would suggest that - although differential health outcomes suggest that some of the money could be spent better - the NHS is hardly an enormous drain on our resources. Ezra Klein, an American wonky blog, had a whole series of really quite informative posts on healthcare systems a while ago which'd be excellent sources for this kind of thing

1/30/2006 09:33:00 pm  
Anonymous tom p said...

Nosemonkey, what's wrong with you? You misspelt 'teh interweb'.

I still would like to know what the nation's finances could be better spent on than our health? Other than, perhaps, education, of course.
Maybe we could put your putative (short-term) savings to good use creating nonsensical intrusive and ridiculously expensive ID card schemes or fighting illegal wars. What else that governments spend the nation's money on is more important than health (or education)?

Your means-testing proposal would lead to the moderately poor (and genuinely poor alike) being afraid to go to the doctor because of the fear of the cost. Also, as soon as there's any pricing involved, then governments keen to cut back a few billion but without pissing off those in marginals will start fucking with the bands for when one has to pay to make it harder to access.

You can go to any old chiropracticioner. The british chiropractic association's website strates that it is "a primary health-care profession", therefore you shouldn't need a GP's referral.
However, I take your general point, and it's a good one. Certainly physiotherapists can't be visited without a GP's referral, which is silly because they are paid less than GPs, so it would be cheaper for those who need physio to go there first and see what's wrong. GPs are far from specialised so a physio is as likely to know what's wrong with a patient's joint or muscles as the quack actually is. Maybe a super physio qualification with diagnostic powers is needed. The quacks would whinge, but the patient's health is not best served by the current system.

I quite like your idea of being fined for missing appointments, my dentist operates such a poilcy, but then there's the problem of when one really can't help it, and again this would most likely affect the poorest in society, who are most prone to being at the mercy of public transport and if the quacks are hard-arsed about it, they may say , for example, that over 20 minutes late means it's missed (as my old doc used to enforce, rigidly).

You've a point about the waste on beaureaucracy. Both of my parents are also in the medical side of the NHS (and I was, for a while in the ancillary side as a porter), and I have a friend who's a hospital accountant. The waste from excessive financial managers (caused largely by this internal market bollocks) and from false economies such as constantly employing agency staff when an in-house solution would be much cheaper is incredible. But no more than in any other organisation where they've tried to shoehorn in market 'reforms' where they are inappropriate.

The tabloid line is mainly one of attacking the NHS by whatever means possible (and also attacking anyone not aggressively hetero). Look at the MRSA bollocks, when there wasn't actually any to be found and they had to go to some dodgy spiv in a shed at the bottom of his garden who didn't know what he was doing (
I understand that the number of gender-change ops in this country is tiny, and, one could argue, is probably useful at keeping the surgeons' collective eye in and developing new techniques for when genito-urinary surgery is truly necessary, after all, who better for them to experiment on than people who don't really need the surgery but do really want it. Also, I always thought that they weren't available on the NHS but then I could be wrong.

Cosmetic dentistry costs the users - dentists aren't really free, just subsidised. Also, what's put down as cosmetic dentistry can be useful for protecting dental health later in life - it's bloody hard to clean your teeth when they're all crooked and have loads of nooks and crannies for harbouring bacteria. Leads to all kinds of nasty abcesses and other gum diseases.

What is a disgrace about the NHS finances is funding for homeopathy. I'm bugging the homeopathic hospitals under the FOI act to get their annual budgets and number of appointments over the last 5 years. The figures are ludicrous.

I have to disagree with you regarding your predictions about the increased NHS costs though. You see, much of the cost of the NHS budget (a proportion that's been increasing all the time) has been medicines. When medicines go off patent (25 years after they've been patented), they then become very, very cheap as all the generics manufacturers pile in. That means that almost every medicine (all the ones that are cheap and easy to manufacture) available today will be as cheap as aspirin in 10-15 years time (because medicines take 10-15 years to come to market). Even those that are difficult to manufacture will cost a fraction of today's prices (in actual terms, let alone real). Also, as we get more information about the safety profile of these medicines, an increasing number will be sold direct through the pharmacist, meaning that the GPs don't even need to be involved with their supply (as happened with the anti-ulcer drugs). I have a friend whose job it was for a while to process the shift from Prescription Only Medicine (POM) status to Pharmacist (P).
NICE will effectively prevent prices spiralling out of control ludicrously as pharma companies try to sell newer and more expensive medicines, 'cos what's available today is, in almost every case, fucking good (that's my considered professional opinion).
In the not-too distant future (10-30 years), the main tangible benefits, both from a safety perspective and a pharmacoeconomic perspective, of new medicines authorised should be reduced side-effects as increased understanding of pharmacogenomics leads to increased personalisation of medicines. The reduced side-efects should lead to reduced hospital admission for side-effects and better patient compliance with the treatment regime and thus overall less money needed to be spent on patients in hospitals.
A far bigger cost increase will be pensions and social housing/care for the elderly, which of course are not NHS costs at all.

Robert Judd - that OECD table was very interesting. I collated the data with it from the data for GDP from the OECD and have found that, of the 30 OECD member states for whom appropriate figures were available on the website, in 2001 Britain was 24th out of 29 in terms of % of GDP/capita/annum with 6.10% (figures were not available for Turkey) and in 2002 was 21st out of 27 at 6.42%, just 0.01 % above Asutria and Norway(figures were not available for Australia, Japan or Turkey).
Even if you add in the extra 1.2% of GDP spent privately on health that the Guardian article you linked to cites, that would still only take us up to joint 13th out of 27 with Korea, just 0.01% ahead of Italy and 0.03% above Belgium.

So, as you can see, Nosemonkey, the (I assume unintentional) negative you used to describe the proportion of GDP that is spent on the NHS ("the NHS east (sic) up...") is quite inappropriate. It's working miracles on a (relative, very relative) shoestring.

The NHS is like Bolton Wanderers under Sam Allardyce. Not glamorous, but doing a grand and canny job making great use of the cheap talent from overseas on which it has become reliant.

Apologies for the length of this comment.

1/31/2006 04:04:00 pm  
Anonymous gndbh said...

oops, that should've been Jubb, not Judd. Sorry Robert

1/31/2006 04:07:00 pm  
Blogger Nosemonkey said...

No idea how it'd affect the rankings, but that Guardian article also reckons that 2005-6 will see NHS spending up to £87.2bn, rising to £105.6bn by 2007-8.

Still, you undoubtedly raise a lot of good points. But as you (briefly) mentioned preventative medicine, the best possible method would surely be improving education? The part of Glasgow with a male life expectancy of 54 was by far the poorest, in a city famed for the healthy delight that is the deep-fried Mars Bar. Better education generally leads to not just better employment opportunities, but also better lifestyle and diet - by far the best bet for cutting down on health service requirements. (At the risk of sounding all classist, it also makes you less likely to get pissed and get in fights, with all the stitches and casualty ward security expenditure that necessitates...)

That still leaves the problem of the elderly, of course - and would in fact most likely make it worse, as people with better diets and lifestyles are likely to live much longer.

So perhaps we should return to my age-old solution - the NHS should only be free to heavy drinkers and smokers, because not only do the extra taxes we pay help keep the thing up and running, but we're also likely to die far younger, thus actually making ourselves far less of a drain on its resources than the selfish teetotal non-smokers who live into their ninties...

1/31/2006 04:26:00 pm  
Blogger chris said...

Aaargh. Socialised health care is not an all or nothing proposition. There are many models, all of which work better than the NHS. How about learning from our European neighbors and have a French style social insurance scheme? Or how about learning from the other system in the UK?

Are you sitting comfortably then I'll begin.

A long long time ago there was a nasty war. Many soldiers died, and many more where left injured loosing feet, legs, arms and hands. When they returned home the people of their small wet island felt so sorry for them as it is hard to hold a cup of tea when you have no hands. But the nice leaders of the island offered them all new feet, legs, arms and hands to replace the ones that they had lost in the nasty war.

The soldiers where very happy to hear this but worried that they could not afford it, but the government said "don't worry, since you've been so brave your new limbs shall be free!" And the soldiers where happy, as where the private companies that competed for the work of building the new limbs for the soldiers and running the clinics that fitted them.

So it continued from that day on, even when the government decided to create a nationalised service to offer other treatments, not just new arms and legs, the arm and leg makers where so good at making them, fitting them, and not charging the people that needed them that they where allowed to carry on as before. And they still do to this very day.

1/31/2006 11:20:00 pm  
Anonymous tom p said...

Chris, have you tried living in France and using the healthcare system there?
It's fashionable to say it's a great system, but they have a huge problem with overmedication and consequent antibiotic resistance (which is because of the conflict of interest for the GPs between doing what's generally best for the patient, namely only giving them medication when they really need it, and keeping their patients happy and thus keeping their patients and thus paying their mortgage).
Although the private services are lovely when you're using them, they are seriously hard-arsed about you needing to show upfront that you have the money for it, otherwise it's off to the sink hospital that picks up the tab for the dregs of society.
I've experienced both sides of their system and I can assure you that if you don't have a comfortable middle-class salary, then the nice hospitals are really fucking scary and the financial worry doesn't help you recover one bit, and the state hospitals are pretty much invariably shit and in a scary part of the city and full of junkies, drunks and screaming lunatics (cue the 'and that's just the staff' joke).

you say "There are many models, all of which work better than the NHS", clearly indicating that you think the NHS is the worst healthcare system in the world (or did you just word it inaccurately?). What possible basis have you for claiming this? It's an incredibly bold statement. Have you any evidence or suggestions for how such a thing should work?

You know, America spends about twice as much as we do on health (as a proportion of GDP per capita per annum), and only the most one-eyed yankee would try to claim for a moment that their healthcare system is better, taken in terms of safeguarding the health of the population as a whole, than the NHS. Having a largely privatised system doesn't necessarily improve it at all. I'm all in favour of free enterprise, but only for things one doesn't need. For example, in times of plenty, then food distribution is best served by free-enterprise (with, obviously, appporopriate regulation on quality and standards), but in times when it's scarce, eg WWII, then it's best served by government control to ensure that people don't starve. Where you have private provision of goods and services you have winners and losers. It is surely incumbent upon any state to ensure that there are an absolute minimum of losers when it comes to the health of the public, otherwise they have no justification for ruling over that public.
This can be acheived through both health spending and also education as Nosey pointed out, giving people opportunities to get out of self-destructive cycles.

Anyway, what could the NHS learn from the UK private halthcare sector? That having an A&E department is a bad thing? That they should only treat well-off middle-aged people and their families 'cos they have the fewest illnesses? That they should always build their hospitals close to NHS ones so when operations go tits-up the patient can be taken over to the NHS one to fix things and make use of the intensive care beds (like I said earlier, my parents both work in the NHS (well, my dad is currently technically employed by a healthcare charity, but all their money comes directly from a the NHS and the DSS) and so did I and we know of plenty examples of this) which are incredibly expensive? That it's just nicer all round to be a glorified hotel with a spot of routine orthopaedic and cardiovascular surgery on the side? That you can cherry-pick the best consultants from the NHS at a top salary for part-time work if you don't have to pay to train them up over the previous 20-odd years? That by cherry-picking these consultants you can artificially increase the waiting lists at the NHS hospitals thus boosting the desire for your services amongst the public?

Nosey - I agree with you entirely about the education. One can easily sound snobbish when discussing people in such terms, but if the cap fits...

2/01/2006 11:03:00 am  
Blogger chris said...

I was talking about the Prosthetics sector. NHS prosthetics clinics are privately run, staffed, and trained. Private companies compete for contracts to run them from the NHS but they are still free to the patients (or rather tax payer funded). All with considerably less bureacracy, waste, and weird accounting than the rest of the NHS.

2/01/2006 04:02:00 pm  
Anonymous tom p said...

They're also considerably smaller than a whole hospital.
I'm sure that they do the one thing they do very well, but that's the difference, they do one thing.

Prosthetics are technology-intensive innovative therapies. The manufacturers are essentlially more like pharmaceutical companies than a national health service. Yes they need to run a residential facility to properly fit the prosthetics and teach people to use them, but they're doing essentially what the drugs companies are doing, namely supplying a medical need with a product. They don't need to employ huge bodies of doctors and nurses, they don't have blood and urine samples being carried all over the place, they don't have dead bodies in the morgues, and all the attendent necessary paperwork that goes with all of these things and the many, many more that hospitals do. They just have patients who have had all the help given to them that doctors can and are as fit and healthy as they're going to be (having lost a limb or limbs) and now need fitting with a new device. They're like a hi-tech wheelchair shop.

2/01/2006 04:49:00 pm  

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