Friday, 20 June 2014

Bracken's Law and the NHS

Everyone knows Godwin's law:

"As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1". 
Some then suggest the law says 
"and whoever does so, has lost the argument".
In discussing healthcare, I propose this law: 
"The longer any discussion about the NHS goes on, the closer the probability a spurious invocation of the US system of healthcare gets to one, and whoever does so has lost the argument".
If you are reading this post, there is a good chance you've been sent this way, by me, during an exchange on Twitter. Before we go further, let's be clear what I actually believe on the subject. 
  1. I am in favour of free(ish) at the point of delivery services.  By Free(ish) I don't rule out the likes of Prescription charges and nominal charges to see a GP or charges for missed appointments, which seem like reasonable demand-management to me.
  2. I am in favour of Tax Payer funding of healthcare. I cannot see any practical difference between compulsory insurance and tax-payer funding. Insurance is just risk-pooling. Taxpayer funding is a bigger risk pool. 
  3. The NHS isn't very good. And it isn't very good principally because of its vastness and consequent bureaucracy, not because of its funding mechanism.
  4. More competition is necessary. And competition isn't about firms competing for government monopolies, that's mere crony capitalism, a kind of cargo-cult market that achieves nothing a market should do, and simply allows firms to profit from state monopolies. Competition means the funds following the patient, with the GP as gatekeeper and advisor to the patient.
So, if you accuse me of favouring insurance companies, or wanting companies profiteering, you're arguing against a straw man. 

In international comparisons, the NHS often comes out well. The recent study by the commonwealth fund, whose report led the Guardian to proclaim the "NHS is the World's Best Healthcare System". However that is using patient-satisfaction survey data, and measures of cost. The Guardian's own report contains the remarkable passage: 
The only serious black mark against the NHS was its poor record on keeping people alive. On a composite "healthy lives" score, which includes deaths among infants and patients who would have survived had they received timely and effective healthcare, the UK came 10th.
Basically, the commonwealth fund finds the UK healthcare system cheap. This is because private-sector, insurance-based provision is effectively banned in the UK as co-payments are not allowed. You cannot top-up your healthcare. We spend about the same as most of Europe on state healthcare, without asking people to top up through insurance, as most of Europe do. Thus we have barely adequate healthcare, but which is very inexpensive. This is why the UK scores well on "efficiency".

Ease of access and equality are based on Patient-reported surveys. And as the NHS is healthcare in the mind of most Britons, and such surveys are skewed towards patients who, ahem, survived, then I can't see such data's all that reliable. It's just a reflection of the almost mythical, religious support Britons have been brainwashed into giving what politicians STILL call "the envy of the World".

Where the data does stack up is the NHS's excellence in dealing with Chronic conditions. Here the ability to marshall resources and the bureaucracy to back it up helps. The problem in the NHS is the customer facing bit - particularly diagnosis and A&E. This is where patient choice and a functioning market with competing providers would make all the difference. Once in the machine, the NHS functions as a first-world healthcare system. Getting into the machine requires sharp elbows, luck and knowledge. Delays in getting into the machine are behind the NHS's poor record in combating cancer in particular. There is very little immediate punishment for failure, which is too easily covered up; South Stafford Hospital for example.

The sooner the NHS starts treating its patients as customers for whose business they compete, not an irritating cost to be borne by the long-suffering nurses, the sooner the NHS will warrant the plaudits lefties so desperately want to give it.

But in prioritising "efficiency" over "keeping people alive" in order to give your pre-chosen answer (a state-run system) a big gold star is a bit desperate, and nothing short of policy-based evidence making. Or as I prefer to put it, immoderately, LYING.


lost_nurse said...

"So, if you accuse me of favouring insurance companies, or wanting companies profiteering, you're arguing against a straw man"

Except that this is precisely the result of the current reforms (which, IIRC, you were vocal in supporting). The DoH rhetoric about "putting drs in charge" is merely surface gloss. Companies like Circle (whose PR gets swallowed wholesale by Daily Failograph editors, with barely a mention of acuity/casemix) and CareUK are leeching off NHS acute capacity & workforce training. It's not "competition", in any sense - it's simply taking the piss. It's also worth pointing out that co-operation across the service was a major factor in keeping the NHS cheap (by international standards) - & as that is fragmented, costs are going up. Buck-passing between multiple providers is leading to huge pressure on the frontline - with the [very] visible pile-up in A&E being but one example.

The point being: the NHS is very much a curate's egg - when it's good, it can be amazing, when it's bad, terrible - and these reforms are not helping to improve the ratio of good:bad, in the slightest. Even if a continental-style system was the end-goal, the focus should have been on keeping core services steady thru the existing programme of cost-savings. Instead we have Lansley's convoluted & expensive diktat, and - as was widely predicted - it is an utter fcuking disaster. But at least Jane Ellison finds it exciting.

Jackart said...

The NHS is shit. It doesn't follow that I support the coalitions' proposals, which I think, as you spotted, as a bit corporatist.

The disease though is the NHS. That is the cancer which must be cut out before any progress can be made.

Matt said...

From the Guardian article you quote:

"On a composite "healthy lives" score, which includes deaths among infants and patients who would have survived had they received timely and effective healthcare, the UK came 10th.

The authors say that the healthcare system cannot be solely blamed for this issue, which is strongly influenced by social and economic factors"

If this is true, then should the NHS be blamed for (say) a culture of binge drinking? Or unhealthy eating? Or people not exercising?

Jackart said...

I have never seen a supporter of the NHS blame low American life expectancy on anything other than their healthcare system. The NHS also fares badly on "deaths amenable to healthcare", but this isn't a measure that the commonwealth fund seem to think important.

lost_nurse said...

"The NHS is shit"

Except when it isn't, of course.

I've done the best part of twenty years on the wards - I've seen the best & worst of the NHS, and plenty of it. And I judge it accordingly. "Progress" is going to require more than just easily-dispensed platitudes about competition - they mean very little in acute care (and, like Rome, all roads eventually lead there... "gatekeeper" GPs will send you in, just to cover themselves), even in better-invested social-insurance systems.

Even if I often disagree with your posts, you generally talk a good game - don't ruin it with pisspoor generalisations.

Jackart said...

Didn't i detail where I thought the NHS is good? But A&E and Diagnostics are dreadful. Shocking and a national embarassment which kills people. Proper market mechanisms, as almost every other successful healthcare system has, would help.

lost_nurse said...

I'm with Macmillan - improved diagnosis, response & lead-in times for cancer treatment are going to require increased investment, however you slice/organise the cake. And that's quite aside from the public health debate that so excites Tim Worstall.

"Proper market mechanisms": as you no doubt agree, change introduced in the name of marketisation is generally nothing of the sort. In fact, it's fcuking cheeky of Mike Parish (CE of Care_UK, and co-author with serial Blairite Paul Corrigan of the recent REFORM report) to use variability in NHS outcomes as justification for more out-sourcing, given that his company simply cherry-picks the easy stuff, and remains dependant on the NHS for everything else... Happily for him, the Coalition has turned the NHS logo into a kitemark, via an expensive & muddleheaded re-org (despite saying they wouldn't). Meanwhile, things on the frontline are going downhill, and fast - & it's going to be an interesting electoral battleground. Personally, I despair.

Anyway, I've had a long (and grim) weekend at the coalface. I'm off to ride my bike.

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