How Labour should respond to the coming NHS crisis


10:44 am - January 6th 2011

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contribution by Richard Blogger

The NHS financial crisis I outlined yesterday will be a terrible thing, but it could also be an opportunity for Labour.

For a start, it will finally convince the public that the Tories can never be trusted with the NHS: never again will a Tory leader be able to tell the British public “the NHS is safe with me”.

The problem is whether there will be any NHS left for a future Labour government to protect. The other problem is that GP commissioning is here and it cannot be removed and Labour attacking GP commissioning will be a losing battle.

I am not saying that Labour should not oppose the plan, just that it should not expend too much energy on it.

Instead, Labour should concentrate on Lansley’s plans for providers. The plans to take all NHS hospitals out of public ownership; the plans to mandate that a fixed proportion of NHS paid work must be provided by the private sector; the application of competition law; the whole “any willing provider” policy.

These are the areas where Labour must attack Lansley. They must attack these policies because they are wrong, and because the majority of the public are against them.

And one final point. Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned.

Drop the “mutuals” idea because this is too close to Lansley’s “social enterprises” idea.

NHS hospitals should be publicly owned, publicly run and publicly accountable.

Surely that is a simple enough message for the Labour party to make the case for?

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Reader comments


What if the general public don’t want hospitals to be publicly owned and run?

@1. Tyler

What if the general public don’t want hospitals to be publicly owned and run?

There will be a referendum in May, that would be an ideal time to ask the public, just add an extra question to Clegg’s vanity referendum. I am up for that.

I agree, it would be an ideal time to ask.

Though I think it’s tougher than a yes/no answer in terms of disbanding the NHS.

A lot of people, myself incuded, would be more than happy to see its current form dissolved or reformed significantly, given how expensive it is at producing a worse outcome than private medical. That’s not the same as saying poor people should be enied access to medical care though.

The NHS is not even organised as one giant monolithic organisation across the UK but split and financed as different divisions under the aegis of the NHS.

Essentially what the NHS stands for is a brand encapsulated by the ethos of free at the point of use.

It is already using private resources to offer some services and ‘privatisation’ was started under Labour during the Parliament.

What good reason exists that the NHS should be wholly owned by the State?

The UK spends as a proportion of GDP the equivalent of what Sweden does.

So why is our health service not as good as theirs by the WHO’s measures?

Speak to some of the medical practitioners in the NHS, I mean from sisters through to senior medics, how many to you think have private medical insurance?

Why do you think that is?

@tyler

Can you explain to me why if there are “a lot of people” in favour of taking hospitals out of public ownership Cameron and Lansley did not mention it at all during last years election? If, as you seem to claim, there is a large number of people in favour, it should have been a totemic policy, one that would have got Cameron the landslide he coveted? Or perhaps Cameron and Lansley thought that if there was the slightest whiff of a suggestion that NHS hospitals would no longer be publicly owned under a Conservative government the public would not vote Conservative? I think the latter was the case, and that Cameron did not get a majority because a large number of people still did not trust him on the NHS.

During the election campaign I asked Cameron about this issue of privatisation of the NHS in a Radio 4 phone-in. As soon as he heard the word “privatisation” he just spouted platitudes about the NHS, avoiding the question completely. Clearly this was a subject that he knew he was vulnerable on. Sadly, Martha Kearney, who was the presenter on the phone-in, did not insist he answer my question, and I was not allowed a response.

“roducing a worse outcome than private medical.”

Well duh.

Nobody is going to pay for a service that is worse than that they can get for free. A private health care provider that provided worse services than the NHS would go out of business.

Unfortunate for those of us who disagree, but fetishising the current structure may well be a vote winner.

Why no other country in Europe has decided that “publicly owned, publicly run” is the way to go, while they appear to believe that “accountability” is best achieved through the market mechanism, is a mystery which no politician dares broach except by stealth.

Which I agree is dishonest.

@ 5 Richard

Don’t know what Cameron thinks, but your view of Lansley’s reforms is hyperbolic. It’s not privatisation by any means.

I think a lot of things contributed to the conservatives not getting a majority, but I’d say the 8% built in advantage to Labour through boundaries was a lot more important than any feeling about the NHS.

@ 6 Planeshift.

You’ve missed the point, again. The point is not that the NHS is worse in outcomes, but worse in outcomes AT A HIGHER COST.

The NHS costs about 1750 per head in the UK. My UK private medical insurance (admittedly, no A+E) was 500 cheaper.

My current SA medical insurance costs about 1400 a year, but includes private A+E.

If the NHS offered better value or better outcomes that would be one thing, but in reality it offers neither.

” the whole “any willing provider” policy.

These are the areas where Labour must attack Lansley. They must attack these policies because they are wrong, and because the majority of the public are against them.

And one final point. Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned.

Drop the “mutuals” idea because this is too close to Lansley’s “social enterprises” idea.

NHS hospitals should be publicly owned, publicly run and publicly accountable. ”

You’re really going to have to help me out here.

Why is it important that hospitals, health care, are publicly run, publicly owned?

I get why financed, no problem with that. But why ownership and management? Just about no one else does it this way so could we have some explanation as to why this is necessary?

“My UK private medical insurance (admittedly, no A+E) was 500 cheaper.”

That is because your private medical insurers don’t have to cover everyone, and most people paying for it are in the middle to upper income bracket who have less need anyway. Most NHS costs come from expensive chronic care for people who – for obvious reasons – don’t have the income to pay for private providors. In any case, all private healthcare in the UK means is you get your own room, and you get to skip the queues. You still end up being treated by the same staff in the same buildings.

11. Chaise Guevara

@ 8 Tyler

“You’ve missed the point, again. The point is not that the NHS is worse in outcomes, but worse in outcomes AT A HIGHER COST.

The NHS costs about 1750 per head in the UK. My UK private medical insurance (admittedly, no A+E) was 500 cheaper.”

Does your insurer cover everything available on the NHS? Because if not, it’s probably not including expensive treatments with unimpressive outcomes.

NHS accountability at work:

http://blogs.telegraph.co.uk/news/judithpotts/100070484/my-mother-in-laws-shocking-experience-at-scarborough-hospital-and-what-it-says-about-the-nhs/

Of course no-one dares make too much of a fuss because you have to take what you are given or you or your relative are totally f*cked.

Any monopoly has you by the balls.

So I too would be grateful for an answer to Tim W’s question: publicily funded, yes; but why publicly owned and run?

“hat you are given or you or your relative are totally f*cked.”

If the NHS fucks up, you or your relative can take legal action.

10
‘you still end up using the same building’
Correct, and what many who argue that private costs less with better outcomes forget, is that there was an agreerment at the inception of the NHS (to get doctors on board) that they could use NHS facilities for private practice. So if you factored in the cost of using the equipment, space and staff provided by the public, which, of course, isn’t charged, you would have a totally different figure.

“If the NHS fucks up, you or your relative can take legal action.”

Well that’s good to know.

I’d rather not be treated like Judith Potts’s relative in the first place though, wouldn’t you?

16. Planeshift

Well yes, but it demonstrates there is accountability.You can have crap treatment in a private place as well.

The biggest problem Labour will have is, as in other areas, to convince the public that they would be better than the Tories. It was plain before the election that Labour were going down the privatisation route so, with simple promises from Cameron, the NHS was no longer apparently a significant issue.

Talking to people there seems to be a general feeling that Labour will not fulfil its promises and will follow Tory policies, perhaps slightly watered down. They have to prove that this is no longer the case.

Well litigation is rather a last resort, isn’t it?

I’m not sure that’s the same as “accountability”.

Yes you can get crap treatment anywhere.

But in competitive markets you can go elsewhere.
Producers in such markets know this…hence less likelihood of crap treatment.

19. Planeshift

“but why publicly owned and run?”

I’ll have a stab at it.

Generally introducing the profit motive has several effects; on the plus side you get compeition between providers that brings prices down (if you design the tendering process correctly). Plus choice for consumers in some areas (not A+E) of the service will help to maintain or improve standards.

On the other side you risk creating the situation where the private sector grabs the profitable bits, and leaves the rest of it to charities who can’t provide things properly. Hence expensive treatments get provided (over-provided) and the cheap stuff gets ignored regardless of outcome. You also risk creating a disease industry not a health service. You risk a health industrial complex that lobbies for the service to be designed around it’s interests. This means health care becomes reactive and orientated around supply of expensive stuff, rather than a preventative service that seeks to stop people getting ill. You’ll see anti-smoking work ended in favour of just letting people get lung cancer instead. Plus people have an instinctive moral reaction against people making money from misery.

Have to say I am an agnostic on the issue, but think any major reforms should not be done during periods of cost cutting (you make the savings after the reform), should be done slowly and carefully and based on evidence of effectiveness rather than because a few right wing economists and think tanks drew squiggly lines on a board.

20. Chaise Guevara

@ 18 cjcjc

“Yes you can get crap treatment anywhere.

But in competitive markets you can go elsewhere.
Producers in such markets know this…hence less likelihood of crap treatment.”

Fair point. However, even assuming you system would be able to prevent things like people who would receive treatment under current triage being refused for having an “economically nonviable” condition, the private players would want their cut, adding a layer of expense.

Trains were apparently shit under apathetic state management. They provide a better service now under state-supervised capitalism, but many people are priced off them.

21. Planeshift

“Well litigation is rather a last resort, isn’t it”

Sometimes, for some people, it seems to a be a first resort unfortuantly.

“the private players would want their cut, adding a layer of expense”

Indeed – but *total* costs may still be lower while quality (under competition) should be higher.

I mean you would not suggest that a nationalised food monopoly would provide either cheaper prices or better quality, would you?

@ Planeshift

My medical insurance was all-encompassing, including many things not provided on the NHS (like the 800 gbp knee brace I’m now forced to wear skiing). My current South African medical insurance is even more so – I even get free contact lenses and glasses on it…even a discount on gym mebership.

But, once again, you miss the point. The average cost per person in the NHS is much higher than private medical….as in my NHS estimate i haven’t deleted the millions of people with private medical insurance. The real cost of the NHS is higher still. I take your point that poor people can often have more health problems, but that isn’t limted to the poor by any means. That the NHS is more expensive in itself might not be a problem were it for the fact that the outcomes it provides are often far worse.

@ Other people

I never had private treatment in an NHS hospital. Always private hospitals or surgerys.

Some consultants did also work for the NHS. Some were purely private. My knee was done privately by the chap who does England Rugby. On the NHS it was done by a newly qualified surgeon…..and part of the reason I needed another op 3 years later is that it wasn’t done well on the NHS. That of course, is after the NHS let me limp around for 18 months whilst filibustering over my op….making the problem that much worse.

Just as a question to everyone;

If you had the choice, and the money wasn’t an issue, would you rather have private medical insurance or rely purely on the NHS?

Be honest now…..

….and then answer why we spend so much on the NHS that we could pay for medical insurance for everyone in the country for the same money or less?

25. Alisdair Cameron

Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned

I’d agree he should do that, but he can’t and won’t. He is still a New Labour creation, despite attempts at distancing himself from that taint, and it cannot be forgotten that New labour, especially the uber-Blairites were damnably keen on Lansley style demolition and ‘privatisation’ (not full-on privatisation, but rather the gifting of great chunks of public money to private providers, who typically gave and give worse, and certainly not universal service, despite being universally funded: witness ISTCs,the cherry-picking with extortionate cost of waiting-list initiative farming-out and cherry-picking etc etc).
Why publicly owned and run?
Three good reasons:
a) It’s paid for publicly.
b) Universality.
c) Outcomes not outputs.

It’s worth considering that there’s a big difference between running a retail company – where you do things people want, and profit from supplying – and a state – where you offer things people may not want (like tax collection…) but that the state needs. And you don’t profit from supplying.And in many areas you have to supply good to everyone,regardless. Cherry-picking isn’t an option.
Many public services – from night buses to the NHS, from business advice leaflets to the police – are never going to show any kind of profit. Would you therefore shut them down?
I’d hope political imperatives (you don’t know with this Govt), but more pointedly, societal practicalities mean that you couldn’t. You can’t simply hive off ‘unprofitable’ services, nor can service delivery be outsourced overseas.
There is probably something to be done in terms of changing the worst elements of some public sector workers’ attitudes, but a transfusion in of private sector ethos is not, in my eyes, any kind of an answer, and will prove counterproductive: you’d see an immediate dissipation of the extant public sector ethos and the added value of the goodwill that holds so many services together, plus a growing reluctance and resentment towards ‘unprofitable’ public service users with complex or awkward needs, who can’t be jettisoned . The state is there (in part, at least) to supply what people need, rather than simply what they want. In place of saying what the state needs, I should probably have said what society collectively needs, and for which the state is the platform to ensure universal access and provision.
Supporters of public services must never fall into the trap of defending inefficiency or opposing changes that genuinely improve public services.However, attempts to measure public sector efficiency are almost always deeply flawed and narrow. Efficiency is simply a measure of outputs against inputs
The problem is that the public sector does not lend itself to such crude measures. If you double class sizes and exam results only decline by a third, then that class has become more efficient. Yet the education system is worse as a result.Again, it’s back to the duty to preserve the universal, to maintain the system that marks out the public sector.Quite different to the private sector where the system (including the market itself) is something to be gamed/exploited/subverted wherever possible.
In too much discussion of the public sector, including amongst policy-makers themselves, productivity and effectiveness are often wrongly used as if they are interchangeable. But effectiveness is actually a very different measure – defined as the ratio of the outcomes which an organisation aims to achieve, divided by the total inputs. Thus, effectiveness in the public sector is a much more complex concept and is far more subject to measurement error and to influences from outside developments. Outcomes are far more elusive and trickier than outputs, more changeable, and conditional upon social & political vagaries and many,many other externalities.
Those of us who argue for a public realm say that some activities simply do not lend themselves to private sector/market solutions, just as most of us accept the converse – that some activities should not be done by the state.One clue for where the boundary should lie comes from asking whether for any activities simple productivity measures make any sense.
Consider a hospital that halves the numbers of doctors but whose death rate less than doubles: in productivity terms that’s an improvement, but in outcome terms it’s a deterioration. Talking plain productivity, it could also be raised by not treating all-comers, and filtering out those with chronic complaints,complex,costly and time-consuming cases, etc (to a great extent, that is what cherry-picking private providers actually do). Outcomes not outputs are what counts in public services:people often cry out for police to be visible on the streets, but that’s not actually terribly productive in terms of hard outputs. It is valuable though in respect of outcomes: greater trust from, and links with the community, plus of course the gathering of useful ‘background’ information, which helps give a feel for things.
All of the private health providers I know of who have publicly-funded contracts have wriggled and wriggled like hell to escape that, either never taking on, or not handling (ie blanket referring onwards to others) the awkward,costly,non-straightforward cases.See where you get trying to make a hard econometric case: look at the shitstorm NICE finds itself in every few months.Private postal services won’t deliver to the outer Hebrides without an outrageously large supplement (and in the end delivery gets sub-contracted two or three times).Universality, in terms of whole population and whole of the nation (geographically) service is really rather alien to the private sector (bar the odd element tightly regulated and which was gifted state infrastructure via privatisation). Like it or not, there is considerable public and political attachment to the nation-state, and the concomitant demands of universality and equity, demands with which the private sector is uncomfortable and unacquainted, and for which a bounty is demanded, way more costly than state provision (cf ISTCs).
I do not believe that all public services are sainted. They are not, and many areas can and should be improved.The private sector can do stuff around the margins if the evidence is there regarding the outcomes they can deliver, but cherry-picking by privateers must be avoided,as must a race to the bottom in marketised services.

26. Planeshift

“you miss the point.”

No I understand it perfectly. You’re the one missing the point everyopne has made. Your private insurer charges you less because it has come to a price based on your own personal risk – which as a wealthy city boy who plays/played rugby is going to be low. The NHS has to cover the risk of everyone. If your private insurer was forced to cover people who were higher risks, not to mention pay infrastructure costs, the average premium would rise.

“I never had private treatment in an NHS hospital. Always private hospitals or surgerys.”

And this is exactly where your arrogance and stupidity lets you down – you assume your own experience is typical. Many people reading this have themselves, or know people who have, had treatment privately. My fiancee’s mother as an example. In their cases private treatment basically meant jumping the list and getting their own room with a nice TV. Same surgeon though.

“My knee was done privately by the chap who does England Rugby. On the NHS it was done by a newly qualified surgeon”

Again, utter stupidity. The guy who does england rugby is somebody at the top of his job. Hence probably has high wages, and does exclusively private work. The NHS couldn’t afford him (and if it did, the taxpayers alliance would get hysterical over his pay). The newly qualified one simply didn’t have the experience to command such fees. Hence obvviously you get a better outcome if you pay, private insurers simply can’t offer a worse service. The NHS is the baseline.

23
You also need to factor in the cost of education and training because whether or not individual doctors decide to work for the NHS and.or do private work, or simply set-up in non NHS areas, the taxpayer will have forked out for the training. Perhaps it might be fairer to charge those practioners who work privately for the the cost of their education.

28. Planeshift

“.and then answer why we spend so much on the NHS that we could pay for medical insurance for everyone in the country for the same money or less?”

If you forced private insurance to do all the work of the NHS then it would charge more. The reason you get cheaper premiums is because it doesn’t have to.

It is clearly wrong to suggest that healthcare spend would be lower under an insurance based system. (Sorry Tyler.)

Spend is on average somewhat higher in Europe under such systems.
And with ageing pops. etc. spend will have to rise further both here and there.

The issue is indeed *outcomes* which are unequivocally better in Europe.

The UK left appears to argue that all you have to do is increase spending without changing the structure. Well we tried that. Did we get a proportionate return? No.

Trouble is given NHS (envy of the world – except the world has chosen to do something else) fetishism and politicians’ cowardice in the face of same, we can’t get there from here. Except in dribs and drabs and by stealth.

#9

Why is it important that hospitals, health care, are publicly run, publicly owned?

I get why financed, no problem with that. But why ownership and management? Just about no one else does it this way so could we have some explanation as to why this is necessary?

Unlike many, I will not point towards the private hospitals in the US, instead I will point towards the nonprofit “social enterprise” hospitals in the US. You may be surprised to hear that half of all US hospitals are “social enterprises”. The problem is that they are not accountable (I note that you missed that clause off your quote). Since there is no public accountability and no shareholder accountability their executive boards pay themselves million dollar salaries, far more than equivalent NHS hospitals. Remember, this is the model that Lansley wants. The US situation is odd because of the cartel behaviour of the insurance companies and providers, but it is telling that the US “social enterprise” hospitals are much more expensive than the private hospitals: they charge more because they can. remember that this is the model that Lansley wants.

Public accountability is the unique aspect of the NHS. A “social enterprise” hospital is not accountable to the public, and a private hospital is market driven, hence there is no public accountability. So a “social enterprise” hospital can close down a service and there is nothing that local people or politicians can do. A private hospital can also close a service. An NHS hospital cannot because since it is publicly owned.

You may not care about that, but a lot of people do. At this point I should point you to Richard Taylor who was elected an independent MP because of his opposition to a local hospital re-configuration. That is localism: local people voting to say that they wanted their hospital left alone. You lose that when a hospital is taken out of public ownership.

@17. Cherub

The biggest problem Labour will have is, as in other areas, to convince the public that they would be better than the Tories. It was plain before the election that Labour were going down the privatisation route so, with simple promises from Cameron, the NHS was no longer apparently a significant issue.

Talking to people there seems to be a general feeling that Labour will not fulfil its promises and will follow Tory policies, perhaps slightly watered down. They have to prove that this is no longer the case.

Indeed. This is why I say that if Ed Miliband gave the simple statement above he would show that Labour was different to the Tories and would get the national debate going.

It is pathetic, when there are large numbers of people in the NHS, economists and policy makers, saying that Lansley’s plans are not only unachievable, but will be extremely damaging, the labour party are almost completely mute on the subject.

32. Chaise Guevara

@ 22 cjcjc

“I mean you would not suggest that a nationalised food monopoly would provide either cheaper prices or better quality, would you?”

Cheaper, maybe. Better quality, no.

But you’re still missing the problem that, unless very, very carefully managed, private firms would be a lot happier to let people slip through the cracks than the NHS. And even if the required management could be pulled off, the firms would blame their every failing on “bureaucratic meddling”.

@30 thanks for pointing out some of the problems in the US

Does those problems occur in Europe?

Does? Do…

@32 – same question. Does that problem occur in Europe?

As all are insured, I assume not?

@24. Tyler

If you had the choice, and the money wasn’t an issue, would you rather have private medical insurance or rely purely on the NHS?

Let me answer that with a question:

Where are the most skilled people, where is the research and the new innovations being developed, in NHS hospitals or in private hospitals?

If you were to have a major organ transplant, or treatment for a rare cancer, where would you have that? If you say “private” then you are just saying that you want the hotel services of the hospital, since the experts will have been trained and obtained their expertise in the NHS. (Oh, and by the way, that’s another thing the private sector do not do – training. It currently costs the NHS £5bn a year.)

.and then answer why we spend so much on the NHS that we could pay for medical insurance for everyone in the country for the same money or less?

Not true. Your figures have already been discounted as nonsense.

1) you do not get A&E
2) your insurance won’t cover chronic conditions, and once you get one of those you will either be dropped or your contributions will skyrocket

The £1800 or so per person is a risk pooling against the situation when you will need care for a chronic condition. I am surprised that you do not understand how social insurance works.

Another question.

In what meaningful sense (other then resorting to litigation!) is the NHS accountable to its patients now?

@ Planeshift

“Your private insurer charges you less because it has come to a price based on your own personal risk”

You’d think so, wouldn’t you, except I’ve been in an out of hospital with various injuries and illnesses. One op I had cost over 10k. Yet my insurance premiums have barely moved….?

((worked it out as 4% increase a year, less in fact than NHS inflation, and that includes the increase in premiums for my many claims. Competing insurance companies reduces costs…))

((I’ve got enough metal in my body now to set of some airport scanners…..it’s quite embarrassing, let me tell you))

And don’t get me wrong, but I’d have been perfectly happy with having my surgery done in an NHS hospital if it meant jumping the queue – as I say, I waited 18 months for one op on the NHS. Jumping the queue for me WOULD have been a better outcome, even if it was the same junior surgeon.

That I got to the have the operation from a leading surgeon, at a time of my choosing in a more pleasant environment (ever spent any time in NHS wards? It’s no fun) through insurance which costs less than the annual per head cost of the NHS.

And again, you’ve ignored the competing factor the though the NHS might have to pick up the tab for poorer people who can often have more health problems, I included the whole UK population for the cost of the NHS when millions don’t use it at all. I’d guess it cancels out to a great extent, and certianly wouldn’t account for the whole difference in cost.

@33. cjcjc

@30 thanks for pointing out some of the problems in the US

Does those problems occur in Europe?

I honestly don’t know because I’ve not looked into it. The pay of the executive boards of nonprofit hospitals is a hot topic in the US at the moment.

Note that not all European countries have a private system, but none have a system where the nation-state owns the main provider. In some countries (IIRC Poland and Sweden) public hospitals are owned by local authorities. Since this government is so keen on “localism” why didn’t they decide to go that route? Not only would it remove the responsibility of healthcare provision from the state (which is the main ideology in Lansley’s plans) but it would still provide local public accountability. I would think that the Lib Dems would rather like that idea too.

“In some countries (IIRC Poland and Sweden) public hospitals are owned by local authorities.”

Indeed: and in others there are mixes of such, plus not for profit private (often church run) and for profit private.

I have much less of a problem with public ownership with competition than I do with any form of ownership and monopoly ownership. Even if it’s just local authorities competing with each other.

It’s this capitalism and markets thing. If I have to choose between the two then I’ll take markets please and capitalism can go hang.

41. Chaise Guevara

@ 35 cjcjc

“Does that problem occur in Europe?”

I’m not particularly knowledgable about the intricacies of European healthcare systems, although I assume the answer would differ by country. I’m told by personal, anecdotal account that France’s system works better than ours, though.

@ 36 Richard

In the UK innovation comes mostly out of teaching hospitals. IN the US and Germany, private hospitals. A complex of the system. Its not an argument for the NHS, or against.

Same story for teaching.

I’d definitely have private treatment over NHS for cancer and other serious conditions. The flexibility of when and where you can have your treatment IS massively important and you don’t get that on the NHS.

As I said, my UK med insurance did not cover A+E. It DID cover chronic conditions as long as they were diagnosed after starting the insurance cover.
A+E is also effectively a monopoly in the UK – private companies can’t undertake it easily. The comparison isn’t 10% fair. MY UK health insurance was 70% of the rough cost per head of the NHS. As I say above though, a lot of other costs were paid for by my insurance which the NHS wouldn’t pay for.

My South African health insurance covers all my UK one did (and more), and also A+E services. It is still much cheaper than NHS care. South Africa is actually going towards a public insurance scheme, after rejecting after research an NHS type system.

@37. cjcjc

In what meaningful sense (other then resorting to litigation!) is the NHS accountable to its patients now?

Do you want a list of organisations? PALS and LINks are two, and there is the local authority health scrutiny committee (local councillors). You also have a right to attend (and ask questions) at the board meetings of PCTs and NHS Trusts (hospital trusts). You do not have that right for Foundation Trusts, and there will be no such right with GP commissioning consortia. (In fact, there will be no statutory duty for public accountability.) All NHS institutions are subject to Freedom of Information requests, but private and “social enterprise” providers are not. I don’t know if GP consortia will be subject to FoI.

But ultimately your MP is your main source of accountability. The Secretary of State answers health questions once a month and the Prime Minister is often asked questions about hospitals in PMQs. Once a hospital is taken out of public ownership the SoS and the PM will no longer be responsible and so their only answer will be “nothing to do with me, go to a different hospital”. Under Lansley’s plans much of the work done by the Department of Health will be done by the new Quango the National Commissioning Board. This will be accountable to Parliament once a year.

Basically, you have many avenues to hold the NHS to account now, you’ll have far fewer under Lansley’s plans.

#42

As I said, my UK med insurance did not cover A+E. It DID cover chronic conditions as long as they were diagnosed after starting the insurance cover.

Right. So that is why the insurance is not more. The NHS pays for chronic conditions whether they are new or existing conditions. I would also point out that many private insurers drop people after they get expensive conditions.

(This is anecdotal, sorry) I had a friend who was diagnosed with cancer in the 80s and because the waiting list was so long he used the private health insurance he got through his employer. He saw the same doctor he would have on the NHS, just earlier. He also used NHS facilities (at that time the private sector could not afford MRI machines, the NHS could and the private hospitals bought time off the NHS). The only difference was that he was treated in a comfortable, carpeted hospital out in the country, rather than the lino-floored crumbling Victorian NHS hospital in the city. After a year of treatment and a couple of years of remission the cancer returned and the insurance company refused to pay. He was back to the lino-floored crumbling Victorian NHS hospital in the city, with the same doctor and the waiting list.

My South African health insurance covers all my UK one did (and more), and also A+E services. It is still much cheaper than NHS care. South Africa is actually going towards a public insurance scheme, after rejecting after research an NHS type system.

I know nothing about the SA system.

“Just as a question to everyone;

If you had the choice, and the money wasn’t an issue, would you rather have private medical insurance or rely purely on the NHS?

Be honest now…..”

NHS, no doubt. My mum is a nurse. As a newly qualified nurse in a private hospital, she was placed in charge of the night shift- something she was totally unprepared for. In one of the NHS Hospitals she has worked in, they ended up getting sent all the patients that the nearby private hospital had messed up.

CJ @ 33

while quality (under competition) should be higher.

Yes, that would explain why or current hospitals are gleaming sterile environments, unlike the pre-privatised cesspits of yesteryear.

Why do you assume that a private company would do anything better than a public body? Is this just more idealistic bollocks?

People who go into hospital are not ‘customers’ or ‘clients’, they are patients. They have things wrong with them, in some cases they have life threatening illnesses that they rather not have. How you can draw an analogy with say, treatment for cancer versus buying an HD TV is beyond a joke.

Let us imagine that we have an oncologist consulting a patient. The patient presents with the same symptoms irrespective of whether or not the doctor is answerable to a board of shareholders or not.

Are you trying seriously to suggest that an oncologist will give a more accurate diagnosis and/or prognosis if he is working for a private company? For Christ sake man, think about this for twenty seconds.

Tory voters should be stopped from using the NHS because they obviously hate it so much that they vote for rich brownshirts who want to destroy it.

I see the usual tory trolls are on here salivating at the chance to destroy it. All you morons who want an insurance system piss of and join the private insurance schemes now. Nothing stopping you. Oh and when you get sick with something that needs years of drugs and looking after don’t come back to the state system when your corporate masters have laughed your claim out of their office.

Tyler, if South Africa is so fucking good, why don’t you go and live there and keep your unwanted nose out of our business?

48 – He does live in South Africa I believe. And there’s not actually a rule that you can only comment on the domestic politics of the country you live in.

Are our current hospitals gleaming sterile enviroments?

Leaving the abusive tone aside, it might just be that we have something to learn from other countries, given that none has adopted our approach…and that, talking of oncology, cancer survival rates are far better in Europe?

It might just be worth at least having a look at how others do things, no?

51. Flowerpower

Sally @ 47

Tory voters should be stopped from using the NHS because they obviously hate it so much that they vote for rich brownshirts who want to destroy it.

One would hardly guess from your comments that it was the Conservative Party that is currently pledged to year-on-year increases in NHS spending, while Labour’s policy is to cut it.

Funny old world, innit?

That would be the same people who said they had no plans to put up VAT would it?

CJ @ 50

Irony doesn’t always come across on comments boards, sorry. The point I was using irony on here is the fact that since hospital cleaning was sold off, it has got ‘cheaper’*, but the cleaning itself has got worse. In fact, in some cases, we really do have cesspit hospitals and we now use the money ‘saved’ from the private cleaning firms and put that towards paying for deep cleaning. We cannot use the profits made from the private companies of course.

it might just be that we have something to learn from other countries

Yes, I agree, if want a system as good as Germany or France we need to spend the same amount in France or Germany. Nice to see we finaly agree on something, CJ.

*cheaper at source of course, the taxpayer has been forced to pickup the pieces in otherways, unemployment, tax credits etc.

Our grandparents fought and died in World war 2 to get the NHS and the welfare state, if we want to keep our rights, we must fight for them or lose them.
This bunch has no respect for the people who died for a better future back then and they have been waiting a long time to do this. People, stand up and be counted or you will be shafted by this government, and do it now!!

flowerpower @ 51

To be fair, the Tories lie about these type of things, though. Given they hate the NHS, they are lying about spending more money on it.

Not so funny ‘old World is it? In fact it is a familiar old World.

42
How does public health work in South Africa? Here the NHS is big on protection, who pays for vaccinations that not only protect me they protect the rest of the population from catching many serious diseases And what about emergency treatment, how does that fair?:
You still fail to address my comment at 27, your treatment received privately was still subsidized by the NHS and consequently the taxpayer.
When we analyse the so-called affectiveness of markets and private health-care in the UK we find that it isn’t quite what it appears.

54
This is a very good point, in fact when those such as cjcjcj contiue to ask why we only have the NHS model it’s because it was promised to those who fought in the war and their famelys, even Churchill (a supporter of the free-market) was in favour albeit not totally for altruistic reasons.

58. Chaise Guevara

There’s an argument that says something on the scale of the NHS would be very, very unlikely to be set up under any conditions other than the sort of mass rebuilding programme you got after WWII, especially if the country concerned already has a working UHC system in place, and that therefore it’s no surprise that it’s unique.

It is just mindless head in the sand to believe we have nothing to learn from other nations who get better outcomes. Personally, I don’t care who owns the buildings or runs services as long as it is free to all at the point of need and publicly funded. The notion that we are big health spenders vis-a-vis comparable nations is nonsense. We spend the OECD average.

http://pjep.org/uploads/resources/1262014762.jpeg

If the NHS is wasteful then the other nations who spend more must be even more wasteful. With an ageing society we really can’t afford to believe the NHS can’t be improved. So, retain the principle and learn ways to improve it from other nations is eminently sensible.

Comparing NHS costs with the private sector in the UK is obviously a load of rubbish. The private sector is not bearing the human capital costs of training. Where the NHS trains nurses, doctors, consultants etc they are bearing the costs. The private sector benefits from that state spending but does not carry the training costs. What would be the costs in the private sector if they had to pay for the costs of training school leavers right through to them becoming a consultant?

60. Chaise Guevara

From my POV, the NHS obviously throws up problems and the occasional horror story (it’s too big not to), but it’s generally pretty great as long as it isn’t squeezed too tight by politicians of any creed, or otherwise messed around with unwisely.

61. Luis Enrique

Our grandparents fought and died in World war 2 to get the NHS and the welfare state

I must be reading the wrong history books

62. Chaise Guevara

@ 61

LOL!

In any case “people fought in the war for…” is not a justification for anything in itself, so the point’s moot.

61
Don’t know which history books you read but @54 does have a good point although WW2 wasn’t fought to acquire the welfare state. The whole post-war settlement was sold as ‘providing a country fit for heroes’ but it had several purposes, not least to ensure fit young men to fight what was seen as the next threat (USSR) It was reported that Churchill was terrified of a revolution after Russia but in particular he believed that the conditions of the UK after WW1 would not be tolerated after WW2,

@59: “It is just mindless head in the sand to believe we have nothing to learn from other nations who get better outcomes.”

The healthcare system in France is generally well-rated in independent international assessments. Readers may be interested to see this introduction, from French sources, to the financing of healthcare services in France where the services are not, in general, “free at the point of delivery”.

However, patients can recover most or all the costs incurred for treatments depending on the extent of their additional cover from complementary or occupational insurance to top-up the basic cover provided by the state scheme.
http://www.frenchentree.com/fe-health/DisplayArticle.asp?ID=197

Healthcare in the Netherlands is another highly rated system in international assessments and this is a Dutch brief on its functioning in the Amsterdam area:
http://www.amsterdamtips.com/tips/healthcare-netherlands.php

Briefs on a selection of national healthcare systems from the Civitas think-tank can be found here:
http://www.civitas.org.uk/nhs/health_systems.php

65. alienfromzog

Just as a question to everyone;

If you had the choice, and the money wasn’t an issue, would you rather have private medical insurance or rely purely on the NHS?

Be honest now…..

….and then answer why we spend so much on the NHS that we could pay for medical insurance for everyone in the country for the same money or less?

Seriously, An NHS hospital every single time.

Oh, and I’m a doctor.

If you ask surgeons and anaesthetists, (as I often do) the majority (~80-90%) in my straw poll will tell you the same.

Now, admittedly it’s not science, it’s just me asking people I work with but the reasoning is very informative.

If you have an operation in a private hospital, you will get a lovely room with the door closed and the nurse might not notice if you are ill. The doctor on site will be an RMO who may or may not know anything about the speciality. And if you are properly sick, you will be transferred to an NHS hospital.

Some of my colleagues will tell you that their choice depends on the operation in question – they would go private for a minor operations for the nicer environment but for anything serious they want to be where the specialist care is available if anything goes wrong.

That tells me that the NHS needs to improve the quality of its accommodation and food. Not the medical care.

So, let’s just address some of the nonsense posted above.

1. Free market economics do not work in healthcare – as ANY economist can tell you. The basic supply/demand balance falls apart. Not to mention specific issues such as supply-induced demand and moral hazard. Furthermore, the idea that competition drives up standards is somewhat flawed because it assumes various things such as 1) standards are immediately obvious to ‘consumers’ – which they aren’t 2) the inefficiency of duplication of resources is more than balanced out by the benefits of efficiency from competition – something that does not actually work in healthcare. Can we please move beyond the ridiculous myth that the market is the answer to every question. It’s not. There are some things that are done much better in other ways.

2. As mentioned above, avoiding the profit motive has significant advantages in terms of promoting health rather than having a ‘disease-industry’ as it was so eloquently described above.

3. The idea that the NHS is not accountable is absolutely laughable. Come and follow me around for a day or two and I’ll show you. In fact, much of the bureaucracy that is the so-called inefficiency problem is due to the way in which we are accountable. (And there are some areas here where reform would be useful, but that’s a different debate.)

4. As has been alluded to above, private healthcare providers in this country cherry-pick services and this is how they keep costs down and appear (YES APPEAR) to be more efficient. There are countless examples of this but here’s a simple one:

Many straight-forward hernia operations are now done in the private sector. This means that a lot less are being done in the NHS. This is a problem for surgical training. It is a really good operation to learn skills on. Surgical training is an apprenticeship – there is no other way to learn than by doing. In the NHS, a hernia repair will often be done by a trainee under supervision. Now I’m quite good at it but compared to some of my bosses I’m still slow – it might take be 40 minutes to do a straight-forward one (total operating time) which my boss could do in 25 minutes. So in the private sector one surgeon will do 4-5 cases in an operating list, whilst in the NHS, 2 surgeons (me plus consultant) will do 3-4 cases.

So which is prima facie more efficient? But how the hell did those surgeons get trained in the first place? Not to mention that anything more than a simple case will get bumped back to the local NHS hospital anyway.

5.The comparisons with other developed countries are dangerously simplistic. It’s important to note, that prior to 2000, the UK’s spending on healthcare was well below the European average. It takes time for the effects of changes to filter through. This is one of my greatest fears about these reforms: by the time people finally realise just how bad they are, it will be too late to fix it.

Just a quick example: It is often quoted that the UK has worse cancer outcomes than most of Europe and therefore, the argument goes, the NHS must be rubbish and we should do something different.

There was a very good article in the BMJ last year explaining why taking the cancer survival figures at face value was very misleading. (Happy to provide reference is wanted). Put simply, the way each country collects data is very different. Because the UK’s national databases are more robust than other countries systems, it produces a skewing of the data suggesting that the UK has worse outcomes than it actually does relative to other countries. Interestingly, over the past decade no other country has had a bigger improvement in cancer outcomes than the UK. (In this countries are more comparable because this analysis is produced by comparing each country to itself year-on-year).
This explains part of the difference.

Another factor is that multiple papers have shown that UK patients present later than our European neighbours. This is important as the correlation between late presentation and poorer outcomes is extremely well established.

Now, this is just one example, and there are lots. The argument that the NHS is worse, is significantly flawed. Now, I’m no expert but… Hang on a second, I am an expert and if you want to argue that the NHS should be reformed because of its problems and issues that is an interesting and important debate. However if you want to argue that it needs reform on the basis of non-facts then the argument is both tedious and extremely annoying.

6. There is a documented problem with independent providers of over-treating. Doctors and hospitals who get paid more for doing more, tend to do more. Which is fine, but what if you didn’t actually need that operation and there was a better alternative. Even with the best will in the world, this happens.

Oh and 7. No country in the world – not even the USA has a truly freely competitive healthcare sector – because it just doesn’t work. If you look at the French and German systems, they are not free markets. There is a lot of government control.

AFZ

P.S. My sincere apologies for the ridiculous length of this post.

The right wing were shocked after the 2nd world war at how many people rejected Churchill, so quickly. But many returning soldiers were just as shocked when they went through places like Holland, and France to find living conditions for working folk far better than anything they had got back at home.

They did not fight the war for the NHS but after the war they wanted a better life than the tory brownshirts were offering. The problem for the NHS is that it has been too successful, and far too many people don’t understand how lucky they have been. Ignore the trolls they are just cannon fodder for their corporate masters.

The threat is though, once the NHS loses a critical mass of infrastructure and I mean right down to say, beds and x ray machines, then the private sector retains the whip hand. What is to stop a hospital holdings firm taking a few million quid a year out of the NHS budget, then announce it will no longer seek to tender for the NHS contract and move entirely into the private sector? The NHS would simply cease to exist via default as it would be little more than various plaques on various walls. There is little point in the NHS existing if it cannot carry out an operation. Once the NHS buildings go, the concept will surely follow.

I do not trust the Tories, the Lib Dems or factions within the Labour Party with the fate of the NHS. These groups have, quite successfully, chipped away at the post war settlement. The welfare State is on its last legs and the Tories are after the last to monoliths of the enlightenment; explicitly in the case of the BBC and perhaps more implicit at the NHS. The destruction of either would be a huge prize for Cameron and Clegg, to be fair the BBC seem intent on committing Hari Kiri at this very moment, but surely there are boxes of fireworks retained in Milbank square for when they bring down the last bastion of Socialism.

It is possible to see private health care as a form of eugenics, especially when good health care is so expensive. In this age, we need to provide state funded health care to level the playing field but we must also deal with those in the system who exploit it, as one says above, doctors and nurses trained by the state go on to pay themselves out of the pockets of paying sick trying to jump queues. I can get treated net week if i can pay, or next year maybe if i can’t, by the same doctor!
We already yhave a 2 tier system by that truth.
We need to incentivise the people who work in health care and be able to sack the dead wood when they fail or go corrupt. We need to force private work to go through the same waiting lists as the public NHS do and we need to make sure that private conveys NO advantage!
If we do these things, we can eliminate the private system from the NHS and relegate it to faciulities funded entirely by those doctors andf nurses who want to provide private advantage. If wwe do these things, we can go a long way to repaiiring the NHS.
The other thing to tackle is the cost of drugs, and start using generics more and also, start researching unprofitable but promising therapies like LDN and the many others that get ignored by the pharma industry because they undermine profit.
There are many promising things out there, often natural substances that are just unpatentable. Also, we need to listen more to patients who in the internet age can become very well informed experts on their conditions (I have MS) but who equally can become very misinformed if they lack research skills. However, they make choices base3d on thius information and only if we do the research can we prove or disprove these choices – ie homeopathy – just do the trials and you will demonstrate if it is a placebo. And LDN, which is used by thousands, but needs a prescription from doctors who are terrified to give one in case they get sued until the research gets done – except it won’t get done when it is only patients who want it.
There is a lot that can be done to make the public NHS work as it is supposed too, and it see4ms to me that it is the influence of private healthcare and drug money that is doing most to drag it down – plus of course the tories.

@65
Thankyou for this post.
Health is a human right but rights are lost if people don’t fight for them.
The labour party should recreate the NHS as it was intended to be even if this lot tear it down. It is not true to say that anything this lot do is irreversible, if we have the will, we can!
Pleae people, don’t let these pirates destroy the greatest thing ever done by a government in the history of the human race.

“Free market economics do not work in healthcare”

Bollocks. Entire and total bollocks.

I’ll agree with you that entirely, no government involvement at all, leads to a socially undesirable outcome when applied to health care. But then I would agree with you that that stricture applies to food as well (and when we do see people who cannot afford food we don’t create a National Food Service, we give them money to go and buy at Tescos, don’t we?).

Market economics works just fine in health care just as it does in food. The failures of both are an argument for government, tax, financing for some or all, but not of a rejection of market economics altogether.

“Not to mention specific issues such as supply-induced demand and moral hazard. ”

Oh dearie me, you may be a doctor but as an economist you’re a great doctor. “Supply induced demand”? That’s like the existence of sex change operations on the NHS, at zero financial cost to the requestor, leads to more sex change operations is it?

Or did you have some other idea of supply induced demand in your mind?

Or “moral hazard”? Moral hazard is when we don’t have to, personal;ly, pay the costs of our own actions. Like, you know bankers betting all and getting bailed out when they fuck up. Or, of course the existence of the NHS paying to treat our liver and lung cancers when we overdo the boozen’tabs?

Seriously, you want to use moral hazard as a defence of the NHS when the NHS its very self is a cause of moral hazard?

“Furthermore, the idea that competition drives up standards is somewhat flawed”

And now you’re starting to drivel. For the argument isn’t that competition drives up standards. It’s that it drives up productivity.

We know very well, the Soviet Union showed us that (and I can, if you wish, use wonderfully lefty economists like Paul Krugman (Nobel Laureate) to prove this point) planned systems, centralised systems, cannot improve productivity, total factor productivity (TFP), in the same way that market, competition based, systems can.

In the 20th century, the Soviet Union managed growth of nothing in TFP. 80% of the “western” world’s growth in wealth came from growth in TFP.

And as Paul Krugman loves to point out, productivity isn’t everything: but in the long run it’s almost everything.

We needs markets in the NHS, just like we need markets in all these things except those very few where we really don’t want them at all: in order to increase productivity.

“Health is a human right”

Drivel.

Are my human rights being violated because one of me knees is a bit dodgy? Are the human rights of that woman over there being violated because she’s got cerebral palsy?

We might have an interesting discussion over whether health care (to some level: is the denial of very expensive treatments by NICE a violation of human rights?) is a right, but health obviously and clearly is not.

“Bollocks. Entire and total bollocks.”

Oh excellent, a doctor vs Tim Rand who knows nothing about nothing, and who’s only claim to fame is that he regurgitates Adam Smith talking points.

@70
Very good, we are nothing like the soviet union.
What about those of us who rely on benefits due to our disabilities? We are condemned to a life of second rate care because popous asses like yourself don’t want to help your neighbours in an organised way. We are not denying capitalism at all, we are saying that we need state funded healthcare, state funded police, state funded armies.
Some things are better done collectively, and not left subject to economic whim.
We only have to look to the USA to see what hapens, a country where a third of the people have no healthcare and another third will only find out they are not covered by their insurance if they get ill.
Private health care only works for the wealthy and obviously you are bcause you seem to resent those of us who are not, well that sounds like eugenics again.
Let’s evict the private merchants from thye NHS, now!

“Health is a human right”

Drivel.”

Well it is drivel in the Rand world that you live in where the selfishness of the individual is all.

“Very good, we are nothing like the soviet union.”

No, we are not, but that is the same line they always spew out. Every right wing nonsense is always put up against a straw man.

@71, it is healthcare that is a human right, but rights must be fought for and defended, so if you want them, be prepared to fight for them.
Let Tim pay for his healthcare and leave us to fund ours by taxing him, but tax him do!

77. Charlieman

@66 Sally: “But many returning soldiers were just as shocked when they went through places like Holland, and France to find living conditions for working folk far better than anything they had got back at home.”

A remarkable statement, even for you, Sally. Thousands of people from occupied Europe were granted admission to the UK in 1945 for basic health treatment. There was little wrong with them apart from malnourishment, so they were given double rations and basic health care. All the same, some died.

Yeah, great living conditions in occupied Europe…

“we are saying that we need state funded healthcare”

Look up the thread a bit buddy. I’ve already said I’m just fine with state funded healthcare. I’m arguing only about the way in which the delivery of that is organised.

Through a government owned and run monopoly or through multiple suppliers competing to provide the best service possible for that some government funding?

“We are not denying capitalism at all, we are saying that we need state funded healthcare, state funded police, state funded armies.”

Look up thread again. I’ve already denied capitalism: I’m arguing for markets, not the absence of government funding of these things. And I’m one of those who has oft made the point that we don’t even want markets in police or armies….but we probably, in fact definitely do in health care.

“It is possible to see private health care as a form of eugenics, especially when good health care is so expensive.”

Unfortunately there is a lot of truth in that. The ultra, free market, Darwinian Rand model that is so attractive to many on the right. Where People are just units, to be used and then discarded. The death of most workers before retirement would be seen as excellent for the pressure it would take off the pension bill, and elderly care.

@78
it is good management that creates efficiency, not privatisation.
The biggest problem with the NHS has been tory fiddling, even when it is the labour party behaving like tories, private influence in healthcare has created a 2 tier system and that is where the waiting lists come from and hence much of the inneficciencies, caused by lack of resoiurces because the resources are too busy doing private work.
Private business can never be more cost effective because they have to make a profit, so if the two systems wok to the same efficiency, the private system must cost more – de facto.
We just need to make the public system as efficient as a private one and then we will reap the benefits in full, nhot encourage privatisation. They will do it on the cheap until they have eliminated the competition from the NHS, then they will raise their prices. If you don’t believe me, just look at what has happened to our railways.

77

Do some basic research troll. I have read letters, and have heard accounts that were sent back to wives and girlfriends from soldiers in Holland, Belgium. They could not believe that so many houses for the working class had inside toilets.

I know this does not fit with your troll central talking points, but then if you get your history from the Sun that is your problem.

@65 AFZ

Brilliant post. Facts from the front line.

@65:

I don’t have private medical insurance but many of my friends do. With ageing comes increasing reliance on healthcare services and my personal experience has led me to conclude that my friends were wise in their choices.

Btw I’m not in the least surprised that clinicians receive good treatment in NHS hospitals. It is naive to suppose otherwise. What concerns me, is what happens to the rest of us.

A brief summary of recent personal experience of NHS hospital services is: medicine/surgery usually good; quality of care uneven – after 7 days in an NHS hospital I was discharged to a private convalescence home – which I was paying for – with bed sores.

In talking with other patients, they seem to have reached similar assessments based on their experience. Several independently witnessed poor treatment of elderly patients and that accords with this recent study reported in the news:

In a recent study of the care of the elderly in NHS hospitals, only just over third were judged to have had good treatment:
http://www.bbc.co.uk/news/health-11728163

I’ve already posted in another thread reasons for describing NHS administration as completely shambolic.

Another classic personal experience was receiving a letter in August 2007 asking me to return to the Pathology Department at the local hospital so they could take more blood since insufficient was taken at my recent test. The “recent” test was, in fact, in April. It took the Pathology Department from April to August to discover that they had insufficient blood to conduct the requested tests. Fortunately, the tests weren’t critical.

The manifest failings of the NHS have been widely documented of late. Until the New Labour government increased the output of medical school graduates, Britain had one of the lowest ratios of qualified physicians per head of population in western Europe – France had almost twice as many. For many patients, this is the quality of NHS healthcare as reported:

“The Royal College of GPs (RCGP) is calling for appointments for standard patients to be increased from 10 to 15 minutes so doctors can spend more time with the growing number of people with long-term conditions such as diabetes, cancer and obesity.”
http://www.guardian.co.uk/society/2010/mar/23/gps-consultations-ill-patients

The predictable outcome of the 10 minute appointment regime is that GPs mostly just hand out pills.

“Britons are increasingly turning to prescription drugs to cure every ailment, a new study found. The average number of prescriptions dispensed per person rose from eight a year to more than 16 over the past two decades, according to the paper, titled A Pill for Every Ill.”
http://www.independent.co.uk/life-style/health-and-families/health-news/britain-turning-to-prescription-drugs-1930212.html

Btw again, as a retired member of the Government Economic Service, although not a health economist, I am not claiming tthat healthcare services can be left to free market forces. Healthcare services are widely regulated and publicly funded in many advanced, developed economies for reasons that have been extensively discussed in a substantial professional literature. Many other west European countries are rated in indendent assessments to have better healthcare services than we have in Britain. That seems to me a good reason for finding out why rather than trying to whitewash the NHS.

If the NHS survived Thatcher it can survive Cameron.

@65

Absolutely spot on.

@85: George W Potter: Absolutely spot on.

A dispassionate regard for the documented facts and the personal experince of patients shows that @65 is talking nonsense.

@86
We know there is much wrong, it’s what we plan to do to fix it that matters.

@87: “We know there is much wrong, it’s what we plan to do to fix it that matters.”

Which is why I posted links @64 to various briefs on the healthcare services in France, the Netherlands and other countries.

@88
Insurance is a poor solution which would just increase the costs to indic=viduals and disadvantage the poor – there is nothing wrong or unfair about paying for this with taxes.

“If the NHS survived Thatcher it can survive Cameron.”

But can it survive Cameron and Clegg?

Times have moved on from Thatcher. Many of the tory party is even more right wing than many mps in the 80’s. Also since the end of the cold war the international right wing corporations want the destruction of all social, and state run healthcare.

91. alienfromzog

“Free market economics do not work in healthcare”

Bollocks. Entire and total bollocks.

Ahhh, finally the debate is getting interesting.

I would not claim to be a health economist per se. But on the other hand I do know the basics. So, let’s look at your points;

1. Supplier-induced demand.
This is not an issues unique to healthcare economics. However it is a particular issue in healthcare consumers are not generally best placed to know what they want. If you get referred to a surgeon with a particular complaint, you may be offered a surgical treatment, regardless of whether there is a non-surgical option which is better. Patient do not choose healthcare. Patients see a doctor who diagnoses them and then offers a treatment.

2. Demand is not affected by price in the same way most commodities or services are. This is obvious when you think about it. I might not wish to pay £500 for TV, but might pay £200. Alternatively, if I am dying I don’t care whether the treatment costs £5000, I will scrape together all my savings to pay for it.

3. Your point about moral hazard is almost valid. It is indeed the case that the NHS’s Achilles Heal is moral hazard. However my point was a bit more subtle than that – if moral hazard exists in the system then it is not behaving like a free market.

Oh, and for extra points – if free markets are the way forward, why don’t we privatise the armed forces. Just think, whichever army brings back the most plunder can get the contract for next year. Similarly, whichever naval fleet manages to capture the most Spanish fishing vessels we win the tender for the next five years…

AFZ

92. Charlieman

@81 Sally: “Do some basic research troll.”

I scarcely need to do so. The house in which I live was built post-war on pre-war plans. It is a metroland type of semi, 1930s design with inside toilet and bathroom. It was built for private purchase, but similar features are found in council semis built here after 1930. Many of them are the same design.

And whilst having an inside loo might have been desirable in 1945, a greater percentage of the population had a living diet in the UK than in occupied Europe.

@91
I can tell you are not sick. I am.
I never allow doctors to tell me what to take, I do my own research and choose, but I do listen to my doctors and I do disagree if they are wrong, but then I am also well educated and good at research.
Also, I do care if the treatment cots £5000 because that makes it out of my reach, because I depenjd on benefits to live.
While I agree with yoru earlier post, this one is the voice of someone who doesn’t really understand the mind of a sick person. I don’t blame you for that, you are trying to help us, but your kind do need to understand that patients do make choices and maust be given the information needed to make their choices by your kind.
Ohly when we indicate we want you to take control shopuld you, or also when we are incapable of making that indication.
Just a poiunt of order there

For information:

The latest official data I can find on Health expenditure as a share of GDP in OECD countries is for 2008:
http://www.oecd.org/dataoecd/45/55/38979836.pdf

The UK comes close to the average for OECD countries.

Note this recent report of the National Audit Office:

“Hospital productivity has fallen over the last ten years. There have been significant increases in funding and hospitals have used this to deliver against national priorities, but they need to provide more leadership, management and clinical engagement to optimise the use of additional resources and deliver value for money.”
http://www.nao.org.uk/publications/1011/nhs_hospital_productivity.aspx

As for relative pay of healthcare professionals, we have this from the Office of National Statistics:

The full-time occupations with the highest earnings in 2010 were ‘Health professionals’ (median pay of full-time employees of £1,067 a week); followed by ‘Corporate managers’ (£757); and ‘Science and technology professionals’ (£704). The lowest paid of all full-time employees were those in ‘Sales occupations’, at £287 a week.
http://www.statistics.gov.uk/cci/nugget.asp?id=285

95. alienfromzog

@93

No, I totally agree with you.

There has been a big move in the last 10-20 years away from a paternalistic approach to medicine. Which is in general a good thing.

However, if you look at healthcare economics as a system, these things do apply. Your argument is an ethical rather than an economic one.

Similarly my point about a theoretical cost of £5000, is to do with how people in the whole population behave. The American system is a mostly free-market and hence costs are really high. Of course that puts healthcare costs beyond the means of many. That’s why it is so sick and wrong.

However, the cost being beyond some does not drive costs down in the way it might do with consumables.

AFZ

@91 AFZ: “…if free markets are the way forward, why don’t we privatise the armed forces.”

and Tim Worstall previously: “We needs markets… except those very few where we really don’t want them at all…”

Armies and police forces are examples of the state being permitted to conduct violence in defined circumstances. Not well defined enough, I agree. Armies and police forces are bodies that we sanction within limits and which require constant inspection.

Which is why we do not permit bouncers to impose asbos. It is why Tim W and AFZ might actually agree with one another…

Credit for starting a national welfare state must surely go to Count von Bismarck, first Chancellor of the German empire (1871-90), who launched not only state pensions for the aged but, in 1883, a social insurance scheme to cover personal healthcare costs:
http://en.wikipedia.org/wiki/Otto_von_Bismarck#Chancellor_of_the_German_Empire

Btw Bismarck was not renown for any “leftist” inclinations.

West European countries have generally adopted social insurance models for covering personal healthcare costs – the links @64 are the briefs on the systems in France and the Netherlands.

The unique aspect of Britain’s NHS is that it combines a social insurance system to cover most/many personal healthcare costs with a state-owned and controlled verging-on monopoly provider of healthcare services.

As a consequence, with 1.3 million employees, the NHS is famously the largest single employer in western Europe. With the exception of China’s People’s Liberation Army and Indian Railways, it has few international rivals for sheer size.

Other west European countries have not sought to emultate the NHS by attempting to create a state controlled monopoly supply of healthcare services.

Lets get back on track, what should Ed Miloiband do.
He should remind everyone that we fought for the NHS and we must do so again.
He should also abandon the new labour idea that it is good to involve private health care and to allow private health care people to exploit the NHS for profit.
He neds to get back to basics, tax people and use taxes for positive things like the NHS, not just the negative things like armies.
That is the whole point. The rich only make money when the poor work for them, and so they shoulod not resent their taxes, because all they do is to look after their money making machines/slaves properly, unless we restrict tax spending to armies and police and such, in which case we are not honouring the hard work the ordinary folk give to make the rich rich!

@86:

The looks like an excellent manifesto for entrenching the present failings of the NHS..

shall we just hold a wake

101. Chaise Guevara

@ 98

“He should also abandon the new labour idea that it is good to involve private health care and to allow private health care people to exploit the NHS for profit”

Hang about… what’s the problem with letting private insurers facilitate access to NHS resources that the patient was entitled to use as a UK citizen anyway, assuming that they don’t get to queue-jump?

as long as they don’t get to queue jump, no problem, but then, why bother paying insurance?

103. Chaise Guevara

@ 102

Secondary stuff like having a private room instead of being on a ward. Luxuries, in other words. Actually, I don’t mind people being able to queue-jump for minor treatments if it takes some financial pressure of the NHS… but not for anything potentially life-threatening, or that threatens your ability to work or seriously affects your quality of life.

104. Charlieman

@97 Bob B: “As a consequence, with 1.3 million employees, the NHS is famously the largest single employer in western Europe. With the exception of China’s People’s Liberation Army and Indian Railways, it has few international rivals for sheer size.”

Please don’t inflict such Daily Mailisms, Bob. Comparing the NHS with the Chinese army is misguided and unhelpful to serious debate.

The NHS is an umbrella organisation and, under so many reorganisations that I am unable to count, many care providers are funded by the NHS (through patient fees paid by the NHS) but are secondary providers. The receptionist at your GP is funded by the NHS but the pay cheque comes from the practice.

Reform of the NHS — who provides or manages it — will not make a huge difference to the numbers. A million odd people will be providing care, or providing services to them. If the reforms work, there might be slightly fewer admin people, but the NHS would remain a huge umbrella body.

@100: “shall we just hold a wake”

No – instead of swallowing the regular stream propaganda for the NHS we consider the evidence to assess why the healthcare systems of other west European countries tend to produce better healthcare outcomes for patients.

The argument that those other countries spend more as a percentage of GDP – in fact, not all do – doesn’t wash in the face of the ONS assessment that hospital productivity has been falling for the last ten years.

From many instances of personal experience, NHS administration is completely shambolic and wasteful.

“The NHS is wasting more than £1 billion of taxpayers’ money a year as managers spend vastly differing amounts on the same supplies, the head of a government-backed healthcare efficiency drive claimed today.”
http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-wasting-1-billion-a-year-on-supplies-2174875.html

So much for NHS brand consistency, professional cooperation between colleague, scale economies and NHS buying power,

To be honest, I think the queue jumping is offensive, if you want to jump, go to a private clinic, or wait like the rest of us, serious or not.

107. Chaise Guevara

@ 106

“To be honest, I think the queue jumping is offensive, if you want to jump, go to a private clinic, or wait like the rest of us, serious or not.”

Idealistically, I’m with you, but pragmatically I don’t think minor stuff is worth the argument. And I think queue-jumping for major stuff is appalling whether you use NHS resources or pay for all of it out of your back pocket. Being rich doesn’t mean your life is more valuable, as I’m sure you’d agree.

@105
it doesn’t help to compare differently processed statistics between different systems at all, we need to simply set our own goals and strive to achieve them.
Cost is not the most important issue, we just need accountability and to be honest we do have that. Just work to improve things and stop comparing our system with others, it is just propaganda unless you take measures of other systems using the same analysis techniques, and we don’t.
We must concentrate on rooting out waste and dealing with it, and then we will have a system that is working for best results, regardeless of comparisons. If people are not getting good care, then that must be addressed, and when they are, big it up.
It’s not rocket science to try the best we can.

@107
so what exactly is minor?

“To be honest, I think the queue jumping is offensive, if you want to jump, go to a private clinic, or wait like the rest of us, serious or not.”

Who is queue jumping?

Stroke and cardiac victims, for example, need to be assessed and treated with high priority to minimise the extent of brain damage or the likelihood of a repeat attack. It matters critically how soon after attacks alleviating drugs are administered. Much harm will be done to cardio-vascular patients by insisting on a strict queuing system.

The trouble with New Labour’s waiting list targets was that those encouraged hospitals to deal with easily treatable conditions first in order to cut waiting lists.

There’s a literature about the Soviet economy showing that the Soviets were well aware in the 1950s after Stalin’s death of how planning targets could distort economies. For understandable reasons, disucss of the problems tended to be more restricted while Stalin was alive. All that seems to have escaped the attention of Labour health ministers.

111. Charlieman

@105 Bob B: Quoting the Independent “The NHS is wasting more than £1 billion of taxpayers’ money a year as managers spend vastly differing amounts on the same supplies, the head of a government-backed healthcare efficiency drive claimed today.”

If every NHS Trust purchased from the same supplier, that’s a monopoly isn’t it? Would NHS Trusts be financially served by a monopoly?

Each Trust buys from the supplier who they believe will best serve their needs. Unless the buyer is crooked, which is not unknown in any industry. Some Trusts may put a high priority on cost; others may rate quality of service or reliability.

There will be waste and overcharging. There will also be cases of suppliers selling goods below cost to get a contract with hidden service charges.

The Independent story oversells itself.

@110
TRy getting a cortisone injection when you need on for arthritis, you will wait up to 2 years by the time consultation and scheduling has been processed. Unless you pay, then you can have it next week from the same doctor, That is a concrete example from a friend of mine, and that is how queue jumping works.

@111: “If every NHS Trust purchased from the same supplier, that’s a monopoly isn’t it? Would NHS Trusts be financially served by a monopoly?”

As I understand it, the point being made was that the NHS – even the same parts of the NHS – was purchasing identical equipment or supplies at very different prices. The implication was that procurement needs to be better managed and negotiated, not that the NHS should always buy from the same supplier.

“The Independent story oversells itself.”

There are many other sources for the same news report:

“Giving examples of the widely different amounts which NHS Trusts are paying for the same products, NHS SBS managing director John Neilson pointed to up to 19 different prices for the same pacemaker, and 22 different prices for a surgical tool. These inconsistencies range right across the NHS, from GP practices to Foundation Trusts, he added.”
http://www.pharmatimes.com/Article/11-01-06/NHS_procurement_waste_%E2%80%9Ccosts_%C2%A31_billion_a_year%E2%80%9D.aspx

114. Charlieman

@108 A Barnett: “Cost is not the most important issue, we just need accountability and to be honest we do have that. Just work to improve things and stop comparing our system with others, it is just propaganda unless you take measures of other systems using the same analysis techniques, and we don’t.”

Thanks for that.

If you ask anyone on the street about health services, the response will be contradictory: services should be attuned to local needs and they should be as good as anywhere else. Doctors in Dorset should be as good at treating lung diseases associated with mining as doctors in Derbyshire. Which is clearly nonsense.

The NHS covers all residing in the UK but experts are not spread across the country. On occasions the experts are in a different country. The NHS will treat you well, but sometimes you may have to move to get to the expert.

We should compare ourselves with other countries or regions; but only on a like for like basis.

@112: “TRy getting a cortisone injection when you need on for arthritis, you will wait up to 2 years by the time consultation and scheduling has been processed. Unless you pay, then you can have it next week from the same doctor, That is a concrete example from a friend of mine, and that is how queue jumping works.”

That happened last year to a friend of mine who does have private healthcare insurance. Eventually, the pain while waiting for an NHS cortisone injection became too much so she went for a private injection. What was the alternative?

But as I say, stroke and heart attack victims have to be treated with high priority if drug treatments are to be effective for the patient – and to reduce likely downstream costs for the NHS if initial treatment is delayed.

“Queue jumping” in healthcare is not a simple concept to haggle about.

116. Charlieman

@113 Bob B: “As I understand it, the point being made was that the NHS – even the same parts of the NHS – was purchasing identical equipment or supplies at very different prices.”

We don’t know all of the conditions of the contracts. The buyer may have knowingly purchased widget x at an inflated cost in a deal that allowed them to buy widget y very cheaply.

“The implication was that procurement needs to be better managed and negotiated, not that the NHS should always buy from the same supplier.”

Good management of purchasing contracts is a good thing. John Neilson, the manager quoted in your link comes across as an empire builder and an abuser of statistics. And the other story based on the same source is oversold.

The NHS financial crisis I outlined yesterday will be a terrible thing, but it could also be an opportunity for Labour.

this is a really sick statement. I really hope one day politics grows up and evolves beyond this mentality.

@116: Good management of purchasing contracts is a good thing. John Neilson, the manager quoted in your link comes across as an empire builder and an abuser of statistics. And the other story based on the same source is oversold.

By all means write to tell Mr Neilson of your considered assessment of his motives and competence.

As for me, since I’ve no direct personal experience of NHS procurement, I shall wait to see what critical comments about Mr Neilson’s assessment of NHS procurement practices are reported in the media.

There are many indications that the NHS does not function very efficiently as a joined-up organisation and we were sold the idea that NHS size gave it buying power so taxpayers get a better deal from procurement cost-savings.

A recent personal experience of poor internal communication within the NHS was receiving a letter in the post from NHS Choose & Book offering to book me an appointment to see a consultant at my local hospital which I had the day before.

I phoned Choose & Book to tell them – as I’d kept my special password without which they wouldn’t have talked to me. They were very surprised to learn that I had an appointment the previous day, which I had attended.

119. Charlieman

@118 Bob B: “There are many indications that the NHS does not function very efficiently as a joined-up organisation and we were sold the idea that NHS size gave it buying power so taxpayers get a better deal from procurement cost-savings.”

Newspaper headline prices do not tell us about the reality of spending.

At work the other week, I read a report from a UK consultancy informing me that my organisation owned PCs purchased from 33 companies. That is probably an underestimate. However under our purchasing contracts, 95% of new business goes to three companies and 85% goes to one of them.

It is true that we have 33 PC suppliers. Three suppliers who sell us stuff in volume. The other 30 are suppliers who sold us a PC years ago that is still in the asset inventory, or one that has been inherited. We also get PCs that are bundled with a boxed solution (eg a PC that is tuned to work with a set of lab equipment).

I never said there should not be state funded, free at the point of use healthcare. Nor did I say the NHS should be disbanded, or that many or most of the proffesionals in the NHS are anything but excellent.

However, it would be idiotic to suggest that the NHS is a perfect solution, or even a particlularly good one in many cases. Outcomes are often poor, it is incredibly expensive, very inefficient and productivity (see Bob B’s NAO links) is terrible.

You have to be pragmatic about things. In a large % of situations private medical is better at lower cost. Private healthcare can’t (partly through legislation) cover everything though. That shouldn’t stop the NHS adopting better practices and improving their productivity and delivery whilst lowering costs. A lot of the money funnelled into it in the last decade was simply wasted. Reform IS clearly a necessity.

To think otherwise is simply dogmatic – unfortunately I think *some* of the posters on here are just that, and no amount of argument or evidence will change their opinion. Until of course the NHS fails them…though I suppose that will jsut lead them back to default position no.1 – blame the Tories.

((BTW, to those who say that that money provided better facilites…..they are conveniently forgetting PFI, which keeps the massive cost of new hospitals off the governments books. Those improvements haven’t actually been paid for yet.))

BTW, think DaveBones point at 117 is a very good one.

Surely the discussion should be about how to improve healthcare in an economy which can’t afford increases in spending? As much as Sally would disagree, I doubt any Tory wants to deny free healthcare to the poor. There just has to be an element of realism in that we can’t afford everything we want, the NHS is very wasteful and is often not very good.

@80 “it is good management that creates efficiency, not privatisation.”

Yes, lovely. Now, try reading the economic literature on what leads to good management. It isn’t privatisation. Private monopolies can be just as bad as government ones.

It’s competition that does it. Which is why I am arguing for competition, not privatisation of course…

“Private business can never be more cost effective because they have to make a profit, so if the two systems wok to the same efficiency, the private system must cost more – de facto.”

The second part is true: but we find that over time profit seeking private businesses become more efficient, making their charges, even including profits, lower than organisations not in competition. Again, this is straight economics of the point. Not left, right, neo-liberal or anything, just basic normal economics.

Just as an example, in the last centry, the “market” economies improved total factor productiity by 1-2 % a year. The “planned” (ie, Soviet style no market planning) economies managed 0%. At 2%, because of compunding, this meant that the market economies were twice as efficient as the planned. And after 70 years, 4 times more efficient. Yes, some 25-35% of the market ecnoomies goes in profits to capital: but 35% of 4 times the efficiency is a lot cheaper than not having had the efficiency gains in the first place.

Do note what this “4 times” means. For the same inputs, the same hours of labour, tonnes of cement, joules of energy etc, we now get out 4 times as many useful goods and services. Increasing efficiency, incerasing productivity, doesn’t really matter much in one year to another. But over a generation it’s just about the only important economic thing.

“We just need to make the public system as efficient as a private one”

As I keep trying to point out to you: we don’t know any way of doing that. The only way to get planned systems to be as efficient as competitive ones is to have competition.

@ 91.

Nearly: what you’re doing though is using these words in a manner different from the standard (economic) manner. Supplier induced demand for example is that the supplier has this (treatment, car, geegaw) available and thus induces (through, say advertising) demand for it. There is nothing specific to government run or monopoly situations as opposde to market that makes this any more or less likely.

For example, a government department with a budget and a target for resetting racist attitudes is going to make damn sure it finds some people with racist attitudes whose attitudes it can claim to have reset. Whether or not the racism is of the confessing to rather liking the Robinson’s Golliwog or of firebombing the family round the corner of a slightly darker hue.

Suppplier induced demand isn’t specific to the private sector at all: vide all thos smoking cessation course on offer. This is what the NHS would like us to be consuming, not necessairly what we would like to be consuming. And there’s definitely a whiff of it in the constant battles between obstetrics and midwives over home births, each side arguing for their preferred solution, no?

As to demand not being affected by price in the same way as other commodities….that’s hardly an argument for entirely abolishing price, is it? Until very recently for example, if you were dying and there was an expensive treatment which you could (and as you say, people would spend their life savings on it) purchase but which NICE didn’t think was worth it then you weren’t allowed to spend your own money and get the treatment: and also the other NHS treatment which you had already paid for through your taxes.

This was on the grounds of “equity” I believe. You weren’t allowd to spend £20k on a course of Avastin because not everyone could. You should die so as to stop inequality. A puzzling attitude to me but that was the way the system was run.

As to the existence of moral hazard meaning that it’s not acting as a “free market”. Don’t get too hung up on that “free” part there. Once you get past the first few pages of the economics textbooks it is gently pointed out that the “free market” model is just that, a model. In the real world we have to talk about degrees of freedom, for a truly free market has never existed and never will. It’s simply an end analytical state: as is the entirely totalitarian government run society never happened. Never will, although we can talk about degrees. Pol Pot was clearly at one end of this spectrum (although some people still didn’t do as they were told) 19th century Britain was clearly much closer to the other end.

“Oh, and for extra points – if free markets are the way forward, why don’t we privatise the armed forces.”

Largely because we’ve had this system of competing private armies. We got the Wars of the Roses in return. Bad outcome, so we don’t do that.

Just about every health care system in the world other than the NHS has competition in it. Many such health care systems are regarded as being better than the NHS: so we don’t in fact face a Wars of the Roses outcome.

Finally, about not allowing profit in the NHS. You’re going to abolish GPs now are you?

They are all running private businesses for profit…..you did know that, didn’t you?

A Barnett: I know that we shouldn’t compare ourselves to others, but if you were to talk about “queues” and that kind of “queue jumping” in healthcare to people in France or Germany they wouldn’t know what you were talking about.

Do you not ever wonder why no other country follows our example?

Perhaps it’s British masochism.

A passing reflection on reports of a two years wait under the NHS for a cortisone injection for arthritis compared with near-on immediate treatment by going private to escape the pain:

That’s how markets work. Waiting lists can be nice little extra earners for some clinicians.

127. Luis Enrique

Price Competition to be reintroduced to the NHS

everybody worried about the NHS should read this:

http://cmpo.wordpress.com/2011/01/07/price-competition-to-be-reintroduced-in-the-nhs/

128. Anon E Mouse

Richard Blogger – It makes no difference what Labour should do or even what they will do.

As long as Ed Miliband leads Labour the party will not be elected to government.

Of course the opposition should oppose but needs to do it in a way where it will have an effect. With the current leader any effect will not be felt by the electorate. I was impressed with Milibands acceptance speech but outside of that love in, he has been shown to be dithering, weak and no match for Cameron.

Despite the ruthless streak he clearly has, it is an attribute not shared by the Labour Party and even though only 15% of the shadow cabinet actually voted for him he will lead Labour nowhere electorally.

No one listened about Gordon Brown, made excuse after excuse for him and eventually Labour got what it deserved. Same applies again.

129. alienfromzog

However, it would be idiotic to suggest that the NHS is a perfect solution, or even a particlularly good one in many cases. Outcomes are often poor, it is incredibly expensive, very inefficient and productivity (see Bob B’s NAO links) is terrible.

This is just ridiculous.
1. Outcomes are not often poor. There are sometimes poor but usually excellent. Please refer to my comments above about cancer outcomes.
2. The ONS assessment of productivity is very limited. There is a university of York study which is much more detailed (I’ll see if I can find the link). However it is not about me ignoring the evidence, it’s about the fact that I’ve actually read the evidence and understand its weaknesses.
3. If you’ve been involved with previous threads you will know that Bob B likes to extropolate from his personal experience and suggest this is evidence.
4. One recent international study (The Commonwealth Fund) said that the NHS was the most effecient system across the seven countries it looked at.
5. It is not expensive – compared to what other countries spend, the NHS is very cheap.

As to demand not being affected by price in the same way as other commodities….that’s hardly an argument for entirely abolishing price, is it? Until very recently for example, if you were dying and there was an expensive treatment which you could (and as you say, people would spend their life savings on it) purchase but which NICE didn’t think was worth it then you weren’t allowed to spend your own money and get the treatment: and also the other NHS treatment which you had already paid for through your taxes.

Feel free to lecture me on economics. I admit my knowledge is limited. But if you want to lecture me on NICE and policy you will just look like an idiot. There is a reason why NICE wouldn’t fund those drugs – primarily because they don’t work. [For a more detailed discussion, see here: http://tinyurl.com/3xqe4wg%5D If you are really arguing for increased productivity, then, you should be on the side of nice. Just to be clear, none of these treatments are life-saving. If they were, then they would easily pass NICE scrutiny. Seriously, do you really believe that competition would make these drugs cheaper? Or would demand from patients who don’t understand why these drugs are very unlikely to help them, continue to drive up prices (as in the US)?

AFZ

P.S. Next time I think I’ll talk about the effect of publishing Cardiac Surgeon’s mortality rates has had on patient care.

130. the a&e charge nurse

[126] “That’s how markets work. Waiting lists can be nice little extra earners for some clinicians” – healthy services driven by greed, sounds exciting?

Funnily enough Obama says “The greatest threat to America’s fiscal health is not Social Security, it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care”
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

McAllen (in Texas) is one of the most expensive health-care markets in the USA. In 2006, Medicare spent $15,000 dollars per enrollee here, almost twice the national average – WHY?

Atul Gwande (the doc who wrote the article) gave the McAllen doctors a scenario.
“A forty-year-old woman comes in with chest pain after a fight with her husband. An ECG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine – a problem, in the mind of Obama driven by the relationship between markets and health provision.

Lansley and his chums think a similar arrangement would be good for our health care – this is the real problem, not what Bismark did or didn’t do 100 years ago?

afz,

1. Outcomes are not often poor. There are sometimes poor but usually excellent. Please refer to my comments above about cancer outcomes.

Is sometimes poor and usually excellent really what we should be happy with? I would probably be content with always excellent myself, so any system not delivering that should surely be improved? And just throwing money at an existing system will by the law of diminishing returns not produce constant improvement.

2. The ONS assessment of productivity is very limited. There is a university of York study which is much more detailed (I’ll see if I can find the link). However it is not about me ignoring the evidence, it’s about the fact that I’ve actually read the evidence and understand its weaknesses.
4. One recent international study (The Commonwealth Fund) said that the NHS was the most effecient system across the seven countries it looked at.

Erm. I doubt you are really meaning these two to be read together? After all, if the ONS assessment is limited, what is a study of seven countries?

5. It is not expensive – compared to what other countries spend, the NHS is very cheap.

But the question is not what do other countries spend. It is whether we could get the same outcomes for less spend or better outcomes for the same spend – since no other country actually has a system like ours, and since no-one (outside of Tyler) is suggesting adopting another country’s systems, how does this point matter?

I understand very well what NICE does. It does not measure medical effectiveness, It does a cost benefit analysis of medical effectiveness against cost.

This is where QUALY comes in. Quality Adjusted Life Years. In slang, how many years of decent life do we get for how much money we’ve got to spend?

They won’t approve (except in very special circumstances) a treatment which costs more than £30k per QUALY.

So £60k for a cancer drug that prolongs life by 4 months fails. But then so does a drug or treatment that prolongs life for 10 years (within most people’s definition of “cured”) but costs £800,000.

I also understand why NICE exists and approve of it: yes, we have limited resources and they must be rationed. Which is what NICE does.

But don’t ever try and say that NICE refuses drugs because they “don’t work”. That’s not what they’re for at all. They’re there to decide what doesn’t work well enough for the taxpayer to pay for it.

Which leaves open entirely whether the individuals suffering the disease wish to pay for it themselves though, doesn’t it? And that decision will be different according to different peole. As a man with no children I might well decide to take out a reverse mortgage on my flat to have 6 months more of life. If I had a child that I wanted to leave in financial security I might not.

But that’s my decision, not some bureaucrats.

a&e,

Fair point, but surely the point here is that GPs will still be able to decide what treatment is appropriate (and have to account for it to government not the insurance company – which is useful, in that government has a duty to the whole population).

134. Planeshift

“As a man with no children I might well decide to take out a reverse mortgage on my flat to have 6 months more of life.”

In that situation though, you are also extremely vulnerable to be defrauded. There are more than enough examples of quacks and fraudsters picking on ill people who are vulnerable and taking their life savings for sugar pills.

Watchman, I don’t think AFZ is against any reform per se, but against the governments planned reforms which are going to do more harm than good to say the least. I’d rather have reforms driven by informed opinion and evidence ather than a bunch of people who read an economics textbook and think it provides the answer to everything.

I seem to be alone as the person who represents the majority who cannot queue jump even if we want to. My career was terminated by my MS so the costs are prohibitive. It is the queue jumping that causes the long queues as much as anything else so ending it is essential.
Also, if privatisation is so good at cutting costs, why are the railways in such a mess?
Actually, I was a business analyst (chartered) and I can tell you that private business is not guaranteed to cut costs at all, and often cost cuts are caused by cuts in services, designed to out compete others by undercutting. This would be devastating to the poor in a health service.
Health costs are hard to cut, because they are highly unpredictale on the demand side and very hard to match demand with supply. A business needs to be predictable to become efficient and health is not. This is why private health people concentrate on narrow areas of work, so they can have predictability. The moment the wider ystem goes private, it will be compromised or it will become very inefficient like the NHS is.
So, unless we have a level one size fits all playing field, we have winners and losers based on wealth, and we the poor will fight that fiercly. Eugenics is a crime.
If private health care is so efficient, why is it that in the USA they spend far more per head on health and leave a third of the population out in the cold and another third at risk of being unprotected by their insurance? We don’t want that here, so we need to stop this condem bunch before they destroy pubic health care completely.

Planeshift,

Watchman, I don’t think AFZ is against any reform per se, but against the governments planned reforms which are going to do more harm than good to say the least. I’d rather have reforms driven by informed opinion and evidence ather than a bunch of people who read an economics textbook and think it provides the answer to everything.

I’d suggest that the logic behind the reforms is as driven by informed opinion and evidence as the case against it – the opinion and evidence may be from different sources being the major difference.

@136
Informed by ideology is what is driving this, not informed by the wishes of us patients. We patients are split between thwe haves and have nots but the tories have wanted to undo the NHS since it was created.

@130: “Funnily enough Obama says ‘The greatest threat to America’s fiscal health is not Social Security, it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care.’”

Some confessed “liberals” in America have worried about the downsides of the legislative reforms of healthcare services in America where 46 million American previously had no insurance cover for personal healthcare costs and where unpaid medical bills were the largest single cause of personal bankruptcy.

The potential downside is reportedly already evident as an outcome of the usually automatic corporate insurance cover for employees of top corporations and for their families.

A corportae employee going to see a physician with some adverse symptioms will get routinely prescribed a host of diagnostic tests, regardless of cost, paid for out of the corporate insurance cover – not least to minimise prospects of downstream patient litigation for professional negligence claims.

The problem is recognised but I’m not clear that anyone – including the Obama administration – has a solution to this market driven phenpmenon which continually drives up healthcare costs.

139. alienfromzog

I understand very well what NICE does. It does not measure medical effectiveness, It does a cost benefit analysis of medical effectiveness against cost.

This is where QUALY comes in. Quality Adjusted Life Years. In slang, how many years of decent life do we get for how much money we’ve got to spend?

Ok, so you understand some of what NICE does. They do measure clinical effectiveness first and then look at cost-effectiveness if clinical effectiveness is demonstrated. They also produce guidelines which are very useful in clinical practise.
BTW, NICE are not just a bunch of bureaucrats. Any recommendation they produce is made by a panel of experts – many of them doctors, some of scientists who know the specialist evidence very well. In fact, virtually no-one on any of the panels could fairly be called a bureaucrat – unless you count the people who do the economic modelling which is always complex.

I’m glad we agree that markets do not belong in military planning. My point is I don’t think they belong in healthcare systems either. I think “War of the Roses” is a very apt description of the American healthcare ‘system.’

Is sometimes poor and usually excellent really what we should be happy with? I would probably be content with always excellent myself, so any system not delivering that should surely be improved? And just throwing money at an existing system will by the law of diminishing returns not produce constant improvement.

Who said I was happy with it? I do think there is room for improvement. The point is that the best way to improve the NHS is not to rip it up and start again. Moreover, whilst I am not content with the poor outcomes that do occur, however rare – that is a fact of life, whichever system you use.

There is indeed a law of diminishing returns but no one is this debate has called for more NHS funding – merely a plea not to cut current services.

AFZ

P.S. What Planeshift said. Oh and I’ll spare you the bit about Cardiac Surgeons for now…

@139
Once again, well said my friend.
I spent my professional life doing analysis of business models and designing new systems for them, and I know first hand that everywhere there are people, there is room for improvement. We just neede to send people like myself (before I got sick) in to do the analysis and make the recommendations and then impleme3nt the improvements, and keep doing it. That is what private business does when it needs to, and it’s not rocket science as they say.
But, to burn it all down (because it was a Labour invention) like this lot are doing is the most stupid and cynical piece of work since … well I don’t think there is one so stupid.
People like me with no resources, and we are the majority, will suffer under this new regime, we will be second class people in the health care world, being constantly sidelined as our own doctors postpone us to do private work – much like they already are – Ed Milliband, that was one of the worst things your party got it’s hands dirtied with!
Let’s just keep the NHS away from the Tories, they lie and then they try to kill it by making it more inefficient until the people turn on it when they need to be turning on the tories who started this new NHS under thatcher! It was she that started this rot, and now the NHS is rotten, it is easy to convince people that it needs changing.
Well, if I must spend money on my healthcare, Dignitas will get it.

Watchman @ 131

Is sometimes poor and usually excellent really what we should be happy with? I would probably be content with always excellent myself

Come on, be fair for a moment. What health care system, or any business model for that matter, is ‘always excellent’? I doubt you can name a single private company that deals with so many complex operations every week has a 100% excellent record. In fact, some of the most profitable and arguably the best companies in the World have spectacular failures. Think of all those mis-sold pensions, insurance products, failed companies, product recalls etc. Not too mention the vast number of malpractice suits in the USA over private medicine. Toyota and Nissan have been forced to recall thousands of cars last year, and Boeing had an engine blow up in mid air, are you suggesting that we scrap the car and engine industries have failed on that score?

142. alienfromzog

2. The ONS assessment of productivity is very limited. There is a university of York study which is much more detailed (I’ll see if I can find the link). However it is not about me ignoring the evidence, it’s about the fact that I’ve actually read the evidence and understand its weaknesses.
4. One recent international study (The Commonwealth Fund) said that the NHS was the most effecient system across the seven countries it looked at.

Erm. I doubt you are really meaning these two to be read together? After all, if the ONS assessment is limited, what is a study of seven countries?

Ok, so for anyone still holding on to the idea that productivity is bad in the NHS, here’s Richard Blogger’s very helpful explanation of Productivity in the NHS and the limitations of the NHS study:
http://liberalconspiracy.org/2010/11/29/does-the-british-media-hate-the-nhs/#comment-204554

It is a fair point that the Commonwealth Fund’s study of seven countries will have potential limitations. However, even if you accept that it’s a little bit beside the point. My argument is this; 1. The NHS is not the inefficient money-pit that it is being painted as, see above. 2. There is evidence that moves away from government ran healthcare will make things worse not better. Both of my references support this view.

There are some things (most industries) that are done best by free markets. There are some things that without doubt should have no market involvement at all – such as national defence. This is clearly a spectrum and my view is that healthcare clearly belongs on the ‘non-market’ end of the spectrum, maybe not quite as much as the military, but pretty close.

AFZ

As for what has happened to NHS productivity, complain to the National Audit Office about this statement:

“Hospital productivity has fallen over the last ten years. There have been significant increases in funding and hospitals have used this to deliver against national priorities, but they need to provide more leadership, management and clinical engagement to optimise the use of additional resources and deliver value for money.”
http://www.nao.org.uk/publications/1011/nhs_hospital_productivity.aspx

But let’s be clear, falling productivity isn’t the only criticism made of the NHS.

There are a host of other reasons: lower cancer survival rates compared with healthcare systems in other west European countries; often poor treatment of the elderly; the GP culture of a pill for every ill; the differentially high rate of diabetes-related amputations in Devon and Cornwall proving failings in NHS brand consistency and persistence of a treatment post-code lottery; shambolic NHS administration; the increase in treatment errors:

“At least 100 patients are dying or suffering serious harm each year after healthcare workers give them the wrong medication. The number of alerts relating to errors or ‘near-misses’ in the supply or prescription of medicines has more than doubled in two years, the National Patient Safety Agency said.

“More than 86,000 incidents regarding medication were reported in 2007, compared with 64,678 in 2006 and 36,335 in 2005. The figures, for England and Wales, show that in 96 per cent of cases the incidents caused ‘no or low harm’, but at least 100 were known to have resulted in serious harm or death.”
http://www.timesonline.co.uk/tol/life_and_style/health/article6820090.ece

“Accidents, errors and mishaps in hospital affect as many as one in 10 in-patients, claim researchers. The report in the journal Quality and Safety in Health Care said up to half of these were preventable.

“Checks on 1,000 cases in just one hospital found examples of fatal surgical errors, infections and drug complications.”
http://news.bbc.co.uk/1/hi/health/7116711.stm

BB

144. alienfromzog

Bob B,

Do you ever read anything that anybody other than you writes here?

If you scan up this comments section, you will find where I explain that the cancer survival rates comparison is significantly flawed and that the difference between Britain and other countries is likely to be significantly over-estimated.
[http://www.bmj.com/content/341/bmj.c4112.extract] (I apologise that the entire article is not freely available)

Furthermore than British people present late, hence the NHS would have to be over-performing relatively speaking in order to have the same survival rates.

When you quote the figures on medical errors, do you have any conception of how much activity there is in the NHS? Seriously. Do you expect a perfect healthcare system that never makes any errors? Or are you trying to argue that the NHS’s error rate is unacceptably high? Do you have any concept of how safety incidents are reported and investigated?

If you’re looking for a perfect system, you won’t find one. Anywhere in the world. If you’re trying to say the NHS is poor then you need some proper context to your claims about number of errors and problems.

But it does make a nice change from anecdote.

AFZ

For decades – to my personal knowledge – we have been treated to an endless stream of NHS propaganda about how the NHS is wonderful and “the envy of the world”.

Only since the WHO review of healthcare systems in 2000 have we taken much interest in healthcare systems in other west European countries. What has emerged from various independent international assessments is that the NHS rates as fairly mediocre by comparison to patient outcomes in those other countries.

Frankly, I’m amused now by NHS propagandists who persist with evidently increasing desperation in attempting to discredit the mounting criticisms of the NHS – whether from the National Audit Office, the Office of National Statistics, the report on care of the elderly or any number of other informed sources right down to my recent personal experience of shambolic NHS administration. All of them, we are repeatedly told, are mistaken, misguided, misinformed, wrong etc etc. All of them. The NHS is wonderful.

The NHS has been told to make £20 billion efficiency savings over the next four years. The original source of that goes back to this interview in the Financial Times in December 2009 when the New Labour government was still in power:

“The National Health Service can make the £15bn to £20bn of savings needed during the next three years without damaging the quantity or quality of care – indeed while even improving the latter – according to David Nicholson, the NHS chief executive.”
http://www.ft.com/cms/s/0/6fba7dfe-e683-11de-98b1-00144feab49a.html

At the time, the annual budget of the NHS was about £105 billions. I’ve already posted many times in previous NHS threads how extraordinary was a claim from the NHS’s chief executive that the NHS could make efficiency savings equivalent to almost 20 pc of its annual budget without affecting the quality of frontline patient care.

Whatever else, it’s manifestly clear that the chief executive of the NHS doesn’t have much of a regard for the way the NHS uses its financial resources. But what would he know?

146. alienfromzog

Frankly, I’m amused now by NHS propagandists who persist with evidently increasing desperation in attempting to discredit the mounting criticisms of the NHS

So, anyone who disagrees with you is a propagandist? Is it only you who know the truth? Intelligent, constructive, discussion of the complex issues around healthcare are ‘increasingly desperate defences?’ Right.

The thing is, I know healthcare. I know what I’m talking about and I actually want to be completely wrong about this. I want Lansley’s reforms not to be the disaster that they surely will be.

The Financial Times article is an interesting one. The shift from acute care to community care is indeed the way of the future in many ways. Shifting care to the community can be a way of both saving money and improving care.
The thing is, that this is nothing new, it is only the rate of change that is novel. Over the past 15 years there has been a massive shift away from hospital care. Many conditions that were previously cared for in hospital, no longer are or only part of the treatment is delivered in hospital. Bed-stays have plummeted which is why the NHS is treating more patients in less beds. The speed of change that David Nicholson was advocating is certainly challenging – as he himself admitted. I wouldn’t necessarily share his optimism about it being achieved though. But that’s slightly off the point. Not quite sure what you were trying to say though?

AFZ

@146: “So, anyone who disagrees with you is a propagandist?”

I consider what the National Audit Office and the Office of National Statistics say about the NHS, the findings of independent international assessments of healthcare systems on other west European countries, the numerous media reports of NHS failings – many linked above here – etc and throw in my own recent personal experience of shambolic NHS administration and the implications of that interview of Sir David Nicholson in the FT in December 2009 linked @145.

Then I contemplate the continuing stream of NHS propaganda about the “envy of the world”, wonderful etc, all critics are misinformed etc.


Reactions: Twitter, blogs
  1. Liberal Conspiracy

    How Labour should respond to the coming NHS crisis http://bit.ly/ieW4KN

  2. Cal

    Disagreed with this: http://bit.ly/ieW4KN GP commissioning leads inevitably to privatisation, as Polly Toynbee writes: http://t.co/aGJu1UV

  3. ABC

    RT @calalal: Disagreed with this: http://bit.ly/ieW4KN GP commissioning leads inevitably to privatisation, as Polly Toynbee writes: http …

  4. SMS PolicyWatch

    RT @libcon: How Labour should respond to the coming NHS crisis http://bit.ly/ieW4KN

  5. Wendy Maddox

    RT @libcon: How Labour should respond to the coming NHS crisis http://bit.ly/ieW4KN

  6. bobthomson70

    Interesting NHS future debate. http://liberalconspiracy.org/2011/01/06/how-labour-should-respond-to-the-coming-nhs-crisis/

  7. Rachel Hubbard

    How Labour should respond to the coming NHS crisis | Liberal Conspiracy http://goo.gl/ZKfrz

  8. Richard Blogger

    @PeterKenyon how do we get Labour to support our NHS? I am frustrated by their lacklustre response http://j.mp/dZ9PFo

  9. Richard Blogger

    @RichardAngell NewLabour created laws the Tories are using to privatise NHS. It can change. http://j.mp/dZ9PFo

  10. Richard Blogger

    @sunny_hundal Remember these @libcon articles from me earlier? http://j.mp/h3gUcZ http://j.mp/dZ9PFo "NHS Most important issue in 2011"

  11. sunny hundal

    RT @richardblogger: @sunny_hundal Remember these @libcon articles from me earlier? http://j.mp/h3gUcZ http://j.mp/dZ9PFo "NHS Most important issue in 2011"

  12. sunny hundal

    RT @richardblogger: @sunny_hundal Remember these @libcon articles from me earlier? http://j.mp/h3gUcZ http://j.mp/dZ9PFo "NHS Most impor …

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    @jon_s @latentexistence see this http://t.co/MROMWmck

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    @cruella1 hehe. its a good line, but see this http://t.co/MROMWmck





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