Full footage HERE
Showing posts with label NHS. Show all posts
Showing posts with label NHS. Show all posts
Wednesday, 18 July 2018
Friday, 3 June 2016
Why the NHS should not fund PreP
PreP stands for Preventive Exposure Prophylaxis. It is medication that prevents the infection of HIV with a 85% probability for those who may be exposed to high risk with infected partners. PreP is therefore an important armour in the arsenal against the spread of HIV amongst gay men. NICE, the body in England that reviews the effectiveness and economic benefits of medication for the NHS has recently recommended not to prescribe PreP on the NHS and NHS England has declined to do so. Its analysis of costs and benefits suggests that its costs simply outweigh the benefits. This calculation may change soon and there has been a significant outcry from AIDS campaign groups such as Terrence Higgins about the decision. They have branded NHS England 'irresponsible' and 'shameful'. But lets look at this in a bit more detail.
PreP is not medication for people who have contracted HIV but it is a preventive substance for those who are at high risk to contract the disease because they engage in unprotected sex. The groups that typically come to mind that may benefit from this medication are sex workers and people in the porn industry. However, both industries have extremely by now low infection rates. In fact, the porn industry is highly (self-) regulated now and has only seen few (less than 40 compared to more than 400 in the previous year) infections in the last four years. Porn stars (gay or straight) need to undergo regular tests and prove their HIV status to be allowed to work.
So, PreP is not a medication for people who professionally may put themselves at risk. S, who is it for? In essence, it is for a group of gay men who deliberately decide to have unprotected sex. This is crucial in the argument for or against public funding of PreP as there is in fact a simple and cost-effective means to prevent HIV contraction, it's called the condom. However, at the moment, some men decide not to use a condom which exposes them to a higher risk of contracting the disease. At present, many of them self-fund PreP (at about £400 per month).
The argument for publicly funding PreP through the NHS is thus an argument about whether or not to spread (or socialise) risk. One may argue that we do this all the time. We are all exposed to the possibility to have an accident in our lives, say to break a leg when cleaning the gutter on the house. Emergency care is provided free at the point of use in the UK and the costs are borne by everyone through taxation that funds the NHS. The critical difference between an accident and risky sexual activities however lies in the role of agency. In the case of the latter, some men deliberately expose themselves to risks even though they do not need to. Terrence Higgins and others argue that society should pick up the tab for this. I disagree.
So what's the rationale behind their case for public funding of PreP? It appears that they mainly employ a public health argument: to prevent the disease from spreading, those men who decide to have unprotected sex have a right to draw on public funding to reduce the risks. This seems to me to reduce those men to mere recipients of public assistance, when in fact they are actually the agents and initiators of the risks they want others to mitigate for them. The interpretative framework that is often invoked here is that of human rights. It is, so the argument goes, their human right to be free from risk. But human rights are the sort of set of rights that are easily invoked only once active agency is discounted. It has a patronising undertone. Men who decide to have unprotected sex are not like those who have no choice, say women within an abusive marriage who are coerced to have unprotected sex with their unfaithful husband. Gay men do have a choice. They simply decide not to exercise it to the benefit of their health.
My suspicion is that the NHS will eventually fund PreP for everyone. Mainly because the cost-benefit argument that NICE bases its decision on is relatively weak in the face of moral pressure and fake indignation from organisations such as Terrence Higgins. What we really need is a debate about the limits of mutual beneficence and the obligations we ourselves have to maintain our own health.
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| Personal responsibility or a matter for the NHS? Foto: Science Library BBC |
PreP is not medication for people who have contracted HIV but it is a preventive substance for those who are at high risk to contract the disease because they engage in unprotected sex. The groups that typically come to mind that may benefit from this medication are sex workers and people in the porn industry. However, both industries have extremely by now low infection rates. In fact, the porn industry is highly (self-) regulated now and has only seen few (less than 40 compared to more than 400 in the previous year) infections in the last four years. Porn stars (gay or straight) need to undergo regular tests and prove their HIV status to be allowed to work.
So, PreP is not a medication for people who professionally may put themselves at risk. S, who is it for? In essence, it is for a group of gay men who deliberately decide to have unprotected sex. This is crucial in the argument for or against public funding of PreP as there is in fact a simple and cost-effective means to prevent HIV contraction, it's called the condom. However, at the moment, some men decide not to use a condom which exposes them to a higher risk of contracting the disease. At present, many of them self-fund PreP (at about £400 per month).
The argument for publicly funding PreP through the NHS is thus an argument about whether or not to spread (or socialise) risk. One may argue that we do this all the time. We are all exposed to the possibility to have an accident in our lives, say to break a leg when cleaning the gutter on the house. Emergency care is provided free at the point of use in the UK and the costs are borne by everyone through taxation that funds the NHS. The critical difference between an accident and risky sexual activities however lies in the role of agency. In the case of the latter, some men deliberately expose themselves to risks even though they do not need to. Terrence Higgins and others argue that society should pick up the tab for this. I disagree.
So what's the rationale behind their case for public funding of PreP? It appears that they mainly employ a public health argument: to prevent the disease from spreading, those men who decide to have unprotected sex have a right to draw on public funding to reduce the risks. This seems to me to reduce those men to mere recipients of public assistance, when in fact they are actually the agents and initiators of the risks they want others to mitigate for them. The interpretative framework that is often invoked here is that of human rights. It is, so the argument goes, their human right to be free from risk. But human rights are the sort of set of rights that are easily invoked only once active agency is discounted. It has a patronising undertone. Men who decide to have unprotected sex are not like those who have no choice, say women within an abusive marriage who are coerced to have unprotected sex with their unfaithful husband. Gay men do have a choice. They simply decide not to exercise it to the benefit of their health.
My suspicion is that the NHS will eventually fund PreP for everyone. Mainly because the cost-benefit argument that NICE bases its decision on is relatively weak in the face of moral pressure and fake indignation from organisations such as Terrence Higgins. What we really need is a debate about the limits of mutual beneficence and the obligations we ourselves have to maintain our own health.
Saturday, 22 August 2015
The trouble with the NHS
Two years ago the American author David Goldhill caused quite a stir in the US media with his book 'Catastrophic Care'. At the time, Obamacare was being implemented yet Goldhill argued that the extension of coverage to millions of Americans was a sideshow. His critique of the health care system focused instead on the conundrum of rising costs at times of increasing competition (which should drive down costs).
To any observer from the UK, this may appear a worry too far. Since 1948, the UK operates a monopolistic tax funded health care system without insurance intermediaries. Competition is a dirty word here, with politicians of all colour consistently arguing that it's the strong monopolistic position of the NHS that allows it to negotiate low prices with all health economy providers (we will return to this point in a moment).
Yet, Goldhill also showed clearly that all modern health systems suffered the same ills. Profits in health care provision did not amount to anything resembling the mountains of gold presumed by defenders of socialist health care. In fact, 'all the profits of the famously greedy health insurance companies ... would pay for four days of health care for all Americans. Add in the profits of the ten biggest 'rapacious' drug companies: another thirteen days. Indeed, confiscating all the profits of all American companies, in every industry, would cover only seven months of our health care expenses.' (Goldhill, p.53)
In other words, profiteering in health care provision is a red herring when it comes to the magnitude of the cost explosion.
British and European health care systems don't fare much better. Whilst productivity is slowly rising in all UK industries, the NHS is notoriously the only industry where productivity has steadily been falling. The argument has always been that medical care is a labour intensive industry. But does that mean that it is an industry like no other, exempt from the conventional laws of efficiency?
Health care appears to be the only part in society that we positively excuse when it operates at a loss to us as taxpayers. As technology has made things easier for everyone from the local plumber to the car mechanic, health care providers appear to be saying that the more technology they introduce, the more expensive things will become for us as consumers. In fact, we are so used to this argument that, reading this, you may not even have spotted the flawed logic in this sentence. It is only in health care that technology makes things MORE expensive, when, in all other contexts, the aim of introducing technology is the opposite: to make things cheaper by increasing productivity.
So, what's going wrong? What's at the heart of the cost explosion of the NHS? The first issue is that the NHS, as any modern health care in the Western world, deliberately severed the link between patient behaviour and costs. People are not rewarded if they visit their GP less. On the contrary, the more a patient turns up at the local GP practice, the more tests (most of them often useless or positively harmful, as Atul Gawande argued) and clinical interventions are showered on her or him. The system also rewards the absence of self-management of illnesses and almost expects a lack of responsibility for our own well being.
Yet, even more important, what was supposed to be a risk sharing model for acute care needs has become a model of comprehensive health care. Once, illness was narrowly defined as urgent medical attention in cases of life threatening diseases. The NHS was founded as a response to large scale epidemics such as TB. Fast forward to the 21st century and the NHS has become the nanny for all discomforts in life, for free!
The original model of sharing risks at times of acute medical needs, many of those very expensive, has given way to a model of comprehensive care for everything from a brain tumors to blisters on the feet. The health care systems are thus not risk sharing mechanisms anymore, helping the poorest to spread the costs of acute care needs, but a dispensary of all round care for free.
The fact that we don't share risks anymore but appear happy to pay for everything for everybody has important consequences to health care costs. It distorts positive health orientated behaviour (hence the discussion about obesity and gastroband surgery on the NHS), but it also undermines the possibility of establishing truly risk spreading mechanisms that would help share the costs in adjacent fields such as social care. Social care insurance will remain unviable in the UK, as long as much of what goes for care needs is met by the NHS or local authorities (soon helping themselves to NHS budgets in devolved areas).
The advantages of having a strong negotiating position vis-a-vis pharmaceutical industries are puny in comparison to the costs of health care in a dis-incentivised context. Not least because allegedly lower prices of medicines are likely to be cancelled out by the expansive prescribing of low or non-effective pharmaceuticals. As long as we think we have a right to free all round care, we won't be restoring the link between what we do to keep ourselves healthy and what we spend on our health.
To any observer from the UK, this may appear a worry too far. Since 1948, the UK operates a monopolistic tax funded health care system without insurance intermediaries. Competition is a dirty word here, with politicians of all colour consistently arguing that it's the strong monopolistic position of the NHS that allows it to negotiate low prices with all health economy providers (we will return to this point in a moment).
Yet, Goldhill also showed clearly that all modern health systems suffered the same ills. Profits in health care provision did not amount to anything resembling the mountains of gold presumed by defenders of socialist health care. In fact, 'all the profits of the famously greedy health insurance companies ... would pay for four days of health care for all Americans. Add in the profits of the ten biggest 'rapacious' drug companies: another thirteen days. Indeed, confiscating all the profits of all American companies, in every industry, would cover only seven months of our health care expenses.' (Goldhill, p.53)
In other words, profiteering in health care provision is a red herring when it comes to the magnitude of the cost explosion.
British and European health care systems don't fare much better. Whilst productivity is slowly rising in all UK industries, the NHS is notoriously the only industry where productivity has steadily been falling. The argument has always been that medical care is a labour intensive industry. But does that mean that it is an industry like no other, exempt from the conventional laws of efficiency?
 |
| Productivity down, costs up - and still no happy Unions - NHS unions in 2007 |
Health care appears to be the only part in society that we positively excuse when it operates at a loss to us as taxpayers. As technology has made things easier for everyone from the local plumber to the car mechanic, health care providers appear to be saying that the more technology they introduce, the more expensive things will become for us as consumers. In fact, we are so used to this argument that, reading this, you may not even have spotted the flawed logic in this sentence. It is only in health care that technology makes things MORE expensive, when, in all other contexts, the aim of introducing technology is the opposite: to make things cheaper by increasing productivity.
So, what's going wrong? What's at the heart of the cost explosion of the NHS? The first issue is that the NHS, as any modern health care in the Western world, deliberately severed the link between patient behaviour and costs. People are not rewarded if they visit their GP less. On the contrary, the more a patient turns up at the local GP practice, the more tests (most of them often useless or positively harmful, as Atul Gawande argued) and clinical interventions are showered on her or him. The system also rewards the absence of self-management of illnesses and almost expects a lack of responsibility for our own well being.
Yet, even more important, what was supposed to be a risk sharing model for acute care needs has become a model of comprehensive health care. Once, illness was narrowly defined as urgent medical attention in cases of life threatening diseases. The NHS was founded as a response to large scale epidemics such as TB. Fast forward to the 21st century and the NHS has become the nanny for all discomforts in life, for free!
The original model of sharing risks at times of acute medical needs, many of those very expensive, has given way to a model of comprehensive care for everything from a brain tumors to blisters on the feet. The health care systems are thus not risk sharing mechanisms anymore, helping the poorest to spread the costs of acute care needs, but a dispensary of all round care for free.
The fact that we don't share risks anymore but appear happy to pay for everything for everybody has important consequences to health care costs. It distorts positive health orientated behaviour (hence the discussion about obesity and gastroband surgery on the NHS), but it also undermines the possibility of establishing truly risk spreading mechanisms that would help share the costs in adjacent fields such as social care. Social care insurance will remain unviable in the UK, as long as much of what goes for care needs is met by the NHS or local authorities (soon helping themselves to NHS budgets in devolved areas).
The advantages of having a strong negotiating position vis-a-vis pharmaceutical industries are puny in comparison to the costs of health care in a dis-incentivised context. Not least because allegedly lower prices of medicines are likely to be cancelled out by the expansive prescribing of low or non-effective pharmaceuticals. As long as we think we have a right to free all round care, we won't be restoring the link between what we do to keep ourselves healthy and what we spend on our health.
Saturday, 28 March 2015
Shall we cap profits in health care?
As the general election campaign is limping from one damp squib to another, Labour came up with an idea on the NHS. Yesterday Ed Miliband made a commitment that all profits from health care contracts with private providers should be capped at 5 per cent. Any profits above that threshold will be seized by the government and ploughed back into the NHS.
The suggestion to cap profits resonates with many people's gut feelings that health care provision should not be a matter for capitalist profit. Health, so the reasoning goes, is not up for sale.
The principle is a well respected one and echoes fundamental reservations about mixing up health and capitalism. However, at closer inspection, it seems to rest on confusing two different dimensions of health care provision. The first dimension is the relationship between doctor and patient. Whatever goes on between patient and doctor is regulated by codes of medical practice and national guidelines. Profits have never played a role in this relationship despite GPs being private enterprises since the foundation of the NHS in 1946. And neither should they.
The second dimension is the health care market grouped around the first domain, ranging from the supply of protective gloves to syringes and capital investment into NHS hospitals. To wish away the market element in the supply of the health economy is like legislating for sunshine on Tuesdays.
Labour's proposal willfully confuses the two dimensions, the doctor patient relationship and the health care economy around it. As a former Labour health minister noted today, Ed Miliband's NHS policy amounts to little more than bluster.
So, what do other countries do about profits in the health care economy? The issue has been intensely debated during the introduction of Obamacare in the US and the lead of the implementation team (no other than Larry Summers) decided against a profit cap. Why? He argued that profit caps eliminate the (only) positive effect private providers bring to the health economy: their ability to look for savings.
Private providers have an incentive to seek out lower prices for comparable services or products because they can pocket the difference (the profit). If profits are capped, that incentive does not exist and prices will inevitably rise. This can be disastrous for a tax funded service like the NHS or one like Obamacare, since without the pressure of providers to identify cheaper options prices for the buyer (the NHS) will increase. In other words, eliminating the market element in private provision leads to higher costs for tax payers.
Miliband claims he is an ideas man. Looks like precious little thinking has gone into his last policy.
The suggestion to cap profits resonates with many people's gut feelings that health care provision should not be a matter for capitalist profit. Health, so the reasoning goes, is not up for sale.
The principle is a well respected one and echoes fundamental reservations about mixing up health and capitalism. However, at closer inspection, it seems to rest on confusing two different dimensions of health care provision. The first dimension is the relationship between doctor and patient. Whatever goes on between patient and doctor is regulated by codes of medical practice and national guidelines. Profits have never played a role in this relationship despite GPs being private enterprises since the foundation of the NHS in 1946. And neither should they.
The second dimension is the health care market grouped around the first domain, ranging from the supply of protective gloves to syringes and capital investment into NHS hospitals. To wish away the market element in the supply of the health economy is like legislating for sunshine on Tuesdays.
Labour's proposal willfully confuses the two dimensions, the doctor patient relationship and the health care economy around it. As a former Labour health minister noted today, Ed Miliband's NHS policy amounts to little more than bluster.
So, what do other countries do about profits in the health care economy? The issue has been intensely debated during the introduction of Obamacare in the US and the lead of the implementation team (no other than Larry Summers) decided against a profit cap. Why? He argued that profit caps eliminate the (only) positive effect private providers bring to the health economy: their ability to look for savings.
Private providers have an incentive to seek out lower prices for comparable services or products because they can pocket the difference (the profit). If profits are capped, that incentive does not exist and prices will inevitably rise. This can be disastrous for a tax funded service like the NHS or one like Obamacare, since without the pressure of providers to identify cheaper options prices for the buyer (the NHS) will increase. In other words, eliminating the market element in private provision leads to higher costs for tax payers.
Miliband claims he is an ideas man. Looks like precious little thinking has gone into his last policy.
Saturday, 28 February 2015
Why Andy Burnham will never be health secretary (again)
Labour has built its electoral strategy for the May election around the NHS. That made sense given it polls strongly on the NHS. Yet, its NHS policy boils down to only two components: a robust rebuttal of the so-called 'privatisation' of the NHS and a proposal to integrate health and social care provision. Both are looking increasingly too weak to function as the main pillar of a general election strategy and here is why.
'Privatisation' is a serious concern for many people in the UK. Labour has read the polls carefully and consistently identified the Health and Social Care Act 2012 as being widely discredited. Andy Burnham, the Labour's shadow health secretary, built his health care policy around the repeal of the Act. This has brought him plaudits from people who dislike tampering with the NHS. However, the agreement around the rejection of the Act is brittle and insufficient to act as long term policy. And the electoral appeal of 'anti-privitisation' rhetoric does not extend much further than Labour's core supporters. In addition, repealing the Act may also quickly emerge as disruptive to the fabric of the NHS. The 'anti-privatisation' agenda could thus become tarnished with exactly the same brush as the Act itself: endless re-organisation of the health care service.
To offer something positive, Burnham suggested to integrate health and social care. Yet, his proposal, three years in the making, still remains obscure. Health care through the NHS is free, whilst social care is means tested. Burnham's proposal was riddled with contradictions and he knew it. So, with only slightly more than 2 months to go to the general election, he has still not spelled out how the integration of the NHS and social care is to be achieved. The policy remains a shell at best.
Cue George Osborne. On Thursday, the Chancellor announced that Greater Manchester will have direct control over the entire NHS budget for its area. In 2017, the elected Mayor of Manchester will assume full responsibility for social care and health care provision for almost 3 million people. It's hard not to see this as a preemptive stroke of genius by the Chancellor (and a snub to Burnham by the local Labour councillors who did not even bother to inform him about the imminent agreement). Without having to fill in the detail of HOW to integrate health and social care, Osborne has given local authorities the powers to embark on integration as a local response to local problems.
The consequences are devastating for Burnham. As the consensus around his 'anti-privatisation' rhetoric becomes increasingly fragile and reveals its ideological thrust, his other main policy proposal is stuck in the mud of detail. In the meantime, Osborne devolves health care budgets to local authorities, strengthening the narrative around local accountability without having to provide any detailed health care policy on the complexities of integration.
The upshot is that Labour's health policy hangs by a thread and so does Burnham's political career. During his tenure as shadow health secretary he has failed to develop any significant and substantive policy proposals and the Labour leadership knows this. Their entire electoral strategy was built around the NHS and Burnham has left their flank undefended and open to attack. He is likely to pay the price for this blunder.
'Privatisation' is a serious concern for many people in the UK. Labour has read the polls carefully and consistently identified the Health and Social Care Act 2012 as being widely discredited. Andy Burnham, the Labour's shadow health secretary, built his health care policy around the repeal of the Act. This has brought him plaudits from people who dislike tampering with the NHS. However, the agreement around the rejection of the Act is brittle and insufficient to act as long term policy. And the electoral appeal of 'anti-privitisation' rhetoric does not extend much further than Labour's core supporters. In addition, repealing the Act may also quickly emerge as disruptive to the fabric of the NHS. The 'anti-privatisation' agenda could thus become tarnished with exactly the same brush as the Act itself: endless re-organisation of the health care service.
 |
| Going nowhere - Labour's Shadow Health Secretary Andy Burnham (Foto: EPA) |
To offer something positive, Burnham suggested to integrate health and social care. Yet, his proposal, three years in the making, still remains obscure. Health care through the NHS is free, whilst social care is means tested. Burnham's proposal was riddled with contradictions and he knew it. So, with only slightly more than 2 months to go to the general election, he has still not spelled out how the integration of the NHS and social care is to be achieved. The policy remains a shell at best.
Cue George Osborne. On Thursday, the Chancellor announced that Greater Manchester will have direct control over the entire NHS budget for its area. In 2017, the elected Mayor of Manchester will assume full responsibility for social care and health care provision for almost 3 million people. It's hard not to see this as a preemptive stroke of genius by the Chancellor (and a snub to Burnham by the local Labour councillors who did not even bother to inform him about the imminent agreement). Without having to fill in the detail of HOW to integrate health and social care, Osborne has given local authorities the powers to embark on integration as a local response to local problems.
The consequences are devastating for Burnham. As the consensus around his 'anti-privatisation' rhetoric becomes increasingly fragile and reveals its ideological thrust, his other main policy proposal is stuck in the mud of detail. In the meantime, Osborne devolves health care budgets to local authorities, strengthening the narrative around local accountability without having to provide any detailed health care policy on the complexities of integration.
The upshot is that Labour's health policy hangs by a thread and so does Burnham's political career. During his tenure as shadow health secretary he has failed to develop any significant and substantive policy proposals and the Labour leadership knows this. Their entire electoral strategy was built around the NHS and Burnham has left their flank undefended and open to attack. He is likely to pay the price for this blunder.
Friday, 6 February 2015
Labour's NHS trap
It all seemed so clear. The battle lines were drawn and the trenches
dug. As Andy Burnham came on Newsnight
on Thursday night to talk about the NHS, Labour had prepared a well rehearsed
argument, something well liked by its faithful and seemingly cutting through to
the public: ‘The Tories are privatising the NHS’.
The Labour leadership believed that this argument resonated with
rank and file members and offered the simplicity of clear ideological division.
Tories equal private, Labour equals public. In addition, the argument has
‘recognition value’ as marketing experts would say, harking back to a pre-Blair
time when Labour was against privatisation of public services. It also linked
in with other policies, such as public ownership of the railways, a potential
battleground with the Greens challenging Labour from the left.
As Burnham started the interview, the position fell apart fairly
quickly. Kirsten Wark’s point of attack was Labour’s own record of
‘outsourcing’ and the fact that, under the last Labour government, private
business amounted to 4.4% of the total NHS budget. Now, it stood at just above
6%. Hardly the ruthless Tory privatisation wave Labour claimed, Wark argued.
Yet it seems that it was current levels of outsourcing that broke Burnham’s
argument. More likely, Labour appears to have misjudged the depth of knowledge
(or lack thereof) about the NHS within the population. The main confusion at
the heart of Labour’s argument about the privatisation of the NHS was that,
from the perspective of ordinary people, it is little more than a deliberate
obfuscation.
People encounter the NHS as patients. The patient doctor
relationship determines the perceptions and views of people on the NHS. That
relationship is governed by clinical guidelines designed by NICE and Labour’s
privatisation argument somehow suggests that this could change.
Yet, the complexity of health care delivery through the NHS in the
UK means that privatisation anxiety makes little sense. GPs in the UK are in
fact private enterprises. Aneurin Bevan’s National Health Service Act in 1946
made them so. Yet, this is not what Labour trained its guns on. Its main
artillery was pointed at the health economy around the patient doctor
relationship. It claimed that, somehow, because of private involvement, doctors
would have to take profit into consideration when making clinical decisions.
This is a difficult argument to sustain for two reasons. On one
hand, doctors are bound to make decisions in line with clinical guidelines, and
profit is ostensibly not part of the picture. Yet, on the other hand,
efficiency (and consequently rationing) is and has always been part of the NHS.
In fact, NICE guidelines take into account both the effectiveness and the
efficiency (in terms of life years saved) of medication and interventions
before approving it. So, in a sense, considerations of efficiency have always
been with us. The notion of a fully resourced health care system is a utopian
make belief. Doctor’s clinical decision making process will always need to
navigate patients’ expectations, in other words: say ‘no’ at times.
The real issue is whether, within the health economy that is grouped
around the clinical patient doctor relationship, competition would drive down
costs or increase costs for the NHS, or the tax payer. This argument is
worthwhile having and Lord Darzi has made an important contribution to this recently.
Everything, from pharmaceuticals to protective gloves, is after all produced
within the market economy of the UK and to advocate a unilateral withdrawal of
the NHS from this health economy is like saying we should bake our own bread at
home. It may be wholesome and nutritious but hardly ever enough to feed a large
family.
So, Labour’s argument about privatisation offers a false dichotomy.
When articulating an anxiety that profit considerations would encroach on the
patient doctor relationship the argument is ostensibly false. Doctors are bound
by clinical guidelines. If taken to refer to the health economy around medical
care, the argument is little more than a common place. The NHS always operated
as a public service within a market economy. An autarkic healthcare system,
insulated from economic pressures, is a pipe dream.
Boxed into the argument about privatisation and sensing its failure,
on Thursday, Burnham tried to move the discussion on to the issue of
integrating health and social care. It is a valuable idea and one that has been
around for decades. It cannot have escaped him though that the earliest
protagonists of health care integration are Kaiser Permanente; you guessed it:
a private US insurance company with nearly $50 billion in revenues and more
than $1.6 billion in profit. Health care may just be a policy field that proves
impervious to ideological battles. And that may be a good thing.
Saturday, 6 September 2014
Are you satisfied with your doctor?
On a regular basis I receive a letter from the NHS. It's a survey which asks me to complete several questions about how satisfied I am with my GP. Invariably, the letter goes straight to the bin. And here is why.
The NHS have conducted patient satisfaction surveys for several years now (done by CQC) and they are beloved by politicians of all colour. Whenever the discussion turns to productivity or care outcomes in the NHS, politicians are quick to point out that patient satisfaction is at an all time high in the NHS (it currently is about 96%). Somehow patient satisfaction rates are meant to counter any criticism of the NHS. I believe this is a spurious argument and one that does not stand up to scrutiny.
There are clearly some things surveys can find out. They fall into the category of 'facts' such as how many times somebody has visited their doctor recently and the like. Although patient surveys are actually not the best way to establish good data on these things, I can see that you may want to ask them in a survey with some justification. I still think responses to these questions should still be treated with caution given that we are all human beings and our memories play tricks on us with even more mundane issues such as remembering whether it was raining yesterday or where we put our car keys.
Be that as it may, the real problems emerge when it comes to the responses these surveys are really after: patient satisfaction. A typical question of this sort runs like this (this is an actual question from the regular GP survey I receive): 'How would you describe your experience of your GP surgery'? 'Very good, fairly good, neither good nor poor, fairly poor or very poor.
Well, let me think about this... First of all, I am not sure what this question refers to. Do they ask me to rate the pictures hung up on the surgery walls? Or are they after my opinion about the doctor's willingness to give me the drugs I want?
Yet, it is not only the fuzziness of the question that makes this survey an exercise in futility. More importantly, how would I know what is a 'fair, good or poor' experience? I tend not to visit my GP and then pop to another one down the road to see if she is any better. The nature of the healthcare experience is that it is rarely comparable. I have not heard of a single person who had a liver transplant at a London hospital and then, for the purpose of gaining comparative expertise, drove to Newcastle to test the local surgeon's skills by asking them to perform a similar operation.
Since the medical experience is most likely to be unique for most people, personal opinions of what constitutes a 'good' or 'poor' service are likely to be indiscriminately hovering in the 'satisfied' range, with only those patients blipping on the radar who have, for one or another reason, been seriously disgruntled about the service they received. Those are most likely to have encountered problems with their care which often end up at tribunals or on the desk of a solicitor. So, no surprise then that NHS surveys regularly indicate a high satisfaction rate of patients. We wouldn't know better! That's why the survey letter from my GP always goes straight to the bin. I happily profess my ignorance!
The NHS have conducted patient satisfaction surveys for several years now (done by CQC) and they are beloved by politicians of all colour. Whenever the discussion turns to productivity or care outcomes in the NHS, politicians are quick to point out that patient satisfaction is at an all time high in the NHS (it currently is about 96%). Somehow patient satisfaction rates are meant to counter any criticism of the NHS. I believe this is a spurious argument and one that does not stand up to scrutiny.
There are clearly some things surveys can find out. They fall into the category of 'facts' such as how many times somebody has visited their doctor recently and the like. Although patient surveys are actually not the best way to establish good data on these things, I can see that you may want to ask them in a survey with some justification. I still think responses to these questions should still be treated with caution given that we are all human beings and our memories play tricks on us with even more mundane issues such as remembering whether it was raining yesterday or where we put our car keys.
Be that as it may, the real problems emerge when it comes to the responses these surveys are really after: patient satisfaction. A typical question of this sort runs like this (this is an actual question from the regular GP survey I receive): 'How would you describe your experience of your GP surgery'? 'Very good, fairly good, neither good nor poor, fairly poor or very poor.
Well, let me think about this... First of all, I am not sure what this question refers to. Do they ask me to rate the pictures hung up on the surgery walls? Or are they after my opinion about the doctor's willingness to give me the drugs I want?
Yet, it is not only the fuzziness of the question that makes this survey an exercise in futility. More importantly, how would I know what is a 'fair, good or poor' experience? I tend not to visit my GP and then pop to another one down the road to see if she is any better. The nature of the healthcare experience is that it is rarely comparable. I have not heard of a single person who had a liver transplant at a London hospital and then, for the purpose of gaining comparative expertise, drove to Newcastle to test the local surgeon's skills by asking them to perform a similar operation.
Since the medical experience is most likely to be unique for most people, personal opinions of what constitutes a 'good' or 'poor' service are likely to be indiscriminately hovering in the 'satisfied' range, with only those patients blipping on the radar who have, for one or another reason, been seriously disgruntled about the service they received. Those are most likely to have encountered problems with their care which often end up at tribunals or on the desk of a solicitor. So, no surprise then that NHS surveys regularly indicate a high satisfaction rate of patients. We wouldn't know better! That's why the survey letter from my GP always goes straight to the bin. I happily profess my ignorance!
Monday, 17 March 2014
The demise of the Co-op movement
I once strolled into a Co-op shop in Cardiff, more by accident than by purpose and my instant reaction was one of horror. I have never seen a shop that offered so little of value yet excelled in drabness. It's shelves seemed to be filled with lots of apples of indistinct age (and taste, no doubt) and rows and rows of sugary lemonade. I made a mental note never to enter a Co-op shop again.
In a way, its food retail section is the least of the worries for the Co-op movement, given a 2 billion pound hole in its books and a former Labour minister (of all people!) declaring the company to be unwilling to reform. Oh, and yes, it also just lost its CEO, for good measure, probably driven out by vicious (and wrongful) briefing from its own board members about his (alleged) bonus take .
So, what does this mean for the Co-op movement? And why has it all gone so horribly wrong? The Co-op is closely aligned with Labour, sponsoring several MPs (and their re-election campaigns) to the tune of £50k each and giving to the Labour Party itself close to 1 million pounds per annum.
But it's main motto, to be the last bastion of mutualism, seems to be a figleaf for fiendish levels of incompetence amongst its non-executive directors (drawn from 'ordinary people') and shocking tales of morals in free fall, with the crystal meth snorting former director Paul Flowers only the tip of the iceberg.
The cause of the problem however seems to lie in a useful conceit that lies at the core of the Co-op movement philosophy, that 'ordinary people' can and should run diversified companies operating in a highly complex market place. In a sense, this philosophy always lacked credibility ever since Marx wrote several thousand pages in an attempt to analyse something that is thought to boil down to simple supply and demand by the popularisers of market economics. Yet, this 'ordinary people should run it' philosophy extends right across public services as well, including health care.
The Labour Government under Tony Blair invested heavily in so-called partnership boards that were supposed to have a say in the decision making of health boards (now disbanded in England). This was not a way of increasing shared decision making for patients with their own GP but was a way of getting communities involved in large scale decisions such as commissioning of services in an area the size of several counties. Naturally, it never worked, but the reason why it did not deliver more involvement is interesting to note. In essence, the professional classes in healthcare had enough authority (based on their training and knowledge) to swat away any serious attempt by ordinary people to keep a check on their decision making. Eventually, there were always just two players of any clout in health: the professionals and the government in Whitehall.
This raises an interesting question about the Co-op. Just like highly complex healthcare facilities, it operates in fast moving markets that require specialist knowledge. It appears that we still have not found a meaningful way of involving ordinary people in the economic and social affairs that are shaped to a large degree by the companies and services supposedly serving them. The reason the Co-op is in dire straits is that it had artificially fostered an environment where 'ordinary people' were put in charge, to the detriment of those who had the competences to run the place and to the loss of the wider public.
In a way, its food retail section is the least of the worries for the Co-op movement, given a 2 billion pound hole in its books and a former Labour minister (of all people!) declaring the company to be unwilling to reform. Oh, and yes, it also just lost its CEO, for good measure, probably driven out by vicious (and wrongful) briefing from its own board members about his (alleged) bonus take .
So, what does this mean for the Co-op movement? And why has it all gone so horribly wrong? The Co-op is closely aligned with Labour, sponsoring several MPs (and their re-election campaigns) to the tune of £50k each and giving to the Labour Party itself close to 1 million pounds per annum.
But it's main motto, to be the last bastion of mutualism, seems to be a figleaf for fiendish levels of incompetence amongst its non-executive directors (drawn from 'ordinary people') and shocking tales of morals in free fall, with the crystal meth snorting former director Paul Flowers only the tip of the iceberg.
 |
| The Rev Paul Flowers - A preference for rentboys and crystal meth when he is not in a suit |
The cause of the problem however seems to lie in a useful conceit that lies at the core of the Co-op movement philosophy, that 'ordinary people' can and should run diversified companies operating in a highly complex market place. In a sense, this philosophy always lacked credibility ever since Marx wrote several thousand pages in an attempt to analyse something that is thought to boil down to simple supply and demand by the popularisers of market economics. Yet, this 'ordinary people should run it' philosophy extends right across public services as well, including health care.
The Labour Government under Tony Blair invested heavily in so-called partnership boards that were supposed to have a say in the decision making of health boards (now disbanded in England). This was not a way of increasing shared decision making for patients with their own GP but was a way of getting communities involved in large scale decisions such as commissioning of services in an area the size of several counties. Naturally, it never worked, but the reason why it did not deliver more involvement is interesting to note. In essence, the professional classes in healthcare had enough authority (based on their training and knowledge) to swat away any serious attempt by ordinary people to keep a check on their decision making. Eventually, there were always just two players of any clout in health: the professionals and the government in Whitehall.
This raises an interesting question about the Co-op. Just like highly complex healthcare facilities, it operates in fast moving markets that require specialist knowledge. It appears that we still have not found a meaningful way of involving ordinary people in the economic and social affairs that are shaped to a large degree by the companies and services supposedly serving them. The reason the Co-op is in dire straits is that it had artificially fostered an environment where 'ordinary people' were put in charge, to the detriment of those who had the competences to run the place and to the loss of the wider public.
Wednesday, 24 July 2013
The slow death of the NHS
Since I came to this country in 1992, the NHS has been in perpetual crisis. First, it was long waiting times, then poor cancer care and treatment outcomes with unusually high death rates, and finally, it was people unnecessarily dying in hospitals.
The answer of politicians is to throw more money at the NHS in a desperate attempt to shore up its capacities to deal with chronic diseases, long term illnesses and complex health problems of an aging population. But the real culprit in the demise of the NHS is a fundamental change in the health care needs of people and the huge financial burdens of medicine developments.
As the body for vaccine licensing in the UK published its latest shocking report, it has become clear that a tax based health care sector is creaking at the seams and is becoming untenable fast. The development of medicines has traditionally been the domain of the pharmaceutical industry, but something significant has happened over the last decade. As diseases became ever more difficult to analyse and combat, medicine development has become ever more costly. Developing an effective vaccine can easily take 20 years and cost 100 million pounds as the various substances are tested and go through a plethora of trials to improve their composition and ensure their safety.
These are enormous entrepreneurial risks and practically no company can take these risks on their own today. So, governments have stepped in and underwritten some of the financing risks of some vaccine developments. While that means broader shoulders for the risks, the costs can be devastating for the health sector as not all vaccine developments are successful.
What does that have to do with the NHS? Spiraling costs in medicine development and care delivery mean that the NHS will always fall short of caring adequately for everyone. And that has been the principle of the NHS since its inception: ration the care to those most at need. Yet, the latest decision of the Department of Health clearly shows it is not the most vulnerable who benefit from the rationing principle. What guides bureaucrats in Whitehall is a lifeless formula which decides who lives and who dies in the NHS.
This problem wont go away. In fact, it will get worse unless the government will find new sources for significant investment in the health sector. There seems to be only one answer. Open the NHS up to insurance based services. It would provide a new income for the NHS and would allow patients to decide how much they want to pay for the care they think they need.
The answer of politicians is to throw more money at the NHS in a desperate attempt to shore up its capacities to deal with chronic diseases, long term illnesses and complex health problems of an aging population. But the real culprit in the demise of the NHS is a fundamental change in the health care needs of people and the huge financial burdens of medicine developments.
As the body for vaccine licensing in the UK published its latest shocking report, it has become clear that a tax based health care sector is creaking at the seams and is becoming untenable fast. The development of medicines has traditionally been the domain of the pharmaceutical industry, but something significant has happened over the last decade. As diseases became ever more difficult to analyse and combat, medicine development has become ever more costly. Developing an effective vaccine can easily take 20 years and cost 100 million pounds as the various substances are tested and go through a plethora of trials to improve their composition and ensure their safety.
These are enormous entrepreneurial risks and practically no company can take these risks on their own today. So, governments have stepped in and underwritten some of the financing risks of some vaccine developments. While that means broader shoulders for the risks, the costs can be devastating for the health sector as not all vaccine developments are successful.
What does that have to do with the NHS? Spiraling costs in medicine development and care delivery mean that the NHS will always fall short of caring adequately for everyone. And that has been the principle of the NHS since its inception: ration the care to those most at need. Yet, the latest decision of the Department of Health clearly shows it is not the most vulnerable who benefit from the rationing principle. What guides bureaucrats in Whitehall is a lifeless formula which decides who lives and who dies in the NHS.
This problem wont go away. In fact, it will get worse unless the government will find new sources for significant investment in the health sector. There seems to be only one answer. Open the NHS up to insurance based services. It would provide a new income for the NHS and would allow patients to decide how much they want to pay for the care they think they need.
Sunday, 23 December 2012
Why a privatised NHS does not concern me
For months now The Guardian has run a hostile campaign against the NHS reforms introduced by (former) Health Secretary Andrew Lansley. However, some dissenting voices are now emerging. In an opinion piece two days ago, the Guardian commentator Ian Birrell admonishes critics of NHS reforms that their caricature of the changes in the English NHS risks missing the most important point: the NHS was established in different times to tackle different problems. If it does not change, it will fail to address the new challenges to provide health care to millions in the UK.
Birrell argues that the main difference between the original NHS and any health care provider in the 21 century is not whether or not services are supplied by private or public organisations. Rather, the main difference lies in the problem it faces. At its inception, the NHS was to tackle infant mortality and infectious diseases. To do this, the newly formed NHS board embarked on a large scale hospital building programme that lasted into the 1980s. Hospitalisation of patients was thought to be the most appropriate care.
The programme had some success as the health of communities across the UK improved significantly. However, it also created monster organisations that were difficult to steer. Change in order to address new health problems was practically impossible to introduce, and staff morale dropped markedly due to scandals of mistreatment of patients. Despite the claim that the NHS was 'centrally controlled', it was was in fact a supertanker without a skipper.
Repeatedly, politicians tried to force the NHS to be more susceptible to steering by forming organisational sub-divisions, such as local boards (Wales for example has a long history of re-organisations of NHS health boards, their number ranging at some point from 22 to now 7).
Exasperated by the resistance of the NHS to respond to the need for change, Tony Blair's government then practically sliced off large parts of the service into semi-private providers, NHS foundation hospitals, that were operating free from central control.
Andrew Lansley's reforms were only the logical extension of the reforms introduced by the previous government: devolving the main bulk of the NHS budget to GPs operating in the communities and commissioning the services they need for their patients.
Critics are scathing about the alleged privatisation of the NHS. But, as Birrell argues, this misses the point. The NHS will remain free at the point of use. GPs have always been private contractors, ever since Aneurin Bevan decided to buy their approval to the introduction of the NHS by 'stuffing their mouths with gold'.
What has changed however is that the location of care has shifted from hospitals to communities. While some surgical procedures will always require hospitalisation, most after-care is best delivered for patients in the communities. This is not just a question of cost. It is above all an issue about the quality of care. It matters little whether a public or private organisation offers this care.
Birrell argues that the main difference between the original NHS and any health care provider in the 21 century is not whether or not services are supplied by private or public organisations. Rather, the main difference lies in the problem it faces. At its inception, the NHS was to tackle infant mortality and infectious diseases. To do this, the newly formed NHS board embarked on a large scale hospital building programme that lasted into the 1980s. Hospitalisation of patients was thought to be the most appropriate care.
The programme had some success as the health of communities across the UK improved significantly. However, it also created monster organisations that were difficult to steer. Change in order to address new health problems was practically impossible to introduce, and staff morale dropped markedly due to scandals of mistreatment of patients. Despite the claim that the NHS was 'centrally controlled', it was was in fact a supertanker without a skipper.
Repeatedly, politicians tried to force the NHS to be more susceptible to steering by forming organisational sub-divisions, such as local boards (Wales for example has a long history of re-organisations of NHS health boards, their number ranging at some point from 22 to now 7).
Exasperated by the resistance of the NHS to respond to the need for change, Tony Blair's government then practically sliced off large parts of the service into semi-private providers, NHS foundation hospitals, that were operating free from central control.
Andrew Lansley's reforms were only the logical extension of the reforms introduced by the previous government: devolving the main bulk of the NHS budget to GPs operating in the communities and commissioning the services they need for their patients.
Critics are scathing about the alleged privatisation of the NHS. But, as Birrell argues, this misses the point. The NHS will remain free at the point of use. GPs have always been private contractors, ever since Aneurin Bevan decided to buy their approval to the introduction of the NHS by 'stuffing their mouths with gold'.
What has changed however is that the location of care has shifted from hospitals to communities. While some surgical procedures will always require hospitalisation, most after-care is best delivered for patients in the communities. This is not just a question of cost. It is above all an issue about the quality of care. It matters little whether a public or private organisation offers this care.
Tuesday, 27 November 2012
The Liverpool Care Pathway - who decides?
Jeremy Paxman conducted a lively discussion yesterday on Newsnight about the so-called Liverpool Care Pathway. The care pathway has drawn some criticism from patients and carers after it has become clear that it is essentially a way to design a dignified death for patients. While this is laudable where patients are terminally ill, critics argue that it is not clear when and under which circumstances the care pathway should be implemented in individual cases, leaving it open to be used as a 'smokescreen for euthanasia'.
The care pathway has originally been developed by palliative care professionals and geriatricians in Liverpool, but it is now widely applied in NHS hospitals. The interesting conflict however is not so much one about when to apply it but one about who makes the decision to do so.
Newsnight showed a brief interview with a relative of a patient who was put on the care pathway. In essence, the relative argued this was a decision to let the patient die without exploring alternative routes to address the illness of patient. She reportedly 'begged the consultant' to save the life of the patient instead of applying the Liverpool Care Pathway. In such situations, the Liverpool Care Pathway may resemble more a professional device to conceal clinical decisions from relatives and patients, rather than an instrument for delivering exemplary palliative care.
The discussion amongst Paxman's guests however moved quickly away from the critical point that was made by the relative of the patient (and another guest in the studio) towards the 'soft' issue of how to involve patients or relatives in the discussion about the care pathway. This however dodged the actual problem of clinical decision making.
As one of the guests emphasised, the question is about WHO makes the decision. Relatives often do not just want to be consulted in the difficult cases but want to make the decision itself. So, in difficult cases, consultation is not enough. The Minister for Care Services Norman Lamb waffled for a while and managed to skirt around the real issue, but anybody who listened carefully couldn't have been in any doubt. As medical knowledge is more widely disseminated in the population, patients and relatives will increasingly challenge clinicians in their decision making and 'consulting' is taken to be synonymous with 'deciding'. No one in the studio pointed out that consultation in the clinical context does NOT mean a fundamental shift of the decision making authority from clinical staff to relatives or patients.
The relative brought this to the point when he said that it should be the family or the patient who decides which services he or she receives. We may agree or disagree with this, but the main message is clear. The times when NHS clinicians could make decisions on their own is over. Nowhere is this more clear then in deciding who lives or dies.
Sunday, 28 October 2012
On good and evil in human behaviour
The BBC and some other large organisations in Britain are currently rocked by the Jimmy Savile scandal. Over many decades, Jimmy Savile, apparently restlessly working for charities to help disadvantaged children, was in fact preying on the very same kids he pretended to help. The police now think that he was a 'predatory pedophile' who abused more than 200 children.
I have not written about this since the scandal broke because words can only fail to express the horror and devastation felt by those he betrayed, the children he feigned to help, as well as those he actually abused sexually over such a long time.
There are however two issuees that got my attention beyond the sheer evil of his actions. The first is that Savile's behaviour was by no means secret. In fact it was widely known amongst his colleagues and perhaps even tolerated by management in the BBC and the NHS hospital he worked in. So the magnitude of this scandal only becomes clear when one thinks about the wall of silence that surrounded his actions, a wall not built by himself but created and maintained by others.
The second aspect relates to the relationship between good and evil in human behaviour. Savile's nephew recently expressed his sadness upon hearing about his uncle's crimes and he contrasted it with the enormous amount of charity work Savile has done over his life time. Yet when it comes to predatory pedophiles this may confuse motivation and behaviour. Savile may well have developed and nurtured his charity role in society exactly because this line of work ensured that he had access to young underage girls and boys.
For predatory pedophiles, contrasting the 'good' they are doing with the 'harm' is a common strategy of defence. In one of the biggest pedophile scandals in the US, the recently convicted rapist Jerry Sandusky (who worked as Penn State assistant football coach) used a similar strategy. In an interview with the New York Times he pointed to all the charity work he has done, arguing that he could not possibly have done any evil because he had done so much good.
We now know that Sandusky founded and developed his charity for disadvantaged boys exactly because it allowed him access to his victims and a perfect cover to groom them for his sexual abuse over a long period of time. It seems that people like Savile or Sandusky do not do good or evil, they do good in order to perpetrate evil.
I have not written about this since the scandal broke because words can only fail to express the horror and devastation felt by those he betrayed, the children he feigned to help, as well as those he actually abused sexually over such a long time.
There are however two issuees that got my attention beyond the sheer evil of his actions. The first is that Savile's behaviour was by no means secret. In fact it was widely known amongst his colleagues and perhaps even tolerated by management in the BBC and the NHS hospital he worked in. So the magnitude of this scandal only becomes clear when one thinks about the wall of silence that surrounded his actions, a wall not built by himself but created and maintained by others.
The second aspect relates to the relationship between good and evil in human behaviour. Savile's nephew recently expressed his sadness upon hearing about his uncle's crimes and he contrasted it with the enormous amount of charity work Savile has done over his life time. Yet when it comes to predatory pedophiles this may confuse motivation and behaviour. Savile may well have developed and nurtured his charity role in society exactly because this line of work ensured that he had access to young underage girls and boys.
For predatory pedophiles, contrasting the 'good' they are doing with the 'harm' is a common strategy of defence. In one of the biggest pedophile scandals in the US, the recently convicted rapist Jerry Sandusky (who worked as Penn State assistant football coach) used a similar strategy. In an interview with the New York Times he pointed to all the charity work he has done, arguing that he could not possibly have done any evil because he had done so much good.
We now know that Sandusky founded and developed his charity for disadvantaged boys exactly because it allowed him access to his victims and a perfect cover to groom them for his sexual abuse over a long period of time. It seems that people like Savile or Sandusky do not do good or evil, they do good in order to perpetrate evil.
Sunday, 30 September 2012
Why we don't criticise the NHS
A recent survey showed that people are reluctant to criticise the care they receive by the NHS. Whilst we are happy to rate pretty much any service or good we obtain, from mobile phones to hotel stays, we are far less likely to say something critical about the NHS. The Guardian has reported on the result of this survey and the figures are revealing. Only about 250 people go online every day to rate their experience with the NHS, out of 1 million daily encounters in the NHS between care staff and patients.
The authors of the report suspect reverence for medical professionals the main reason. But another reason for why we rarely say much about the NHS is that we simply don't know. Look at it this way.
Rating a good or a service inevitably involves comparing it to a previous experience. We may often not be aware of this comparative exercise, but when we say something about a movie we have seen, we intuitively judge it against a previous movie experience. Although comparisons are complex mental exercises, the fundamental component of any comparison is a previous experience of something that we deemed sufficiently similar to compare it to. That may be easy with movies, yet harder to come by when we think about a colonoscopy. Experiences of medical care are mainly non-comparable, singular events in their nature. We do not have an operation to remove our appendix at Central Manchester Hospital and then decide to go to France to have the same procedure all over again. Once it's done, it's gone.
That illustrates of how little use NHS satisfaction surveys are. People simply have nothing to compare it with when it comes to medical care experiences. At best, they may re-visit the same hospital again and their rating may simply reflect whether or not the hospital itself has improved its care quality over time. Cross comparisons between hospitals or even between the NHS and other care organisations can hardly be based on patient satisfaction surveys.
As a foreigner, I have the privilege ( or perhaps the misfortune) to know two health systems, the NHS and the German system, a de-centralised health care model based on mixed economy health providers. I also work in a university hospital in Wales, one of the largest in the country. Although I bristle at the dire state of hygiene in NHS hospitals and the poor food, I could hardly comment on whether Welsh surgeons would do a better job at operating my appendix than any German doctor would. What I do know however is that if I hear any politician speak of how great the NHS is because they have the highest satisfaction ratings in years, I will roll my eyes and hope I never be asked to fill in one of those surveys.
The authors of the report suspect reverence for medical professionals the main reason. But another reason for why we rarely say much about the NHS is that we simply don't know. Look at it this way.
Rating a good or a service inevitably involves comparing it to a previous experience. We may often not be aware of this comparative exercise, but when we say something about a movie we have seen, we intuitively judge it against a previous movie experience. Although comparisons are complex mental exercises, the fundamental component of any comparison is a previous experience of something that we deemed sufficiently similar to compare it to. That may be easy with movies, yet harder to come by when we think about a colonoscopy. Experiences of medical care are mainly non-comparable, singular events in their nature. We do not have an operation to remove our appendix at Central Manchester Hospital and then decide to go to France to have the same procedure all over again. Once it's done, it's gone.
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| Not your usual NHS staff - or so you hope! |
That illustrates of how little use NHS satisfaction surveys are. People simply have nothing to compare it with when it comes to medical care experiences. At best, they may re-visit the same hospital again and their rating may simply reflect whether or not the hospital itself has improved its care quality over time. Cross comparisons between hospitals or even between the NHS and other care organisations can hardly be based on patient satisfaction surveys.
As a foreigner, I have the privilege ( or perhaps the misfortune) to know two health systems, the NHS and the German system, a de-centralised health care model based on mixed economy health providers. I also work in a university hospital in Wales, one of the largest in the country. Although I bristle at the dire state of hygiene in NHS hospitals and the poor food, I could hardly comment on whether Welsh surgeons would do a better job at operating my appendix than any German doctor would. What I do know however is that if I hear any politician speak of how great the NHS is because they have the highest satisfaction ratings in years, I will roll my eyes and hope I never be asked to fill in one of those surveys.
Sunday, 8 April 2012
Socialism reborn - Welsh Labour and the NHS
The NHS in Wales is in real difficulties. The budget has been slashed (before inflationary effects are taken into account) by about 9% this year. This spells trouble for the Welsh NHS. A medical service whose costs are constantly growing because of increasing demands from an aging population, requires more resources, not less. Yet the Labour Government in Cardiff thought it can get away with it. This onslaught on the Welsh NHS has been long planned and carefully prepared by the then Health Minister Edwina Hart. She made sure that the NHS now collects less performance related data than ever in its history. Transparency of the service and how it measures up to clinical benchmarks is at an all time low. Performance targets were removed by the Labour politicians in case they may turn out to embarrass them.
Yet for some, the dire straits of the Welsh NHS are all the fault of the evil doctors who work every day in its wards and clinics. The Bevan Foundation, a socialist Think Tank has just published a pamphlet by a Welsh clinician, Julian Tudor Hart (no relation), who argues that the NHS should be further nationalised and general practitioners, who are currently working under a contract with the NHS, should be forced to work as employees of the NHS with fixed salaries.
His pamphlet is sprinkled with vacuous slogans, but the ultimate aim of his proposals for the NHS is revealed in the last paragraph. The document culminates in a phrase straight out of Stalin’s writings: ‘We need to make Wales NHS into the property of the people, personally and collectively – a national institution shared and owned by everyone... This is the only way to ensure it will never be taken away, and that Wales NHS can resume development as a potential birthplace for democratic socialism.’ Taken away by whom? Aliens? Evil doctors? Or even patients perhaps?
Anybody remember what happens to institutions and organisations that are allegedly ‘owned by everyone’? Yes, no one feels any responsibility for it. The fact is that Hart’s wish to make the NHS ‘owned by everyone’ reflects a breathtaking ignorance of the dynamics of large scale organisations, of which, incidentally, the NHS is one of the biggest in the world with more than 1 million employees in the UK. If he thinks that commitment and work discipline can be instilled in the people who work there by telling them that ‘they own the place’ is naive at best, crooked at worst.
As Leo Trotzky wrote long time ago about the Soviet soialism: if everyone owns everything, no one owns anything. We know where this all ended, don’t we?
Tuesday, 20 March 2012
What's rail privatisation got to do with the NHS?
With the health and social care bill going through parliament, some commentators have likened the changes in the NHS with the privatisation of the railways under John Major in 1993. Besides the strange logic of this analogy, the argument put forward for the privatisation of the railways made much about railways competing for customers (or passengers) and this argument is now widely regarded as lost. So why can railways not compete against each other? And if this is so, is the privatisation of any public service bound to fail?
The main case against railway competition rests on a specific understanding of the nature of the service offered and the way in which it is consumed. Railways require the use of tracks and hence, where they compete for passengers, they must use the same resource. Since they cannot use the same track simultaneously, competition can only occur where people are on non-essential journeys. This narrows the chances for genuine competition between railway operators significantly. No passenger commuting for work between Bristol and London can effectively delay her journey until the next train arrives which may be cheaper.
But the issue on which competition between railways really falls down is price. Railways gain the approval to run trains on particular lines through franchises which are granted by the government. Nothing stops the government to grant two or more licenses for the same line in certain areas, say between Birmingham and London. Theoretically, train operators could compete for passengers by offering lower prices than any other providers for this section of the line. Why dont they?
There are lines where two independent rail companies do operate services, London Victoria to Gatwick Airport is one of them. Now franchises explicitly prohibit railways to cross-finance operating costs, so they cannot, say run a line between London and Birmingham on a profit and transfer the profits of this line to offer prices below operating costs on another line. This means that bidding wars (such as the Murdoch price wars in the British press in the 1990s) are ruled out.
Yet the railway system is also set up in such a way that even genuine price competition between operators on the same lines do not translate into lower fares. The Gatwick line is a good example. Despite the choice passengers have between two different train companies, both only offer (roughly) similar prices for the same route and distance, which are incidentally higher than for other comparable routes. Why is that?
The reason is that choice is a blunt instrument for price competition once you do not allow providers to cross finance losses. Both operators on the Gatwick route know that passengers have no other option than to take one or the other operator. Journeys to Gatwick Airport are ‘essential journeys’ given the lack of alternative transport options. This means that, once the lowest ceiling is set through the franchise and the ban on cross-financing, both operators can safely cash in on whoever needs to get from London to Gatwick Airport (and back).
In other words, the chances are stacked against genuine choice due to the very nature of rail transport. And so railway competition as a means to drive fare prices down is unlikely to succeed. This does not however mean that privatisation is wrong or that it would not have an effect on the costs of running railways. What the privatisation of railways did achieve in the UK is that the railways are run far more efficiently now than they used to. So, privatisation does have a positive effect, just not the one politicians often want it to have, leading to lower fares through direct competition for business.
It is interesting that in the public debate the two things are often mixed up. Privatisation is taken to have failed since competition between train operators cannot occur to lead to lower fare prices. Yet privatisation is not just about competition, often more importantly it is about driving out inefficiencies that creep into any publicly run organisation funded through a guarantee of government funding.
This is where the case for railway privatisation is relevant to the NHS bill. While competition on price between providers is highly unlikely to have the desired effect (of cutting health costs), running a large organisation as an efficient business drives down costs where publicly funded organisations are more likely to waste money.
Incidentally, this is what Tony Blair’s government recognised by pushing most NHS Hospitals into independent trusts that had to stay within their budget. And this is behind the recent warning of the Welsh health minister that trusts in the Welsh NHS that rake up significant losses wont be bailed out. The question is what works: wagging the finger at large public organisations or introducing effective drivers for change. I’m all for the latter.
Thursday, 1 March 2012
The dilemma of the NHS
The NHS bill for England currently going through the House of Lords is in deep trouble. If you had any doubts about this, note that the Health Secretary Andrew Lansley has volunteered to give an interview to Jeremy Paxman (who was uncharacteristically civil last night, you can watch his interview with Lansley HERE ).
Whatever you think of the politics of the NHS reforms, there are some aspects that hint at a deeper dimension of how we think about our public services. What do I mean? Consider briefly how different the approaches are to the NHS in England and Wales. It is no secret that the Welsh Government has little appetite for radical NHS reforms. While there is a lot of 'policy noise' from Cardiff about improving public services, integrating health and social care and more community care, the Welsh Government has consistently rejected to give front line professionals the means to change things for the better.
We know that, in order to reform public services, you need to introduce the things that drive positive change; well meaning policy is not enough given the inertia of established practices and the attraction of 'things as they are'. We are all creatures that value constancy and stability whilst trying to reduce risks.
In public services this may result in a false dichotomy as the most recent developments in Wales may demonstrate. Leaving the NHS the way it is means effectively to shrink it in its scope and resources. Wales, more so than England, has a rapidly aging population, with the attendant problems of increasingly expensive treatments and medication. And I have not yet mentioned the issues of personal choice and care quality for which there is a clear preference amongst patients.
This all creates a perfect storm for the NHS in Wales which is facing reduced resources, spiraling costs of treatments, an aging population and current practices that privilege highly inefficient and costly approaches to health with poor care integration, and preference for hospitalisations over community care.
Now, contrast that with what patients want and you realise that it takes courage and an enormous amount of risk to drive through changes in the NHS. As the latest demonstrations in front of the Welsh Assembly show, patients above all want one thing: the continuation of things as they are.
Incidentally, that is exactly not what is likely to happen if things are left alone.
So, in essence, there are no easy solutions, with politicians more than ever trying to muddle through complexities of care systems and exploding costs. Whether we like it or not, the NHS will increasingly adopt the role of an emergency care provider (free at the point of use) with patients being signposted to private providers where non-urgent clinical care is needed. Should we regret this?
Whatever we think about free health care, it is only free at the point of use. The aim should be to ensure it remains largely free for those most in need. That would be an accomplishment we could celebrate even if, in future, many of those who can afford it may have to pay something towards their health care costs.
Tuesday, 27 September 2011
What is Labour for?
Life on the benches of Her Majesty's opposition is tough. Hardly anybody wants to hear what you say and even fewer people care. The fall from grace for Labour was particularly hard. Under Gordon Brown, the party achieved the second worst result in a general election in its history.
As the Labour conference is coming to a close in Liverpool, the party had to answer above all one question: what does the party stand for? What is Labour for?
The instant answer is the easy one: to hold the government to account, to scrutinize ministers and to offer an alternative to the government's agenda. However, at the heart of the struggle for influence in the public's psyche always stands another quest: to define the public debate, to shape the way in which we think about the challenges ahead for society.
It is this grander project that Labour has to find answers to over the next couple of years. The way back into power will only be possible if it can persuade the British people that its vision of British society contains the right answers to the difficulties of a modern state with a market economy that is operating on a global scale.
There are two main challenges to defining such a viable vision. The first is that Britain is placed in a difficult spot with a diminishing manufacturing sector, an overgrown banking sector that has failed to invest in technology and the things that create jobs outside the City. Returns for investments in stocks and shares were a manifold of what investment in manufacturing or engineering promised. A skewed education and skills sector has failed to create strong links with industry, producing fewer and fewer apprenticeships and training places.
The second big challenge is political in nature. While individual lives are lived in villages and cities, in concrete environments and people demand ever more control over their lives, the mechanisms to drive change and impose order on society have become more and more centralised over the last decades. The best example is the NHS. This great national institution is riddled with contradictions: devolution of the NHS into the four components of the home nations England, Wales, Scotland and Northern Ireland; a drive towards 'eliminating post-code lottery' and health inequalities exist simultaneously with an emphasis on individualisation and the need for personalised health services.
The previous Labour government relied on one dominant mechanism to drive change: central government and targets. It attempted to micro-manage public services but, reluctantly, also created some limited elements of local control, such as local regeneration partnerships. It didnt work. While it frustrated communities that they didn't get sufficient control over important decisions, central government also never managed to ensure that public services improved in line with the enormous amount of extra expenditure they received.
So the lesson is simple: the state cannot drive change in public services in the way it used to. Once this is clear, the magnitude of the challenge for the Labour Party is revealed. Who or what is to change society for the better? Local communities will want to have more choice, more say and more decision making powers; industries will be more global and public services under the control of central government will become less and less responsive to targets. The old certainty of change driven by central government is gone. Increasing expenditures does not guarantee that lives are improved on a local level. Labour has to formulate a convincing answer to this if it wants to shape the discussions on the future of British society. If it does not, Her Majesty's opposition will consist of the same party for a long time to come.
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