Thursday, September 13, 2007

The doctor's Rant in private

The Dr Rant team are banging on about how private medicine is evil. Again.
Another of our favorite refrains is 'I pay my taxes' and 'give me my money back and I'll spend it on health care as I see fit'.

Let's just work out what that adds up to.

Health Care spending in the UK is currently around £75 billion. There are about 65 million of us, so that works out at £1153.85 per person per year.

This is for everything - ambulance fees, A&E visits, GP consultations, outpatient visits, surgery, home nursing care.

What do you think £1152.85 per year would buy you?

Hmmm, healthcare spending is nearer £80 billion this year and Burning Our Money, examining the latest Wanless Report, gives us just some of the reasons why.
The bald facts are these. Since his first report in 2002, total NHS spending has surged by nearly 50%, or £43.2bn. That's a real terms growth of 7.4% pa, and takes us close to the EU average for health spending as a percentage of GDP. So as of now, nobody can argue the NHS is substantially underfunded.

But as we've said many times on BOM, spending money is easy: it's what you get back that's counts. And across 321 weighty pages Wanless confirms that we've had abysmal value.

To start with, getting on for half of the increased spending (£18.9bn) was gobbled up in those big pay and price increases (see many previous blogs on the NHS pay deals). More money has been poured into hopeless projects like the NPfIT, where the report demands a full drains up.

Second, although there has been a huge increase in NHS staff numbers - up by one-third to 1.3m - their productivity has fallen sharply.
...

Third, the top politicos and their ranks of health commissars did an appalling job at directing the splurge.

But, the Rant team have some exciting news to impart.
Bear in mind that this works out at a little over £22 per week, and the average person visits their GP six times per year, has 3 basic blood tests per year, and receives 20 prescription items per year.

Really? What the fuck for? I have visited my GP three times in the last 11 years (including my original registration). The other two times, I got antibiotics on one occasion and a prescription for Betnovate on the other (I don't believe that this requires a prescription anymore). I have had no blood tests and no other medication.

Some people really are either very unhealthy or really fucking paranoid. Although, might I venture to point out that taking average in an organism, such as humans, which need more care as they get older might be a little skewed? No matter, on we go...
Devil's Kitchen will no doubt point out that they can get 'fully comprehensive' private medical insurance for £50 a month. Read your policy again: it does not cover ambulance fees, emergencies, primary care, prescription drugs. Even the surgical fees that it does cover (for example, a hip replacement) are heavily discounted because if anything goes wrong the NHS provides all the super-expensive rescue care (such as a bankruptingly expensive stay on a High Dependency Unit).

As promised, I have been getting up to date quotes (from Health-On-Line, who paid for my mother's recent (and entirely satisfactory) operation). The current quote, fully comprehensive, is £49.26 per month. Interestingly, the fact that I smoke has no effect on the price!

There are a few small bits of small print, but they are all quite acceptable; the main one is that you do have to pay an excess of £100 per year (i.e. you pay the first £100 of any treatment in any one year), and they will not pay for treatment for a known existing condition until you are two years into the policy (unless that condition has required no treatment for the previous 5 years).

Now, onto the Rant teams accusations. First, ambulances are required by law to deliver to a state A&E hospital. Second, of course, there is only one private A&E centre in the country at present: one could argue that this is because the state does it better. One could also argue that, since ambulances have to deliver to a state A&E department, that is distorting the market.

Anyway, my contact has come back with the follwing remarks.
PMI policies do not cover Primary care, out-patient prescriptions or emergancy calls.

However they do cover all in-patient drugs and dressings and ambulance costs between hospitals where medically necessary.

Cancer drugs are covered in full, so we are only talking normal prescription medicines that we would all normally obtain from a pharmacy.

Once a patient has arrived at an A&E department, unless they have a six week plan [which Health-On-Line do not sell], there is no reason as to why they should not be moved to a Private Hospital.

The real point about private medicine is that you can get a replacement hip in 2 months (as my father's wife did back in June) rather than two years. It's all very well saying that the NHS is good value for money, but if you need that CAT scan now then getting an appointment to see a consultant in 6 months, who will book you an appointment to get a CAT scan within the next 6 months, simply isn't good enough.

I cannot emphasise this enough: the NHS is not free. In fact, it costs someone on the median wage, of roughly £23,000, more than double what private medical insurance costs. If people paid the money that is taken off them in NICs into a private health insurance plan, at least it would actually go towards their fucking healthcare and not into the pockets of lazy, corrupt fat-cat politicos.

However, if we are to maintain the NHS, I can agree with some of Team Rant's interim policies.
Personally, I think a better service is more likely if we:
  • fire 80% of the managers.

  • get rid of all the form-filling red tape and give tactical control back to front line professionals.

  • get rid of the culture of institutional corruption (targets, lying managers, 'best year ever')

  • cancel 'big idea' IT projects and go back to using home grown, successful, 'small provider' local solutions.

  • stop diverting money to big companies (PFI, ISTCs etc..).

  • go back to old-fashioned nursing (I don't know what they are teaching in nursing school, but I do know its not nursing).

  • stop designing services for the vocal minority (like our very own Anonymous).

  • stop giving every Ivory Fuckwit with a mouth free reign to implement their pet project.

  • use the savings to reduce bed occupancy to 70%, bring cleaning contracts etc.. back in house, hire more nurses, hire more physios, increase nurse:patient ratios, and bring long term elderly care back into the NHS.

On the last note, it is worth pointing out that the NHS has hired more nurses. In fact, if you look at the chart below (pinched from Burning Our Money), you can see that, instead of hiring the 20,000 extra nurses that they had planned to, the NHS instead hired 67,878: 239% over target.

And yet, Team Rant and Dr Crippen both tell us that nursing is in a shocking state. Which is why I agree with the "go back to old-fashioned nursing" point above.

But what Team Rant do not seem to realise is that as long as the NHS is run by politicians, none of this is going to change. And as long as the NHS remains entirely public and funding remains entirely through taxes, this is not going to change.

Privatising all hospitals and forcing them to compete properly would be a stunningly good start, even if you are going to keep the whole monolith publically funded.

37 comments:

Mark Wadsworth said...

Privatising all hospitals and forcing them to compete properly would be a stunningly good start, even if you are going to keep the whole monolith publically funded

Agreed. It is best to look at the provision side and the funding side as two completely separate issues. Even if publicly funded, it wouldn't be a monolith, would it?

Anyway, aren't GPs exactly that - publicly funded but competing private providers?

Zarathustra said...

As regards the point about "old-fashioned nursing" versus "university/too posh to wash/over-educated" nursing training, I would staunchly defend the current university-based system. (Declared interest: I recently qualified as a nurse via the degree route, passing with first class honours).

My reasons for this are laid out here.

It's certainly true that the old Project 2000 nurse training system was deeply problematic - not enough emphasis was placed on the link between theory and practice, students didn't spend enough time out on the wards. However, these problems have largely been addressed under the new, reformed syllabus that replaced Project 2000 in 2002. Student nurses now go out on placement earlier and more often, local NHS trusts now have more of a say in what goes on the syllabus so that the universities are producing the type of nurses the NHS wants, students complete a three month "management placement at the end of their final year where they act as nurse-in-charge of a ward, so as to get their feet on the ground ready for qualifying.

My experience is that the main problem facing nursing in Britain at the moment is not the education system but appallingly low ratios of nurses to patients. I recently spoke to a nurse who had to deal with 13 high-dependency patients on her own for a 15 hour shift (no breaks). 8 of those were unable to feed themselves, and 10-12 of them were incontinent. Even the best nurse in the world can't provide good quality care under those conditions.

That's why on the Mental Nurse blog we're campaigning for statutory minimum nurse-patient ratios to be set by the government. More about what we're doing here.

Roger Thornhill said...

zarathustra, the argument over "too posh" or "not too posh" is easy to resolve: break up the monopoly and make the UK's healthcare have plurality of provision and decision-making by those providers. Very soon the best system will become obvious and each hospital will decide for itself based upon patient response and people voting with their feet/bedpans.

It really is that simple. We do not need some centralised GOSPLAN to decide for the entire country or for the monolith to lurch from one fad to another.

Zarathustra said...

Actually Roger it was resolved some time ago by an increasing pile of peer-reviewed research evidence.

Paper after paper has provided research showing that nurses with university degrees are significantly better at keeping their patients alive than those with the old-style diplomas. Look them up on Google Scholar if you don't believe me.

the A&E Charge Nurse said...

Roger Thornhill - the Wanless report confirms that A&E attendences have gone through the roof [up by 30% over the last few years].

Today the NHS deals with 19 million A&E visits each year.

Now, take a look at the rates for a private A&E provider, the snappily named "Casualty Plus",
Consultation = £45-£60
Plaster cast = £39-£49
Sling = £19
Crutches = £39
Ear Syringing = £39
I assume they can deal with more than one problem at a time ?
www.casualtyplus.co.uk

Now, add up the average cost for each visit then times that figure by 19million.

The vast majority of the problems that Casualty Plus deal with would be bread and butter to any [NHS] Emergency Nurse Practitioner - in other words private A&Es only seem to offer a service [at hugely inflated prices] for uncomplicated minor injuries and illnesses, or "dross" as some of the dysfunctional adrenaline seeking A&E staff call it.

But even then Casualty Plus fails to provide ANY follow up for fracture management, wound complications [such as infection, removal of sutures], nor do they provide a 24/7 service [which might be a tad inconvient if you sustain an open femoral fracture at 2 o'clock in the morning].

Needless to say there is no on-site specialty expertise such as plasics, orthopaedics, and vascular surgeons, etc [you need a proper hospital for that].
And what do they do when they realise that the elderly lady with a wrist fracture has fallen down because she has just suffered an atypical MI - I mean do they even perform an ECG if they cannot provide thrombolysis or angioplasty ?

A&E has gone from being a national disgrace to a decent service [most of the time]. We continue to introduce innovations such as throbolysis for CVAs [which obviously requires C/T scan back up, neurology expertise, rehab provision, etc, etc.

I find it almost laughable that market lovers persist with the fantasy that there will be x3 A&E depts in the locality, and the crap one will be forced out of business unless standards improve.

We've heard similar argments about schools, but in general if schools are crap it's because they reflect the crap socioeconomic problems of the region - and historically [with one two exceptions, perhaps] this has always been the case, and always will be IMHO.

Zarathustra said...

Just having a browse at Casualty Plus' price list myself:

Dressings
(Standard dressings only - not prescription dressings) £9.00 - £35.00


35 bloody quid to clean out a wound and slap a dressing on it? I'd rather just buy the dressing from Boots and do it myself!

39 quid to have my ears syringed? Jesus!

Zarathustra said...

Also, their FAQ page is proving enlightening:

What happens if my condition is more serious than I thought or a medical emergency arises during a minor procedure?

Occasionally on examination the doctor may decide that a condition is more serious than it first appeared or complications may suddenly and unexpectedly arise. On the rare occasions when this happens, Casualty Plus will always put your safety and well being first. We have specialist emergency facilities to stabilise patients and once we are satisfied that this has been achieved, we will arrange for emergency admission and/or transport to the nearest suitable NHS or private hospital, depending on your wishes. Our primary concern is always to ensure that you receive the best possible care.


So, to translate that into English:

"If you turn out to have anything more serious than a broken leg, we'll call an ambulance and pack you off to a real A & E."

Devil's Kitchen said...

Charge Nurse,

A few points to address:

"Now, take a look at the rates for a private A&E provider, the snappily named "Casualty Plus"... Now, add up the average cost for each visit then times that figure by 19million."

Now, this is all very well, and I take your point: can you please tell me what the equivalent cost in the NHS is?

So, a plaster cast is £39-£49 at Casualty Plus: what is the cost of a plaster cast on the NHS? (Including staff costs, building costs, running costs, capital costs, etc. obviously.) I really doubt that you would be able to tell me (I doubt if even the managers in the NHS know, to be honest.

You are correct that private is expensive, but might that private A&E not actually be reflecting the true cost? After all, it is worth remembering that nearly all PCTs are in large amounts of debt, and some would be considered bankrupt were they private businesses.

"The vast majority of the problems that Casualty Plus deal with would be bread and butter to any [NHS] Emergency Nurse Practitioner - in other words private A&Es only seem to offer a service [at hugely inflated prices] for uncomplicated minor injuries and illnesses, or "dross" as some of the dysfunctional adrenaline seeking A&E staff call it."

Well, that is to be expected as Casualty Plus can only deal with walk-in treatments. As I said earlier, the law requires that ambulances deliver to state hospitals.

As I also pointed out, this skews the market. As does the fact that the NHS A&Es are "free" at the point of use: since, at an A&E department, you will get seen in a matter of hours (admittedly, that might well be over the 4 hour target), this is considered a fair trade-off.

Where private medicine picks up customers is when people are told that they will have to wait a year or more for their elective surgery: with private means, then you will have your operation done in a couple of months. To someone in constant pain with a fucked-up hip (like my father's wife), it is worth going private.

"But even then Casualty Plus fails to provide ANY follow up for fracture management, wound complications [such as infection, removal of sutures]..."

Sure, sure. But again, the "free" NHS distorts the market here. Casualty Plus is a walk-in A&E: I do not believe that NHS A&E provides that back-p either: you would have a routine appointment for such things.

"... nor do they provide a 24/7 service [which might be a tad inconvient if you sustain an open femoral fracture at 2 o'clock in the morning]."

And in an NHS A&E, something might well have been done about that fracture by 6 o'clock in the morning (provided you haven't just been shoved into the "waiting to get treated" area for another 4 hours.

Again, the NHS distorts the market: if NHS A&E did not exist, or was far scantier, or ambulances were allowed to deliver to private A&E clinics, they may well open 24 hours. But, at present, the demand is not there.

Needless to say there is no on-site specialty expertise such as plasics, orthopaedics, and vascular surgeons, etc [you need a proper hospital for that].

Of course, and I don't think that Casualty Plus are advertising that level of care. However, I repeat, were the NHS non-existant then these facilities would be provided. I hesitate to point this out, but we know this to be the case since it happens in every other country that has a private hospital system (even if the funding is not entirely private).

"And what do they do when they realise that the elderly lady with a wrist fracture has fallen down because she has just suffered an atypical MI - I mean do they even perform an ECG if they cannot provide thrombolysis or angioplasty ?"

Again, you can say all of this: and again, I can point out that the NHS distorts the market. Every other country seems to have managed.

"A&E has gone from being a national disgrace to a decent service [most of the time]."

I'll take your word for that. The few times that I have been to A&E (most recently with my girlfriend of the time, in December), I was less than impressed. However, I am sure that for much of the time, it is great. But ask yourself: could it be better?

"We continue to introduce innovations such as throbolysis for CVAs [which obviously requires C/T scan back up, neurology expertise, rehab provision, etc, etc."

Yes, yes, yes, and you have a whole hospital behind you. That's very nice, but it is worth reminding everyone that we have all been forced to pay for it: it is not "free".

"I find it almost laughable that market lovers persist with the fantasy that there will be x3 A&E depts in the locality, and the crap one will be forced out of business unless standards improve."

Why?

"We've heard similar argments about schools, but in general if schools are crap it's because they reflect the crap socioeconomic problems of the region - and historically [with one two exceptions, perhaps] this has always been the case, and always will be IMHO."

You are right. In the places in which voucher systems have been introduced (namely Sweden and a few trial areas in the US), the bad schools have, in general, not shut down: they have got better.

Given that there is huge (and, apparently increasing) demand for A&E services, why do you contend that, were hospitals private companies that had to compete against each other in an open market (let's leave the actual question of how the operations are funded out of this for the present), the same thing would not happen for hospitals as it has for schools?

What makes health provision so completely unique?

DK

Devil's Kitchen said...

Zarathustra,

Yes, quite. They say exactly what they are their to treat: minor injuries, essentially.

Or would you prefer that they did not pack you off to somewhere with proper facilities (and note that it also says you can go to a private hospital, if you so wish) and tried to treat you with inadequate technology and experience?

It's a bit like an NHS hospital packing you off to a more specialist hospital. You know, you have a head injury, so Pembury Hospital will pack you off to Atkinson Morley (if that even exists any more) because that is where you'll receive the best treatment.

DK

Mark Wadsworth said...

To back up DK, in Germany, hospitals are owned and run by a whole range of people; private individuals or companies; insurance companies; local authorities; universities; all sorts of stuff.

And funding is via 'compulsoary insurance' on wages (i.e. a tax) but you can sort of opt out, and pay top up fees if you want a single room not a ward and so on. So it is still as free at the point of use.

And it works fine. Yes, there is the moral hazard aspect that has seen the costs go through the roof, but hey, which leads on to...

CP's charges, like DK said, I am sure somebody can sit down and work out what the FULL cost of such operations or procedures. And the patient signs a chit to say what he had done, and the hospital or surgery or clinic claims it back.

If they can do it cheaper than that price, they make a profit. If not, te management gets repaced or the business gets sold onto the next lot who try again. Like in Germany. Hospitals over there seldom shut (or not as much as over here) they just get taken over by new management or new owners. And nurses don't get sacked, it's just the senior management.

Yes there will be fraud and stuff, but compared to the massive over-spend in the NHS, it ain't significant.

As to moral hazard (part 2) the tax paid by smokers, drinkers and the alcohol industry are difficult to estimate, but are enough to cover about a quarter or a third of the NHS budget. So instead of smokers paying higher premiums, they pay their share (and more) via the tax system.

lost_nurse said...

DK - it's a tired point, but textbook/back-of-napkin/fag-packet notions of "competition" mean fcuk-all when the consumer is rapidly exsanguinating (i.e. re-decorating the walls and ceiling). It's in the small print (next to the big print about free gym membership).

I don't claim unique status for health provision, but nor would I be comfortable in suggesting that intubating joe bloggs with his head injury is like selling white goods. The consumer might well be the expert - but down the mall, he usually has a GCS of 15, with an unimpaired gait. He functions. He shops. And usually in a reasonably planned manner. Is the same true of an acute MI? (ps. economic dogma is not your only guide down this particular patient journey/pathway/ protocol/experience - and if seeing those words together doesn't bring the esteemed Dr Crippen back into the fray, nothing will).

Critics of the NHS often invoke the charitable institutions that form part of its heritage - to me, that's a de facto admission that "the market" ain't gonna take the strain. For sure, things like PBR (payment-by-results) are simply piss-poor State efforts at faux-competition. But they illustrate the dangers of looking at acute care from the outside, and saying "if only it was all just like a supermarket - now bring me a flow chart." And that is just asmuch the language of would-be marketeers, as it is of central planners. My dad is not long off retirement after many, many years as a Doc in neonatal intensive care. He is not the swearing kind, but he'd probably outdo even you, if asked about how one competes in emergency/critical medicine. Indeed, in the city I know (and love) best, serious stuff gets done because major hospitals co-operate (as regards differing specialties - e.g. neuro, renal etc etc). As a potential patient, I'd rather have it that way.

Yes, the market for elective surgey is real enough (your mum's hip). But capacity for dealing with messy reality? How do you pool that risk? The infrastructure? The staffing? The culmative experience? All that, uuhh, "out-back" stuff - scanners, theatres etc? Are you envisaging special offers on multiple trauma & mixed aetiologies, as part of your start-up? As for us feckless public sector wasters - "plurality of provision" = "an ever more mobile workforce, moonlighting on a global scale, without bothering to stay on at the end of a shift."* It is - possibly - the future. In some respects, it's already here.

In some respects, I'd rather we moved in the direction of the continent (serving a healthier, leaner joe public - nanny state sensors are no doubt on...). But extant systems in France, Germany etc are not without their own problems. Besides, moving away from witless, top-down diktat doesn't automatically mean "competition" -it might even mean "localisation." Imagine that...

(*And as we continue to bankroll PFI consortia, at the expense of such distractions as decent nurse/patient ratios...why not?)

Devil's Kitchen said...

Lost Nurse,

It is worth pointing out -- again -- that the majority of hospitals are privately owned on the Continent, and their health services tend to outstrip ours in terms of quality.

You might also have noticed that businesses also do work with each other. Being in competition does not mean working towards mutual destruction.

"Besides, moving away from witless, top-down diktat doesn't automatically mean "competition" -it might even mean "localisation." Imagine that..."

Well, yuou know that I would support that. In fact, I have written numerous times about how making the hospitals private would actually encourage localisation: they would have to be more responsive.

As you yourself point out, the "Third way" fudge that is PFI does no one any favours: under PFI, the private sector was supposed to shoulder the risk but it does not because the government cannot afford, politically, to let the hospitals go bust.

I say that we should remove the state entirely and run hospitals as private companies: in this way, the private sector would, indeed, take on the full risk.

As I said above, let's leave aside the funding issues (you can split them, you know) and look at the way in which hospitals are run: top-down central diktat obviously doesn't work, so make hospitals totally independent.

The market then provides the regulation that the government presently does.

I take your point about A&E, of course, and I would assume that current hospitals would maintain their A&E departments.

However, there are many places in which the nearest A&E is a dangerously long way away: in a market, hospitals would see demand and then, probably, open their own A&E departments.

This leads to more local A&Es and less strain on the current A&E departments.

As for this nurse/patient ratio thing: as Wanless pointed out, since 1999 the NHS has recruited 67,878 extra nurses (239% more than the 20,000 extra they had targetted): so where are all these bloody nurses?

DK

Anonymous said...

"fire 80% of the managers"
Would you suggest that as a way to improve Marks and Spencers?

You have fallen for the biggest politicans con on earth - "its the managers fault" - but the managers are there to ensure the Governments policies are implemented.

How d I know? I spent 10 years running NHS hospitals, five years in the Department of Health. Oh and 18 years in the private sector.

Casualty used to make me piss myself laughing - the manager had to carry a clipboard - "Time and Motion study" style. Actually I know a lot of clinicians who are very very lazy and do very little.

Oh no, they are "angels" everyone says. Thats because you think you get health care "free"

Blog on - mostly you are great value.But you have a lot to learn about this £80bn industry

lost_nurse said...

"so where are all these bloody nurses?"

Gossiping in the sluice/sat on the nurses' station/fighting for the quality street/some other cliché?

It does look very "boom n' bust", although to be fair, not all of 'em were destined for hospitals. Different services have been expanded (some of them onto Dr's toes). And existing hospital capacity is becoming ever more "acute" (i.e. "HDU" patients nursed on general wards, faster turnover, more intensive use of beds etc). Nonetheless, as others more, er, senior than I will point out, there's also a fair bit of smoke n' mirrors going on in nurse recruitment - frozen posts, "acting up" etc. Plus, of course, an experienced, battle-hardened band 6 RN is a very different beast from someone like me (7 years as an auxiliary - five months off qualifying as a staff nurse, if I get there) - and by necessity, it's a bloody steep learning curve trying to fill those kind of shoes, when their owner retires/leaves for Australia. It's a given that better nurse:patient ratios are a major factor in patient survival (not to say decent pressure care, nutrition etc etc). But experience counts for a hell of a lot, too. And in that respect, certain specialties (e.g. PICU) are very short...

Anyway, we agree on "localisation" in some form. And in that spirit, I am about to re-localise to the pub... :)

AD627 said...

"the Wanless report confirms that A&E attendences [sic] have gone through the roof (up by 30% over the last few years)."

Yes they have haven't they? Is this because in the 21st century we have suddenly become a nation of the seriously ill?

No, it's because this moronic government renegotiated the GPs' contract, paying them vastly more money but allowing them to refuse to see patients out-of-hours. This has forced millions of people to trek to A&E with their minor ailments because they have no way of knowing that they are not in fact serious or urgent.

That is why DK’s model of competition and localism is vastly superior – it is incapable of being wrecked overnight by a single instance of mind-boggling government ineptitude.

the A&E Charge Nurse said...

ad627 - interesting theory, but somewhat flawed I'm afraid [unless Wanless is a liar].

GP consultations increased by 30% between 1985-2003 - to 250mil in 2005 [p xxi of summary].

And lets not forget the 2.5mil that attend walk in centres.

So if private firms deal with that lot all our troubles will be forgotten, eh ?
Dream on, thats what I say.

Roger Thornhill said...

A&E, DK has dealt excellently with your replies to my earlier post.

Even if GP consultations increased, it does NOT negate the A&E presentations because GPs are just not there out of hours so people have NO CHOICE. If one private health provider bungled their GP contracts as the NHS did it would not matter in the medium term, as everyone would just swap provider until that provider got their sorry arse back around the table to sort it out. It would sort it out pronto, too, otherwise it would rapidly find itself out of business. The NHS just grinds on.

You are still blind to the fact that most of us posting here just want a system that ALREADY works very well in places like Germany and Switzerland. We are not the Utopians.

p.s. zara - peer reviewed papers talk of deaths. People want dignity too. You can squirm all you want, but you must know that a plurality of providers will prevent the monolithic dogmatic lurches we see in the NHS.

the a&e charge nurse said...

Think about it ad627.

We are 30% more sick [in statistical terms] despite;
*more drugs.
*more investigations.
*more services.
*more research evidence.
*more cost.

I agree there is a high degree of ineptitude by HMG matched only by the ineptutde of the worried well who cannot seem to manage the most trivial condition without the full panoply of medical intervention being put at their disposal.

Instead of wasting even more cash on the fatcats, perhaps we should be advising this army of neurotics to get a life ?

Or it may be that you have an alternative theory as to why millioms more now need medical attention [NB ageing population, although pertinent does not explain such phenomenal increases].

the a&e charge nurse said...

roger - the NHS was rated above Switzerland & Germany by the WHO [see most recent rankings].

I agree the Devil is his usual beguiling self, but this does not make him right.

Switzerland is a small country [population of around 10mil I believe] with higher standards of living than the UK.

They pay a lot more for health than we do [as a proportion of GDP] - yet their key outcome measures are not significantly better than the UK - for example, living a few extra months with an untreatable cancer might be seen as a qualified success, at best, in some peoples eye.

Zarathustra said...

DK

So, a plaster cast is £39-£49 at Casualty Plus: what is the cost of a plaster cast on the NHS? (Including staff costs, building costs, running costs, capital costs, etc. obviously.) I really doubt that you would be able to tell me (I doubt if even the managers in the NHS know, to be honest.

It's true that costs can be hard to quantify, but let's have a look at some of those costs quoted on the Casualty Plus website.

The one that leaped out at me was £39 to have your ear syringed. Remember that this is not a high-tech intervention. It's basically squirting warm tap water into somebody's ear. Really not complicated.

So let's start off with labour costs. A nurse's pay starts at about £10 an hour. So let's call it £10 for labour (almost certainly an overestimate, since it hardly takes an hour to syringe an ear. Not unless you're dewaxing Dumbo.)

So what's the other £29 for?

Equipment costs? You need the pulsed water-jet machine, which lasts a long time and doesn't need much maintenance. A small bottle of olive oil to drop in somebody's ear for a couple of weeks leading up to the syringing. Maybe a few paper towels.

Infrastructure? Admin costs? Obviously that's going to add on a bit to the total, but not *that* much when you're dividing the cost among all the other people trooping in and out of the clinic doors daily.

Even so, I find it difficult to imagine that the cost to the NHS of syringing an ear is £29 plus labour.


Then there's the basic objection to privatising healthcare that comes from the many conversations I've had with American friends who simply can't afford health insurance, and are terrified that if they get sick they'll be bankrupted. Certainly the insurance prumiums they quoted would be way outside of my budget.

So, call me a filthy pinko commie if you like (and you probably will) but I think I prefer a mediocre health care system I can access to a world class one that I can't.

Steve_Roberts said...

Well said, DK. Dr rant is excellent on the facts of the problem, but woeful on the solutions, probably because he was frightened by a market as a child.

One suggestion I have is that we disentangle routine primary care (GP and run-of-the-mill A&E), which is low cost and predictable and should be funded by subscription or pay-as-you-go, from 'catastrophe' care (cancer, stroke, spinal injuries), which is high cost but rare, and therefore should be funded by insurance, except for the truly rich for whom pay-as-you-go means they can avoid the costs of involving insurance companies.

As long as we see routine care and catastrophe care as the same thing and fund them the same way we will be devilled [pun intented] by muddled thinking

The a&e charge nurse said...

steve_roberts - WTF, cancer/strokes rare !!!!!

You can't afford to be that naive.

Zarathustra said...

And what do the people who can't afford insurance/pay as you go do?


Do they get a solution other than "die"?

Devil's Kitchen said...

"And what do the people who can't afford insurance/pay as you go do?

Do they get a solution other than "die"?"


Well, take a look at the health service of every other civilised country and you tell me.

Yes, of course they fucking do. Fuck, but I'm so sick of medical types wheeling this shit out as though they had a monopoly on compassion for the poor.

Yes, even the eeeeeevil USA has solutions for this, the biggest being Medicaid for those on low incomes, and Medicare for the elderly (the federal government being the single biggest purchaser of medical provision in the US). In addition, there are charitable institutions, hospitals part-funded by charitable donations, etc.

Or, here's another idea which I amplified some time ago...

""But what about the poor?" I hear you scream, "will they die like rats for want of a credit card?" No, for this is where we look at the alternatives. As part of unemployment benefits, the government will pay your health insurance premiums for you (as NI was essentially supposed to do). They will not pay it to themselves, they will pay to a private company, who will be chosen by you (or your existing supplier if you had one) so that you know that your premiums will actually go towards providing healthcare rather than fat, fucking MPs' over-generous pensions.

If someone should be left without medical insurance, then the solution is simple. If they need medical treatment, they will simply pay back the charges over x years, paying a monthly amount until the debt is paid off. If you can get free credit with a new sofa, then I see no reason why the same thing should not be the case with medical care."


I don't mean it, of course. Actually, I am an uncaring posh boy who is advocating all of this reform as a not so subtle way of killing off the poor, feckless and generally undesirable people in our society.

And I would have got away with it if it wasn't for you pesky kids... I mean, nurses...

DK

Roger Thornhill said...

A&E: roger - the NHS was rated above Switzerland & Germany by the WHO [see most recent rankings].

For "outcomes". God I hate that newspeak. How about being rated by...patients?


A&E: I agree the Devil is his usual beguiling self, but this does not make him right.

And it does not make him wrong, either.

A&E: Switzerland is a small country [population of around 10mil I believe] with higher standards of living than the UK.

It also has mountains and clean air. The very fact that our country is larger is even MORE reason to not have a single privider! More people should mean economies of scale. You cannot throw this stat out with the implication it "means something" without saying what it means. They have a higher standard of living partly because they are not TAXED into the dust.

A&E: They pay a lot more for health than we do [as a proportion of GDP]

We have been over this before. Do stop trotting this raw statement out as it is meaningless. 40% of their spending is OPTIONAL. The basic system has been described as being "excellent" and comparible to a very good private service in Germany or the US.


A&E: - yet their key outcome measures are not significantly better than the UK - for example, living a few extra months with an untreatable cancer might be seen as a qualified success, at best, in some peoples eye.

But they are better, no? With only 60% of their healthcare costs compulsory. 'mazin.

the A&E Charge Nurse said...

Roger - if you think there is a better way to rank health systems [other than that provided by probably the most respected organisations on health matters] perhaps you could kindly share it with us ?

I'm sorry you don't like the phrase "outcomes" but surely it's not my job to invent a new lexicon so as to appease a few blinkered maketeers ?

Satisfaction with services provided by the NHS [and it's staff] have been positively evaluated time and again by patients, both in statistical terms and even on a personal level, for example, our department has received many thank you letters -one recently from a patient who recieved thrombolysis after a stroke - he made a very good recovery.

You may regard my comments about Swiss levels of health expenditure [the highest in Europe] as irrelevant - I don't.

You also seem to imply that Swiss punters are delighted to hand over wads of euros but these exhorbitant sums may be the only way of securing services that we can take for granted in the UK. Look again at the stats on the huge increase in A&E visits, GP consultations, not to mention the millions who pitch up at walk in centres, but it seems some people are never satisfied.

Now, if a country is spending less then the NHS yet doing better in terms of patient satisfaction or [sorry] clinical outcomes, then let me know.

While I value your assessment I prefer to attach more importance to the findings of the WHO - and I think I'm right in saying they ranked the NHS above the Swiss.

Dr Blue said...

We've got our response to Dr Rant: The Wanless Report up now.

We despair of the futility of government action, but don't see the market as the best way of sorting it. We may be proved right or wrong on this second proposition.

The debate is the fun.

Anonymous said...

HMG is crap, the answer ?

Insurance companies apparently.

lost_nurse said...

"Satisfaction with services provided by the NHS [and it's staff] have been positively evaluated time and again by patients, both in statistical terms and even on a personal level."

Well said, A+E C/N - I should clarify that I envy our european neighbours as regards their, uh, healthier lifestyles (all that nordic skiing my Finnish colleauges enthuse about), rather than discontent with the NHS per se. And clichéd nursing sterotypes aside, I am of the opinion that the "Quality Street Index" (as a measure of patient satisfaction) speaks volumes. You could hardly move for donated chocolates on my old SAU - and, horror of horrors, these from grateful punters who had already paid their taxes.

sloshed_nurse said...

colleagues, even.

the A&E Charge Nurse said...

Thanks lost_nurse.
At the risk of sounding like a smug bastard I have a nice bottle of plonk donated to me by a patient who received, gasp, decent treatment [and without any suggestion of being infected by MRSA or any of it's nasty cousins].

I will be thinking of your alter-ego when I'm shlurping it tonight ;-)

Roger Thornhill said...

A&E: Satisfaction

How do 90% of the people know what a really good health service is like? They are given no choice. Like it or lump it. I am not saying the NHS is bad per se, but that the State run monopoly is almost the WORST way to deliver quality and value.



A&E: You may regard my comments about Swiss levels of health expenditure [the highest in Europe] as irrelevant - I don't.

It is your framing that makes the statistic irrelevant, as I said. Can you not see why it is?


A&E: You also seem to imply that Swiss punters are delighted to hand over wads of euros

Swiss Francs, actually (the Swiss are also smart enough not to have joined both the Euro and the pestilential EU)...

A&E:...but these exhorbitant sums may be the only way of securing services that we can take for granted in the UK.

You both presume about both my implication and you presume about it being "the only way". No, A&E, in this argument, the term "the only way" applies to the UK, and it applies to the NHS - the ONLY WAY we can get healthcare today is by having our money taken from us and handed over to a monopoly from which we cannot escape without paying twice. In Switzerland they vote in referendums for their healthcare organisational structures. The system they now have is one that was evolved with direct democracy. Most Swiss must recognise that the system is at least doing a reasonable job for the money otherwise there would be a referendum on the issue.

A&E: Look again at the stats on the huge increase in A&E visits, GP consultations, not to mention the millions who pitch up at walk in centres, but it seems some people are never satisfied.

Has it ever occurred to you that people pitch up because there is no connection between their personal immediate expenditure and the service they get? Is this not part of the "take for granted" you speak of? I will also not accept your subtext here that I am being unreasonable in some expectation and unfairly criticing. No, A&E, my stance is the UK healthcare system is hobbled due to it being a State run monopoly and one rapidly being divvied up by the State into lots of little private monopolies paid for and enforced by the State. The worst "outcome" for some time.


A&E: Now, if a country is spending less then the NHS yet doing better in terms of patient satisfaction or [sorry] clinical outcomes, then let me know.

That is just a request for relevatism as I mentioned above. The French may get a better service but they are just used to it and so complain. They do very well, in fact. Try looking at how they score with their insurance-based system. The Swiss may not sound happy, but because they ARE demanding and wish high standards, they get them but I suspect they consider it "normal". Even if the NHS was doing not-quite-so-bad as others that is still not the point - it would still be organised in a dysfunctional way that prevents it from operating effectively.


A&E: While I value your assessment I prefer to attach more importance to the findings of the WHO - and I think I'm right in saying they ranked the NHS above the Swiss.

OK, lets look at this, then. The WHO puts huge weight on "distributional goals", which they freely admit.

Even then, Singapore was rated 6th. What system does IT use, eh?

Switzerland was second for responsiveness (which involved adapting to patient needs, upholding dignity, treating people as individuals - all those things people yearn for, in fact). UK was joint 26th! Swiss were second for overall goal attainment, too.

And the Swiss came below the NHS? I suspect the NHS got a thumping good score on "distribution goals". No surprise, because in the UK we have NO CHOICE. As with all Statists and Socialists, the issue is not if all get better, just that some cannot be seen to get better or worse than others, even if it means ALL get worse as a result.

The Swiss were 8th in Health Attainment (outcomes, maybe?) and the UK? 14th.

Stats, eh.

the a&e charge nurse said...

Thank you Roger - stats indeed, I daresay we have both used them primarily to reinforce our own prejudices ?

Perhaps I can you leave you with this thought, even if our paymasters do change it will still be the same medical staff that treat patients [given that we haven't got a parrallel workforce].

So if patient buying-power does become the prevailing influence on how services are provided don't be suprised when a tariff is placed on every bit of productivity a la casualty plus [not too mention administrative costs associated with the additional beaurocracy].

Docs/nurses;
*working through breaks,
*staying on after the shift has finished,
*coming in to work on days off [for example when the dept is short staffed, or if there is a major incident,such as the tube bombings, etc, etc, etc] will all come at a cost - and guess who will be paying ?

Well, we already know how much a relatively wealthy/healthy nation such as the Swiss have to spend - and its far more than the NHS.

the a&e charge nurse said...

Devil - maybe you can get a hip replacement quicker when you go private.

But private hospitals don't seem to be too interested if the joint dislocates [ball comes out of the socket] - the most common post operative complication.

We had such a case yesterday and the poor old women came into A&E in severe pain - it didn't seem like the best moment to discuss the importance of duty & continuity of care [concepts that are apparently alien to the privates] - no, you need COMPREHENSIVE services to deal with sreaming old folk with agonising hip dislocations.

Roger Thornhill said...

Stats- The WHO report is blatantly skewed in favour of universal tax funded State healthcare. It is not my prejudice but theirs.

A&E: Docs/nurses;
*working through breaks etc.


You talk as if Docs/Nurses are the only people to do such things! I have done such things all my working life because I am...erm...a professional. You also presume it will not continue.

the a&e charge nurse said...

Roger - which other group of professionals REGURLARLY put in more unpaid hours then docs/nurses ? [and by that I mean every week - including nights & weekends].

For obvious reasons it's not quite the same thing if workers are burning the candle at both ends in order to secure a bigger bonus for themselves at the end of the year.

You distrust of the WHO appears to border on paranioa but surely the criteria used to determine rankings are honerable ones ?
They are;
*responsiveness.
*fairness of financial contribution.
*overall level of health.
*distribution of health amongst population.
*distribution of financing.

As I say the Swiss did OK but they will have to do a little bit better to overtake the NHS.

Roger Thornhill said...

A&E: Paranoia? No, I just relate their own open admission that "distribution" has a heavy, disproportionate weighting in their overall score, so pushing countries like the UK up the list.

At no time did I question their individual criteria, in fact I QUOTED THEM.

I suspect the Swiss would overtake the UK if the WHO's own bais on one metric is removed.

The only paranoia I see here is yours, frankly.