Monday, January 21, 2008

"Clinical need" in the NHS

Dr Rant tears a strip off a pseudonymous medical student, and (nearly) finishes off with this sentence.
The government is flooding the market with doctors, so that it can force doctors of the future to work for poorer terms and conditions in the brave new NHS.

Good for us taxpayers though, eh?

We get cheaper doctors because there are more of them to choose from (your basic supply and demand), plus we get the additional benefit of choosing to employ the very best: sounds good to me.
This brave new privatised NHS will be bad for doctors and bad for patients, as health care is run for profit and not on the basis of clinical need.

Does Team Rant think that we should just carry on as we are? Even after the shocking Taxpayer's Alliance Report into the NHS?
Wasting Lives: A statistical analysis of NHS performance in a European context since 1981 [PDF], analyses data from the WHO to estimate the number of deaths that could plausibly have been averted by the NHS since the 1980s. The measure used is known as “mortality amenable to healthcare”. The calculations compare the UK performance to that of Germany, France, the Netherlands and Spain.
  • If the UK were to achieve the same level of “mortality amenable to healthcare” as the average of the other European countries studied, there would have been 17,157 fewer deaths in 2004, the most recent year for which data is available.

  • This is equivalent to over five times the total number of deaths in road accidents and over two and a half times the number of deaths related to alcohol in 2004.

  • Steady improvements in mortality rates, relative to European peers, have been made at almost exactly the same rate throughout the Thatcher, Major and Blair governments despite huge increases in spending from 1999 to date. There can no longer be any doubt that the Government’s extra NHS spending has completely failed to deliver results.

  • If NHS spending had continued to increase relative to European peers at its pre-1999 rate £34.3 billion – £1,350 per household – less would have been spent between 1999 and 2004. In 2004 alone, £9.8 billion less would have been spent, 9.7 per cent of total spending in that year. This extra money has largely been wasted.

Or, how about this report?
Accidents, errors and mishaps in hospital affect as many as one in 10 in-patients, claim researchers. The report in the journal Quality and Safety in Health Care said up to half of these were preventable. Checks on 1,000 cases in just one hospital found examples of fatal surgical errors, infections and drug complications.

Well, fuck me; if this is how the NHS serves us when it's run on the basis of "clinical need" then, truly, the future must be terrible indeed.

MEMO TO THE GUYS AT TEAM RANT: I am not defending the idiot lass whom you attack, but I would like to remind you that a country's health system is supposed to be there for the benefit of its patients, and not the staff working within it (although, of course, like any other business, it can do both).

Doctors get cheaper? Excellent. We have more doctors to choose from, so that we can employ the best? Even better.

We replace the monolithic NHS with a European-style system (because, as I have pointed out to you many, many times, the US system is not the only healthcare option out there) and 17,000 fewer people a year die? Absolutely fucking fantastic.

And your objection is...?

19 comments:

per said...

strangely enough, the doctor's trade union have engineered a system where we are desperately short of doctors (demand is high), so doctors can charge a packet.

mass exodus of doctors ? not quite. seems some folks are quite happy with their 100K+ per year, and the perks that go with it.

i think you are right to query dr rant.

the a&e charge nurse said...

Devil - I might be wrong, but you seem to fear the system where unfettered market forces have the greatest freedom to shape delivery of health care ?

Perhaps, it's because this iniquitous system has proved to be the most costly in the world, yet still fails to offer universal provision ?

Or maybe it's the growing lists of uninsurable medical conditions, resulting in ordinary people selling property to pay for life saving treatment ?

Or is it simply the fact the doctors are provided with incentives to deny claimants access to various investigations and treatments ?

Maybe you have heard about the disappointing outcomes (despite the shattering proportion of GDP expenditure allocated to health) and the lowly ranking by the WHO ?

Admit it, you'd still prefer a diluted form of socialism in case your own health policy is not robust enough when the chips are down (when other criteria, such as the mood of Richard Branson, replaces clinical need).

Be patient, the NHS, in it's present form, is crumbling and I imagine the new model will be just as exciting as the standard provided by the private dentists......did I tell you about my £550 crown by the way, I'm sure the TPA must be thrilled about it ?

Budgie said...

"Doctors get cheaper? Excellent."

It doesn't work like that: remember this is the NHS. The money "saved" on doctors just goes to pay for more managers.

All those people rushing from meeting to meeting with their NHS provided laptops gobble up the money.

In any case I don't want a "cheap" doctor, I want a good one.

Devil's Kitchen said...

A&E,

Knew you'd pop up! Always a pleasure...

"Devil - I might be wrong, but you seem to fear the system where unfettered market forces have the greatest freedom to shape delivery of health care ?

Perhaps, it's because this iniquitous system has proved to be the most costly in the world, yet still fails to offer universal provision ?

Or maybe it's the growing lists of uninsurable medical conditions, resulting in ordinary people selling property to pay for life saving treatment ?

Or is it simply the fact the doctors are provided with incentives to deny claimants access to various investigations and treatments ?"


I don't personally have a problem with an all-insurance funded system, per se. Were insurance companies not to insure certain conditions, some companies inevitably would take a punt.

However, no all-insurance system exists -- no, not even in the US, where the biggest buyer of healthcare is the state -- which leads me to believe that it probably wouldn't work.

However, it is absolutely true that the European systems work far better than ours. No, they are not perfect (no system is), but they are better than having the same monopoly as both provider and payer.

"Maybe you have heard about the disappointing outcomes (despite the shattering proportion of GDP expenditure allocated to health) and the lowly ranking by the WHO ?"

Um, you are aware that the WHO targets are somewhat skewed, aren't you?

"An international ranking of health systems (from the WHO as I recall) indicated that those with more equitable access (for which read greater tax funding) were better health systems than those more inequitable access. What was a great deal more difficult to find out was that some 50% of the determination of what made a good or bad health system was the equity of access to health care under it. That is, of course, an entirely allowable bias to have, but somehow the statement that "equity makes a good health system so more equitable ones are better" isn't all that surprising a finding."

"Admit it, you'd still prefer a diluted form of socialism in case your own health policy is not robust enough when the chips are down (when other criteria, such as the mood of Richard Branson, replaces clinical need)."

Not really. I am intelligent enough to read the small-print of any insurance policy, and (probably) well-off enough to cope with most problems.

What I am interested in is the best outcomes for all concerned. And that includes the poorest.

"Be patient, the NHS, in it's present form, is crumbling and I imagine the new model will be just as exciting as the standard provided by the private dentists..."

My dentist is private and he is very good. He also makes appointments when it is convenient for me.

"... did I tell you about my £550 crown by the way, I'm sure the TPA must be thrilled about it ?"

Did anyone tell you about dental insurance, A&E, like Denplan, for instance?

DK

Rob said...

The objections are:

They earn less money.
They have less power over patients.

Enough to be getting on with. The NHS is a Stalinist producer monopoly, time to go.

Steve_Roberts said...

a&e nurse: "..the system where unfettered market forces have the greatest freedom to shape delivery of health care.."

Current 'fettering' includes doctor and nurse training - controlled by DoH and Royal Colleges rather than the market; Location, capacity and scope of facilities - frozen from 1948 with clumsy tinkering since then by DoH; Revenue - set by politicians based on desire to be re-elected to / advanced in office; Customer offer - as 'facilities' above; Customer choice - negotiable in principle; etc etc

I think your faith in politicians and bureaucrats to shape healthcare better than an unfettered market is quaint, given the 60 years of evidence of just how badly they actually do it.

Matthew Sinclair said...

It should be pointed out that we have among the best paid doctors in Europe. Doctors have little reason to complain on pay.

http://lysander.sourceoecd.org/vl=5764331/cl=49/nw=1/rpsv/health2007/g4-4-01.htm

A lack of professional autonomy is a more legitimate complaint for doctors in the NHS to make, I think. That situation could be improved with a healthcare system reformed along the broad lines described in Wasting Lives.

Best,
Matt

Roger Thornhill said...

A&E: "Admit it, you'd still prefer a diluted form of socialism in case your own health policy is not robust enough when the chips are down (when other criteria, such as the mood of Richard Branson, replaces clinical need)."

There is nothing Socialist about giving people the right to choose between private suppliers.

the a&e charge nurse said...

You are half right Roger - but if we look at the USA experience we must accept that choice can be a two way street.

Yes, rich citizens, may have greater freedoms in the health goody shop, but remember, private providers can impose their own draconian sanctions as well.

Not only are many people uninsurable because of a pre-existing health condition, but they may be unable to obtain cover because they are fat, or even if they have a few speeding tickets !!!
http://www.opic.state.tx.us/docs/442_2007_health_ug.pdf

American health insurers instinctively reach for the barge pole if you have hepatitis (200,000+ cases of hep C in the UK, the so called silent epidemic), cancer (obviously) HIV, heart disease (over 200,000 MI's each year), cirrhosis (yes, Devil, very tiresome) hell, they won't even touch you if you are pregnant.
http://www.calhealth.net/california_health_insurance_individual_underwriting.htm

Steve Roberts clearly doesn't like the state, and he makes some fair points, but handing health over to the fat cats is not going to make life any easier, especially if you are pregnant, have hepatitis and enjoy the odd shandy.

If you want an example of how easily money corrupts just look at Hewitt and the lucrative deals she has tied up with Boots and Cinven - this woman certainly epitomises all that is rotten with NuLab and how the moral compass soon goes out of the window when profit and the sick collide.
http://news.bbc.co.uk/1/hi/uk_politics/7196420.stm

Roger Thornhill said...

a&e "US bla blah"

Why do you keep resetting to the US as if we want to go down that route?

Stop it. It is boring.

the a&e charge nurse said...

Because the USA is emblematic of the sort of market solutions, so admired by the libertarians, applied to health in the real world (rather than a polite discussion in a blog forum).

Like the Devil, Roger, I suspect you would also prefer state intervention to the fat cats being given free reign - presumably to prevent the health waters from becoming too choppy for the "little people".

Another closet socialist, eh... who'd have thought it ?

Devil's Kitchen said...

"Because the USA is emblematic of the sort of market solutions, so admired by the libertarians, applied to health in the real world (rather than a polite discussion in a blog forum)."

No it fucking isn't. For fuck's sake, how many fucking times...? It is one system that might be proposed.

Will you stop this wilful misinformation, please, A&E. Both Roger and I have consistently said that we would build on the European model: you have consistently failed -- indeed, you have not even tried -- to demonstrate that the systems employed by, say, the French, the Germans or the Swiss are worse than the NHS.

That is because it simply isn't possible to demonstrate. So, please, shut the fuck up about the US.

Although, since we are on that subject, one of my friends is very glad of the US system: he had an endoscopy, the gut tumour diagnosed, and the operation to have it taken out in less time than it would take to get an urgent referral on the NHS, i.e. two weeks. Yes, it was expensive, but he is alive and to him that is the most important thing. OK? Do you see? It's healthcare delivered to the patient's priority, not the convenience of staff, managers or politicians.

"Like the Devil, Roger, I suspect you would also prefer state intervention to the fat cats being given free reign - presumably to prevent the health waters from becoming too choppy for the "little people".

Another closet socialist, eh... who'd have thought it ?"


If your definition of socialist is "not an uncaring monster" then, OK, call me a socialist. Unfortunately, that would just make you look like an utter arse, so I wouldn't recommend it.

Both Roger and I are interested in the best possible outcome and with the minimum possible state interference -- state interference of any kind is only required because so many in our population are stupid, ill-educated and lazy.

As you point out, the US (despite the fact that it is not an unfettered free market in medicine anyway) is not actually a particularly desirable system in some ways (your constant bleating about how much it costs fails to take into account several quite crucial factors, including the availability of technologies that will not be employed by our beloved NHS for many years, if ever).

The best systems, for price and outcome, are those employed by our European neighbours. And if you actually gave two craps about the patients, it is this latter point that you would be most interested in.

DK

the a&e charge nurse said...

Devil - I'm off to a work meeting this afternoon (even though I'm meant to be on annual leave) - your post merits a considered response, and I would like to come back to you in detail.

By the way I'm glad to hear your friends tumor was excised in a timely, albeit expensive fashion.
I sincerely hope that there is no metastic spread since chemo is unlikely to be cheap - I'm sure he will continue to receive the very best treatment, just as long as he is able to pay for it (or has a robust enough employees health policy, since cancer counts as a precondition that is very difficult to insure privately).

I believe these kinds of transactions are subject to market forces in many countries, and in fact, it's one of the reasons the NHS was set up in the first place - so as to get rid of them.

But, yes, your obsession with Europe is an interesting point and as I say I would like to get back to you about it.

Anonymous said...

The NHS is walking dead anyway - the proposal to allow patients to take treatment anywhere in Europe and charge it to their home counties system was only just stopped by Germany - when it gets taken to the European Court, it will probably enacted.

The next step will be private health care organisations demanding the right to a slice of this in the UK. Under the trade/services rules, it will be nearly impossible to stop. Particularly since the ruling will be by European judges who will (mostly) come from countries with mixed provision - to them the idea of private provision will be perfectly normal.

Inside 5 years is my guess...

Tomrat247 said...

A&E,

Something else to consider - just did a quick google search for the phrase "mortality amenable to healthcare US" and came across this:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=640980
Of particular interest is the chart detailing country-by-country rates per 100k people in 2002-2003; the UK is 103 and the US is 110; are you really saying that the UK system is a better situation for healthcare when weight for weight almost as many people die due to crappy treatment due to mismanagement of funds they get?
Also, it weird that the french seem to manage nearly half that rate on their social insurance system though; one that I think DK espouses regularly? And stating that something is a libertarian viewpoint is a bit of a contradiction in terms - there may be agreement but a mans thoughts are his own.

DK,

In Dr. Rant's defence the welfare of staff and wellbeing is in retaliation to the common thread of statist group-think that purvades the MSM and government circles in putting the blame to the doctors whilst still maintaining that their meddling has had no negative effects. You need only read Dr. Rant's welcome message to get the gist of the man, and his comments that some of the time (most of the time) it is not the doctor that someone really needs to "heal" them.

lost_nurse said...

"And if you actually gave two craps about the patients..."

DK: that's a little stiff, even by your standards, oh angry one.

Both Patsy's new appointment and the deeply cloying tone of (now PE-owned) BUPA's "kiss it better" advertising campaign should tell you where we are headed. And it ain't in the direction of our sensible European neighbours...

It's reductive in the extreme to merely slag off the NHS as a 60 year old failed experiment. I'm not going to defend areas of weakness, but like A+E C/N, I'm deeply fecking concerned about the fragmentation of existing (and, yes, efficient) acute/emergency capacity. Not because it is run for my working comfort (I'm getting pretty pissed off with that line - swap jobs with me, eh?), but because I know full well what is being destroyed by NuLab Inc. And since we are swapping anecdotes: the last time I was in theatres, they wheeled in a guy who need emergency surgery for a dissecting aneurysm... and then they had to throw in an anterior resection (for a newly discovered malignancy), for good measure. Now, by any standards, the NHS did not fail him - not as a patient, not as a taxpayer. Glib notions of choice and competition fall down hard in such unexpected scenarios - something to bear in mind next time you see Patsy & co doing the hard sell.

the a&e charge nurse said...

OK Devil lets take a look at how well some of your assertions fit the evidence.

First of all you express frustration at "wilful misinformation" - presumably by this you mean don't mention the USA, or are you contesting the scandelous iniquities mentioned above ?

Alright, if it's so upsetting I won't mention the Yanks again, in fact there are so many reasons to reject their exhorbitant health model that I tend to agree, they are hardly worth bothering with.

It would take too long to provide an in-depth comparison between the NHS and the French, Swiss or German systems, but I accept that in some respects they are all better - the important question, of course, is why.

A quick squint at the OECD data offers a few tantalising clues, try some of these for size;
Significantly fewer doctors in the NHS (compared to the big3).
Fewer hospital beds (>30% less compared to 20yrs ago).
Availabilty of technology, especially C/T & MRI way below OECD average.
Nothing about the insurers, though, strangely.
http://www.oecd.org/dataoecd/46/4/38980557.pdf

Obviously some of the shortcomings in the NHS are related to funding, especially when compared to the big3 - admittedly the gap has closed slighly BUT the additional dosh must still be off-set (at least to a certain extent) against historical deficits.
And as you know Devil, to this day funding of the NHS still lags behind the 3 countries you express admiration for.

You then label the typical Brit as stupid, ill educated, and lazy - well maybe some of them need tough love Devil, certainly the OECD report identifies alarming rates of obseity in the UK, not to mention our ancient penchant for nictotine.
Amazingly, UK life expectancy (currently 78.5yrs) remains above the OECD average, surely anything beyond three score and ten is gravy ?

Tomrat347 thanks for the link - avoidable mortality is a slighly slippy concept since the range of conditions covered is never comprehensive - for example, the stats tend to emphasise only those conditions 'ameanable to medical intervention' - so exclude lung cancer for example.
http://www.statistics.gov.uk/about/Consultations/downloads/PAM.pdf

Lost_nurse - spot on, as usual.

the a&e charge nurse said...

Seperate issue Devil - but personally I do not think the cub medical reporter mentioned in your post should have been "outed" on the net (no matter how reprehensible her views).

Any thoughts ?

Not outed by your good self I hasten to add, perhaps I should take it up with Dr Rant ?

Devil's Kitchen said...

A&E,

Sorry, wrestling with a particularly recalcitrant database but, briefly, I agree with you about not outing the reporter (which is why I did not repeat the her identity).

And I certainly agree with you given that the Dr Rant Team guard their own identities so jealously.

DK