Monday, July 09, 2007

Health reform (again)

It is possible that only your humble Devil perceives this, but there seems to be an air of increasing desperation pervading Dr Rant's entertaining but increasingly hysterical attacks on the concept of competition in British health provision.

After Timmy and I pointed out that Team Rant's reform of the NHS had fallen at the first hurdle, the good doctors have started to engage hyperbolic misrepresentations of the position taken by free marketeers, as in this post...
Dr Rant has played Monopoly: it starts off nicely enough, but it always ends up with one rich fucker gloating about owning everything while a bunch of pissed off losers fight over the left over crisps and snacks.

Julian Tudor Hart in his book 'The Political Economy of Health Care' says:
Economists cannot point to a single real example of any nation that has depended entirely on a competitive market economy for health care of its entire population.

Following in quick succession are a series of questions on private and non-private systems which are not only leading and somewhat simplistic, but are, in some cases, left incomplete in order to give the impression of comparing like-for-like when—in this one, for instance—they simply do not.

Health, most certainly, is a tricky area and, as we all know, the US system is the worst system in the entire world. Or is it?

As Tim Worstall points out at TCS, the WHO's system for measuring how good a system is is actually massively skewed against those that are not funded through taxation; yes, the actual way in which it is measured contains a penalty against those systems that encourage private provision.
We've got a system of rankings of health care systems. France and Canada are in the top 10, the USA, despite spending more, at number 37. But let's look at how those rankings [PDF] are composed [PDF]:
To make the definition of the composite easier to understand, these survey results have been rounded to the nearest one-eighth so that the final weights to be used are 0.25 for health, 0.25 for health inequality, 0.125 for level of responsiveness, 0.125 for distribution of responsiveness and 0.25 for fairness of financial contribution.

Do you see that? Only 25% of the weighting is about the actual health care received. A similar amount is awarded for the equality of care received. So, imagine, say, the Canadian system, everybody waits the same amount of time for a hip replacement, in the American one some get it very quickly, others get it after a long wait: it doesn't matter that everyone in the US waits a shorter period of time than anyone in Canada: the Canadian system would be scored as better here. I'm not saying that those waiting times are actually true, I'm simply pointing to the effects of the weighting: inequality in treatment times is as important here as the actual treatment itself.

And, of course, in health, the treatment really is very, very important. As such, it really is worth reading the entirety of this article by James Bartholomew. Here are a few salient facts however.
Suppose you come down with one of the big killer illnesses like cancer. Where do you want to be - London or New York? In Lincoln, Nebraska or Lincoln, Lincolnshire? Forget the money - we will come back to that - where do you have the best chance of staying alive?

The answer is uncompromisingly clear. If you are a woman with breast cancer in Britain, you have (or at least, a few years ago you had, since all medical statistics are a few years old) a 46 per cent chance of dying from it. In America, your chances of dying are far lower - only 25 per cent. Britain has one of the worst survival rates in the advanced world and America has the best.

If you are a man and you are diagnosed as having cancer of the prostate in Britain, you are more likely to die of it than not. You have a 57 per cent chance of departing this life. But in America, you are likely to live. Your chances of dying from the disease are only 19 per cent. Once again, Britain is at the bottom of the class and America at the top.

How about colon cancer? In Britain, 40 per cent survive for five years after diagnosis. In America, 60 per cent do. With cancer of the oesophagus, survival rates are low all round the world. In Britain, a mere seven per cent of patients live for five years after diagnosis. In America, the survival rate is still low, but much better at 12 per cent.

The more one looks at the figures for survival, the more obvious it is that if you have a medical problem, your chances are dramatically better in America than in Britain.

One of the reasons is wonderfully simple. In America, you are more likely to be treated. And going back a stage further, you are more likely to get the diagnostic tests which lead to treatment.

Very true, of course. Many of these big killers are, to a great degree, time-critical.
"Ah yes," comes the knowing response. "But what about the poor? The rich might get great care in America, but the good thing about the NHS is that everyone gets treated equally. The care is, in the hallowed phrase, 'free at the point of delivery'."

Before going into any detail, let us remember one thing: all those figures at the start about death rates from various forms of cancer were not just for the rich. They were for the whole population, poor included.

It is not all good, of course. James goes on to point out the expensive insurance, the demographics that fall through the gap (although this follow-up is definitely worth reading as it corrects one of the major points raised). But what is the conclusion? [Emphasis mine.]
Let's face it. The American system is a rotten one. It is not even a system. It is a hotch-potch. Most hospital provision is by not-for-profit, private hospitals. But the biggest buyer of medical care is the Government. Through Medicare (for the poor) and Medicaid (for the old) and other schemes, the Government pays for 45 per cent of all healthcare. (The British assumption that American healthcare consists of an unfettered free market could not be more wrong.)

It is a muddle.

Actually, the British system was a muddle, too, until Aneurin Bevan came along in 1945. As Secretary of State for Health he set about un-muddling it. We, too, used to have local government ("municipal") hospitals like America until he took them over. He took over the charitable hospitals too - like St Mary's and Moorfield's and many other famous ones. He made it not confusing at all. What could be simpler than the central government being in charge of everything? Over time, the government put itself in charge of all the doctors, too. So all was made simple and clear.

But the curious thing is, the new, improved, simple state system of Britain does not work as well as the American muddle. You have a better chance of living to see another day in the American, mish-mash non-system with its sweet pills of charity, its dose of municipal care and large injection of rampant capitalist supply (even despite the blanket of over-regulation) than in the British system where the state does everything. It is not that America is good at running healthcare. It is just that British state-run healthcare is so amazingly, achingly, miserably and mortally incompetent.

As I say, do go and read the whole thing, really. It is a fairly even-handed appraisal of the risks and the problems with the US system, as well as its benefits. However, the main thing that I took away from it was that the US system is nowhere near as bad as I had been led to believe (it is by no means perfect, but it is very far from being the car-wreck that we are all told).

Coincidentally, The Nameless One has decided to write about health today. He believes that there needs to be some serious reform of the entire system and his fourth point, in particular, can never be stressed enough.
4. The NHS is not free

Really, it isn't. Yes, it is free at the point of service, but we fund the NHS entirely. The billions thrown at it come from the nation's tax burden. Your income tax and your national insurance contributions fund this creaking, failing tax vampire. The only reason why people think it is free is beacuse when they arrive art A+E, they don't have to pay for it. Solely because they have already paid for it.

The Nameless One doesn't have a solution either, although he does mention another possible idea.
I don't know what could replace the NHS, but I rather favour removing all funding for hospitals and instead using the money to fund vouchers for the population as a whole. Let people vote with their feet. The decent, working hospitals will still get government funding through people spending their vouchers in them. Those that are working will not get the funding, and may well end up closing. But, really, so what? If something isn't working, then why continue to fund it? If demand disappears for a supermarket brand, for example, then it goes out of business. Why not the same for a crap hospital?

This is an idea that I have toyed with, in one way or another, for a couple of years now. My fundamental problem with it is that it would still be massively expensive. However, if people were allowed to save up their vouchers for their whole lives, to save them for when they actually needed them, the vouchers would effectively act as a type of insurance (an insurance that would actually be paid out, rather than a compulsory levy that the government then pisses up the wall, as NICs are).

This system would not, however, reduce the burden on the taxpayer: nor would it encourage people to take responsibility for their own well-being in the same way that a fluid insurance market would. As such, for a combination of reasons, the idea of vouchers has fallen out of favour with your humble Devil.

It has been argued that maybe A&E departments should continue to be state-funded as only the state can provide the sheer range of care, and the facilities to cater for it. This isn't something that I subscribe to 100%, but it is worth considering.

The Nameless One concludes that a fundamental shift of attitude is needed if we are to get a better health system.
So, come on, then, let's not have the job of Health Secretary as career suicide for any incumbent. Let's have a great reforming Health Secretary. Someone prepared to change the perceptions towards the NHS in the UK, and therefore able to contemplate other ways of managing the health of the country.

It is a pity, then, that arch-union man, Alan Johnson, should have been appointed to the post. Indeed, to come full circle, it is Dr Rant who pointed me towards this spectacularly bad Grauniad article.
Mr Johnson's only departure from the course set by Patricia Hewitt, his predecessor, was to downplay the role of the private sector. He said he would only sign contracts for more independent sector treatment centres if they were needed to fill gaps in NHS capacity. He appeared to abandon the Blairite view that private involvement helped spur competition, whether or not extra capacity was required.

Of course private sector involvement does not spur competition per se, although it is absolutely certain that true competition would spur on private sector involvement (something that Team Rant, of course, utterly despises).

However, leaving aside the reporter's economic and market illiteracy, it does show that there will be no upheavals, surprises or radical changes under Johnson. The Nameless One and I will just have to wait until... well... until hell freezes over? Let us hope not.

And, in the meantime, your humble Devil will continue to cogitate and to heed the feedback from those in the front line, and see if he cannot find some ground-breaking, near-perfect health policy of his own.

We could be here a while...


the A&E Charge Nurse said...

Devil - isn't it paradoxical that the solipsistic libertarians demand ever greater freedoms to amuse and abuse themselves, yet they continue to agonise about health ?

On the one hand there is regular incitement for more booze & cigarettes, as well as other mind altering substances all free from tedious state intervention.

Then comes anxious debate about how the NHS compares to other health systems.
I would have thought it far more beneficial to avoid the self indulgent, albeit pleasurable behaviours which are known to increase the risk of cancer, heart disease, CVAs, & diabetes, after all these are the big killers.

I mean it's not very rock'n'roll to double the size of your liver then enter into a dispute about how quickly a biopsy will be performed, is it ?

And most of the low grade stuff could stay well clear of doctors anyway.

Take broken toes: when somebody comes into A&E [providing there isn't an open fracture or deformity/dislocation, or it isnt the big toe] I usually tell people if its sore for 4 weeks its fractured, if it's better after 2 weeks then it was a soft tissue injury - that usually takes about 45 seconds......but you're not going to x/ray it they gasp, what sort of cowboy are you ?

And off they go muttering about NHS incompetence.

Devil's Kitchen said...

Not really, A&E: we solipsistic libertarians are more than happy to pay for our healthcare. And we continue to proclaim that.

However, we do recognise that some people may end up falling between the cracks (in practice, some always will whatever the system).

As I have pointed out before, you tend to deal in extremes because that it what you see. The vast majority of drug users will not end up with permanent damage (or not of any significance) mainly because drugs tend to be, to an extent, self-limiting both physically (the law of diminishing returns) and mentally (people simply grow out of the desire to take them).

What we evil, solipistic libertarians do demand is that if we pay for something, we should get the service that we desire. And if we cannot get that service from one provider, that we should be allowed to take our money to another provider.

The nationalised health service does not, practically, allow this. It stops this choice in two ways; firstly, the compulsory removal of 12.5% of one's earnings through NICs means that private insurance can stretch the finances too far (and you'll remember that I illustrated that, when I was paid £19k a year, the state's insurance worked out double what it would cost to cover the same things privately).

The second is that the NHS distorts the market by crowding out private provision. As such, any expansion of those is necessarily slow (as a market has to be researched) and, because there are few of them, prices are high (basic supply and demand economics).

Your propensity for dealing in extremes is shown by your toe example; if someone has broken their toe there is not usually anything much you can do about it, correct? However, someone could come in showing some sign that could be indicative of a minor ailment but could equally be something more serious: isn't it better to check, just in case?

The only reason that we should compare the NHS to other health systems is in order to compare how the most efficient system might be implemented.


Devil's Kitchen said...

I mean it's not very rock'n'roll to double the size of your liver then enter into a dispute about how quickly a biopsy will be performed, is it ?

I do wish you would stop conflating libertarians with libertines; they are not the same at all.

I mean, seriously, when did I mention taking drugs, i.e. illegal drugs, because it was "cool" or, as you put it, "rock'n'roll". I take drugs (very, very occasionally these days) because I like the way that they make me feel.

The point is that I am happy to take responsibility for the consequences of those drugs on my body by paying for my healthcare.

Or are you saying that if I was a "real" libertarian then I would refuse all healthcare and happily die prematurely. Or perhaps you feel that I should not receive medical care because I have chosen to ingest certain substances?

Because that would be a really interesting idea -- A&E Charge Nurse: judge, jury and executioner.


the A&E Charge Nurse said...

Thank you Devil - if I have understood your argument correctly libertarianism and consumerism are but flip sides of the same coin ?

You offer an interesting proposition, 'if we pay for it we should get the service we desire'.
The implication here seems to be that cash is the final and most important arbiter ?

Perhaps that's why we have developed such a penchant for late crises management, say for smokers who develop lung tumours or obstructive airway disease.

According to commentators such as Roy Porter 'we have invested disproportionately in a form of medicine [Band-aid salvage] whose benefits often come late, which buy little time, and which are easily nullified by external counter prevailing forces' [Greatest Benefit to Mankind, p714].

Now you may or may not agree with such sentiments but the point I'm making is that economics alone fail to provide any moral compass.

For example, Porter concludes that cash would be best spent on prevention [so feared by the libertarians] if you really want to reduce rates of cardiovascular disease, COPD, CVA, liver cancer, stomach ulcers, diabetes, etc, etc.

This is the sort of thing the disgustingly brilliant Rant & Co are always banging on about but lets say your beloved market forces where unleashed, what then.

Well it might result in a few different peaks and troughs but little substantial improvement overall, with plenty of risks and unknowns thrown into the bargain.

Is dentistry any better, while disasterous private finance initiatives in the NHS are too long to list.
You tell us that your tax provides entitlement, and so it does, but if you ever require lengthy and expensive treatment it is highly likely that somebody else would be paying for the consequences of your devilish debauchery.

And that just how I like it even if you accuse me of rolling the dice when it comes to deciding who should or shouldn't get treatment.

Mark Wadsworth said...

DK, there are two completely different sides to the equation.

The main bit is supply/provision. Clearly a system of competing hospitals works better, including private and charitable ones. Even State ones should compete on a level playing field.

The other bit is funding. This is probably less important. Whether you have it out of general taxation, compulsory insurance or indeed voluntary insurance is a more fraught question. Or if in doubt have a mixture of general taxation and voluntary insurance.

Vouchers fits into this scheme very nicely. If you want to top up your voucher and go private, well fine, the same as vouchers for schools.

Problem solved.

the A&E Charge Nurse said...

mark wadsworth - lets call a spade a spade.

Competition [amongst suppliers/providers for example] by it's very nature produces winners and losers, otherwise its not really competition is it ?

Or to quote Dr Ray, in the future we will not all be driving rolls royces [if health is left to the mercy of market forces] some of us will be lucky to even own a bicycle [see Dr Rant thread on the serial anti-NHS commentator 'anonymous, aka 'no one'].

By the way how can you top up your vouchers if your skint [unemployed/disabled/retired] ?

If only 50% of the Rant manifesto was to be implemented then NHS staff would have the freedom to make genuine improvements [for everybody].

Mark Wadsworth said...

Competition - I used to live in Germany and it works fine. The supply side is a mixture of private, church, municipal, trade-union and health insurance company owned. If a hospital gets a bad reputation, the senior staff get swapped over and they sort things out. Hospitals do not get shut down and loads of "frontline staff" made redundant, why would they? The investment is far too valuable!

To use your analogy, Germans don't all drive R-R's, but something like BMWs or Volkswagens. You cannot compare any German hospital to a bike! Even a small number of private competitors, ten or twenty per cent will be enough to drive up standards.

Further, if private providers free themselves of all the targets and bureaucrap-cy, then maybe they'll have more money to pay better nurses' wages? What's wrong with that? They'll be competing for staff as well as patients!

Vouchers - would cover basic cost of basic and/or necessary treatments (I'm not getting into arguments over what is "basic" or "necessary" - that changes over time). Even private providers will do this. Same as vouchers for schools.

cf. ten years ago, waiting list for NHS abortion was a distressing ten weeks, but you could go to Marie Stopes, pay £300 and have it over with.

AntiCitizenOne said...

A7E nurse is a vested interest. For instance she could be crap at her job and killing lots of patients.

I'd bet she thinks as soon as people are given a choice they won't choose her way, and like a true fascist, it's her way or death.

Avoid the MRSA spreading service

the A&E Charge Nurse said...

Thanks Mark - I'm no expert on the German system but I do know they already spend considerably more of GDP compared to the UK on health [according to OECD stats Germanys expeniture is the 3rd highest in the world].

A recent BMJ report [2006] highlighted radical proposals 'to tackle financial crises in health care' including inceased health insurance fees and [for the first time in 150yrs] use of tax revenue.

Although it's probably another argument I think we have a shameful rate of abortion in the UK [now getting on for 200,000 cases per year].
Why bother to invent condoms, the pill, coil, post coital contraception [which is £45 at casualty plus but I'm coming to that in a moment], etc, etc.

anticitizenone - why not toddle off to casualty plus and pay £45 per [basic] consultation, £49 for a plastercast, £19 for a sling, and £39 for crutches, oh sorry, I forgot about fracture reduction that starts at £49, while charges for an x-ray don't seem to be included on the price list, sorry menu.

And who provides fracture clinic follow up after you've been fleeced ?

By the way I didn't know treatment resistant organisms, such as MRSA refuse to infect private patients - perhaps you should like at the stats on some of the state-of-the-art private hospitals in the USA rates of hospital acquired infections.

Mark Wadsworth said...

A&E "Germany's expenditure is the 3rd highest in the world"

For sure, that is yet another variable. But that is changing the topic, I was explaining that competition is not the end of thw world, it is not some wicked plot to cut nurses' wages, have mass redundancies and ensure that the average guy gets shit treatment.

For a given level of spending, competition between providers (not forgetting that Germany is highly unionised and most hospitals are NOT privately owned, they are owned by local councils, churches, insurance companies, trade unions etc) is A Good Thing.

And, like I said (appealing to your naked self-interest) competition between providers also means they'll be competing for staff, so there is nothing to suggest that this is a foul excuse to cut nurses' wages.

Sack all the fucking leech penpushers and Quangista, sure, different topic.

I don't have any particular strong prejudices here, I can only report what I see.

pari said...

just as you said its all an illusion .

Oh yeah? So what has happened for the last ten years, exactly?

Over at the ASI, they are posting some of the winning entries of the Young Writers on Liberty. One does not want to put such keen minds off,...