More evidence that the NHS is providing substandard care
Back in April, the Institute of Economic Affairs released a paper that found the UK’s healthcare system to be severely lagging behind neighboring countries. The research, carried out by author Dr Kristian Niemietz, found that social health insurance systems – especially in the Netherlands, Switzerland, and Germany – perform better than the NHS across the board, from the quality of healthcare provided to the heath outcomes of patients. Most shockingly, Niemietz found that “9,000 more deaths occur each year in the UK than would have if the performance of the NHS had matched that of the German system, in terms of avoidable mortality.” Just last week, the IEA released another paper from Niemietz, called Diagnosis: Overrated - An analysis of the structural flaws in the NHS, which highlights the structural flaws and political hindrances that keep the NHS from producing better results:
The NHS’s status as a sacrosanct institution promotes ‘groupthink’ and undermines the ability to detect and correct instances of failure, and to adapt to changing circumstances. This was most immediately evident after the Mid-Staffs scandal.
The idea that ‘we’, the public, run the NHS ‘collectively’ is a popular illusion. Democratic accountability in the system is so vague and roundabout that it is almost meaningless in practice. There is almost zero overlap between the health policies proposed in general election campaigns and those enacted afterwards. The insistence that ‘the people’ are really in charge is empty rhetoric. The health service is run by the political class, senior bureaucrats and the medical establishment.
More specifically, from the paper:
Under a system of meaningful exit options, patients would not just have had the option to bypass Mid Staffordshire, but funding organisations (e.g. health insurers) would also have had the right to withhold payments, given that Mid Staffordshire was clearly not fulfilling its side of the bargain. A pincer movement of this sort might well have bankrupted the hospital, eventually making room for a more suitable provider. That threat of revenue loss and bankruptcy, not ‘democratic accountability’, is what brings providers’ self-interest into line with patients’ interests.
Niemietz’s findings from both April and December are valuable additions to the accumulating evidence that the NHS is in dire need of reform. His research backs up the most recent OECD report, that found the UK’s quality of healthcare to be “poor to mediocre” and its preventative care measures to be “outstandingly poor”.
Unfortunately, most UK politicians seem deeply committed to maintaining the status quo and providing Brits with substandard care. But slowly, evidence is finding its way into the heart of the healthcare debate, and the successes of market-based systems in Europe can't be ignored much longer, as the NHS continues on to its breaking point.
Well, doesn't this just kill the Marmot Review
We did in fact read the Marmot Review, on the grounds that we suffer so that you don't have to. And we were, we're afraid to have to say it, deeply unimpressed with it. We have no doubt at all that a certain amount of the health inequality in the UK is a result of economic inequality. But we would also insist that a certain amount of the economic inequality in the UK is due to health inequality. And it's that second that Marmot entirely disregarded. The Review insisted that if only we reduced economic inequality then health inequality would disappear: even as it is obvious that reducing the economic form of inequality won't have any effect at all on that second form of it. So, we now see this:
Thousands of people with cancer will feel “cold and lonely” this Christmas because they do not have enough money to celebrate or heat their homes, a charity has said.
Almost 170,000 people in the UK with cancer are unable to join in special family events such as Christmas due to a lack of cash, according to Macmillan Cancer Support.
Its survey of almost 1,000 people living with cancer found 9% had to miss out on visiting family and friends because they could not afford it.
Other research of more than 1,600 people who have been in touch with Macmillan found 28% were unable to adequately heat their home in winter due to money worries.
The charity has previously found 83% people with cancer are on average £570 a month worse off as a result of their diagnosis.
That health inequality leads to economic inequality is therefore proven. Marmot is wrong.
Ten initiatives to help young people: 6. A youth mental help body
A significant number of young people face mental health problems. It might be bullying at school or at work, or sometimes difficulties encountered by discrimination. Often it is depression, depression they find it difficult to cope with on their own. Many face problems with their physical appearance, finding it difficult or impossible to conform to idealized notions of what they think they ought to look like. This leaves them feeling inadequate and unhappy, which in turn can lead to mental problems. The NHS does not do well with the mental problems faced by young people. Sometimes and in some places it does well, but on average it fails to meet an adequate standard of care in this area. Too many young people feel they are facing their problems alone and cannot cope. Some attempt suicide, some tragically succeed.
It is perhaps time to recognize that young people have special mental health needs, and that these are different in some ways than those faced by the general adult population. Young people have little experience of life, are only just coming to terms with who they are, and can feel isolated, helpless and confused. This suggests the need for an independent body to which they can turn for specialist help. Some youngsters find the NHS remote and intimidating, unable to offer the intimate and personal help that is often needed. This is perhaps because the NHS tries to use its limited resources to best effect, trying to save lives where it can. Some critics say it is under-resourced on mental health in general, never mind young people's mental health. What the NHS spends on one thing cannot also be spent on another.
To prevent youth mental health losing out to more strident claims on resources, a separate body is needed, independent of the NHS, but with its services available free at the point of need. Financed partly by the taxpayer, and party from the sponsorship of businesses and private benefactors, the body would be the natural one to turn to when young people needed help. Advertising would help make its services widely known just as happens with the Samaritans. With a name such as "Support," it could readily establish a brand identity such that young people would know whom to turn to when they found their problems more than they could face alone. It could provide expertly trained staff with experience of youth problems, people who would listen sympathetically and at a personal level. It would not solve all the mental health problems faced by young people, but it could contribute to a significant improvement in the lives of many of them.
Yes, that's the point
The Daily Mail has got itself all hot and bothered about the price of pharmaceutical drugs. They cost perhaps £100 to manufacture and are then sold to us for possibly £100,000 a treatment. Worse, poorer foreign countries get charged less than we do. As they say:
Indeed, global drug market analysts suggest England's high drug prices are subsidising the supply of cancer drugs elsewhere, with one saying they may be anything up to 90 per cent cheaper in developing countries. 'Even within Europe prices can vary by 50 per cent or more,' says Christian Glennie, head of healthcare research at Edison Investments in London. 'It is impossible to find out what healthcare purchasers are actually paying, but ultimately it is down to what the local market will bear.'
At which point we do rather have to spoil the most enjoyable outrage by pointing out that this is exactly the point.
These drugs all cost some $1 billion to find, create and test. They're administered to a limited number of patients in any one year and they need to make their money back within a decade (the patent lasts for 20 years, but approval usually takes a decade of that time). Thus they're going to be fearsomely expensive for that decade. At which point they transition to generics and they become hugely cheaper.
Further, yes, the rich world gets charged very much more for these drugs: because it's the rich world, see? The existence of these new treatments can be seen as a public good and why shouldn't the rich pay more for something like that than the poor? It's no different than rich people paying higher taxes to fund other public services like the NHS itself than the poor do.
All of the things that the Mail is complaining about are not faults in the system, blips that we need to do something about. They are the very point and purpose of said system, they're why we do what we do.
Finally, we do not set this up so that pharmaceutical companies make profits on the money they have already invested. We are not talking about anything righteous or just here. It is a purely utilitarian calculation: we want people to invest in the next round of curing the diseases that ail us. To do so we've got to allow the people who spent in the last round of such investment make money. Incentives do, after all, matter.
What happens when you ban e-cigarettes
A quick note on what happens when governments ban e-cigs: cigarette smoking rates rise among teenagers.
Regression analyses consider how state bans on e-cigarette sales to minors influence smoking rates among 12 to 17 year olds. Such bans yield a statistically significant 0.9 percentage point increase in recent smoking in this age group, relative to states without such bans. Results are robust to multiple specifications as well as several falsification and placebo checks.
And, from an earlier version of the paper:
Among those with the highest propensity to smoke, ecigarette use increased most while cigarette use declined: a 1.0 percentage point rise in ever use of e-cigarettes yields a 0.65 percentage point drop in this subgroup’s current smoking rate.
The idea that e-cigarettes 'glamourise smoking' has always struck me as being extraordinarily stupid. Turns out I was right. Now, will people who should know better like Public Health England please stop trying to get e-cigs turned into prescription-only medications?
Rescuing the NHS
The media would have us believe that, due to cost cutting, the NHS is in terminal decline when, in reality, it is thriving and has never had more resources. Political spin aside, the real problems are that it is too big, too diverse, and over-managed. Suggesting that the NHS most needs the removal of political interference is hardly new. The Bank of England has improved since Gordon Brown gave it independence. It has not been privatised. It remains a non-profit making public corporation acting, so far as it can, in the best interests of the country. It would be inconceivable to make the BBC, also a public corporation, part of the Department for Culture Media and Sport.
Of course politicians should set the goals and priorities for the NHS and allocate the resources but continual interference in the way it is managed has demoralised staff and created patient dissatisfaction. What qualifications do MPs have which can usefully applied to the NHS before other equally unqualified politicians reverse any changes as soon as they can? The UK’s biggest organisation, by numbers employed, blows in the wind.
The NHS should have a long-term, not less than five years, charter setting out what it is aiming to achieve and the funds government will allocate. Parliament should agree the mission but not how it should be achieved. And NHS top management should certainly be held to account at the end of each charter.
The debates about “privatisation” exemplify why politicians should leave the NHS stage. Left-leaning MPs claim that allowing anyone to make a profit, however small, in the supply chain raises the cost for the taxpayer. This school of economics was once popular in Leningrad. Now Russia, like everywhere else, recognises that even a public corporation cannot itself make everything it uses. The Norfolk and Norwich Hospital does not take deliveries of iron ore to make their own scalpels. The NHS should do for itself what it does cheaper and better. When buying in services is cheaper and better, the taxpayer gains by so doing. Whether someone has made a profit along the way is irrelevant.
Only local managers can do these calculations: they should be free (transparently) to buy in what makes better use of their resources and to do the rest themselves.
Secondly, prevention (health promotion), cure and care are three very different problems that need three solutions, not one. The NHS should focus on curing people and returning them, as soon as their health permits, to their normal lives or to state care if they and their families cannot cope. Using curing resources for care is not just wasteful but ineffective, and even inhumane, as recent complaints about nursing and mental health institutions testify.
Moves are now afoot to bring care and the NHS closer together which is good in the sense of combining the two caring functions but bad in the sense that the managerially challenged NHS will not be able to cope with both roles. We should stop trying to cure the uncurable: the senile, and those suffering from dementia and many forms of mental health.
The National Care Service should be an independent organisation developing its own pride and professional standards. The Hospice movement is a shining example. It is noteworthy that general practice aside, the great curing institutions tend to shrink in number but grow individually as more specialities have to be accommodated whereas in care, the tendency is to move from large institutions to a multiplicity of small units closer to their communities. Different problems need different solutions.
Finally, preventive health is in practice national publicity intended to reduce the net national cost by persuading us to adopt healthier life-styles. Their effectiveness can be measured, and funded, by the reduction in the costs of cure and/or the benefit to the economy from our working productively for longer. This role could be managed directly from the Department of Health or a separate quango but in either case, the performance measurement of the campaigns should be transparent.
Dear Politicians. Please stop bickering over the NHS: separate its three functions and then leave it to the professionals.
A setback for surrogacy
It is the opinion of some that renting a womb from a poor, often illiterate woman in India, for rates cheaper than in the West, is ‘exploitation’. A few days ago, the Indian government moved to limit this supposedly objectionable practice by banning foreign couples from hiring surrogates there. However, the practice of paying a woman to be a surrogate mother is, in fact, the complete opposite of exploitation. The average wage rate for a woman living in rural India (where the vast majority of these surrogates are from) ranges from 85 to 150 rupees a day, depending on what type of work they do and what region they live in. That’s a range of 84p to £1.50 a day, or a maximum of around £550 a year, if they work a full 365 days.
Now compare that to the £5200 ($8000) the average surrogate receives for just 9 months, and you can immediately see the benefit. For a woman in rural India, the real travesty is the poor wage rates they currently receive for hours of backbreaking work on a farm, not the American and UK individuals willing to pay them ten times what they’d usually get a year.
The next reason this policy fails is because most of the market for surrogates in India is from foreign families - thousands are estimated to use the service a year. Getting rid of demand from abroad will not only reduce in the number of woman hired as surrogates, but also lower their average income, as supply will outweigh demand. This of course ignores the obvious emotional cost to thousands of foreign women, whom will be losing the opportunity to have their own child.
Compared to most developing countries, India has a fairly comprehensive health system, keeping risks to the surrogate’s health low. Many women hiring the surrogates also send out care packages and pay extra to ensure their surrogates are well taken care of in facilities or hotels for the duration of their pregnancy. Although it is true there need to be measures to safeguard the surrogates, simply cutting out a huge part of the market is not the solution. Surrogates frequently use the money they've earned as a springboard into further education or training, or to pay for their own children's school fees, improving their future prospects and alleviating the cycle of poverty- an opportunity the Indian government has just restricted.
Therefore, although well intended, it is clear to see how this policy will actually do more harm than good to those it is trying to protect.
Mummy, what's the World Health Organisation for?
The World Health Organisation now has its little list of the things that cause cancer. The Mail helpfully lists them all. Some are obvious: it should come as no great surprise that ionising radiation from the breakdown of radioactive elements is cancer causing. Others are a great deal more controversial: the inclusion of silica for example. It's entirely true that very fine particles can, if they invade the lungs sufficiently, cause cancer. However, simply listing "sand" as carcinogenic makes Brighton off limits: even while the sort of Greens who live in Brighton insist that we must not frack for gas because it uses that carcinogenic sand.
Similarly, the listing of beryllium is not quite right: it is the dust of it, and more specifically of the oxide and or metal, that can cause berylliosis (a horrible disease, akin to mesothelioma from asbestos exposure).
It's also true that certain smokeless tobacco products do cause cancer: yet things like snus seem to reduce overall cancer rates by reducing the amount smoked. And it would be wonderful to point out that yes, it's true that gallium arsenide is cancer causing, but that's the arsenic in it, not the little chip made of it that sits in the middle of every mobile phone.
However, what confuses us is that the list does not include the one greatest cancer risk that we all face: long life. That we are all mortal, a couple of biblical exceptions aside according to the stories, is a fact of our existence. So thus not dying of smallpox, plague, starvation, rheumatic fever, toothache, measles or idiot wars, as all too many of our forbears did, is thus a cancer risk. Because if we don't die of them we'll survive long enough to get some form of cancer or another.
At which point we rather find ourselves wondering, as with the possibly allegorical little girl who asked this of Gladstone, "Mummy, what is the World Health Organisation for?"
We're going to have to tax middle aged women having unprotected sex
It is of course sad that we've got to make this policy suggestion, perhaps imperative is better than suggestion, but it is for the NHS you know, so it is indeed valid. We're going to have to impose a tax on middle aged women having unprotected sex. It just costs said NHS too much money:
In every year since 2006 more than 110,000 babies have been born to women in their late thirties. This is a level of births not seen since just after the Second World War, and four times the level of the late 1970s, the RCM said.For women in their forties, births have been above 29,000 for four years in a row. These are again numbers not seen since the years after the second world war, and are almost five times the level of the late 1970s.
Cathy Warwick, RCM chief executive, said: “All women deserve the very best care, regardless of the age at which they give birth. Women have every right to give birth later in life and we support that. But typically, older women will require more care during pregnancy, and that means more midwives are needed.
Older mothers cost the NHS more money: therefore those partaking in the risky behaviour which might lead to it costing the NHS more money must be taxed.
We know that this is the correct solution: exploding livers cost the NHS money therefore alcohol must be taxed more highly, perhaps even with a minimum price as well. Lung cancer costs the NHS money therefore cigarettes must be taxed more highly. And people shouldn't be allowed to do it indoors, or in a car, or anywhere near children. Obesity costs the NHS money therefore fizzy pop must be taxed more highly. And no doubt at all, given that processed meat causes cancer now, there will be someone along to shout that bacon butties must double in price and not be eaten where children could believe that such behaviour is normalised.
Therefore, given the basic logic by which our society works, middle aged women who have unprotected sex must be taxed. For the result of this costs the NHS money. And perhaps they should be banned from doing so indoors, in front of children, in cars, and possibly a minimum price must be imposed. And definitely not in pubs where they might enjoy it with a drink.
Alternatively we could suggest that the NHS, which we pay for, is there to treat the results of how free people live their lives. But that's such a radical idea that it will never catch on, will it?
On entirely misunderstanding the mechanics of capitalism
We'd just like to offer our congratulations, once again, to the founder of Corbynomics, Richard Murphy. Congratulations on managing to entirely misunderstand the methods of capitalism and the implications of bankruptcy. Here he is worrying about the possibility of a system of care homes going bankrupt:
The extent of the crisis at Four Seasons, Britain’s largest care home provider, was underscored on Thursday when it appointed advisers to carry out an emergency review of its finances. And:
Four Seasons, which has 22,500 beds in 470 homes, is weighed down by annual interest payments of £50m and debts of more than £500m — meaning it is making less money than it needs to service bondholders.
So, we have another private sector out-sourcing disaster in the making impacting on an enormous number of vulnerable people and their families.
When will we realise that care of the elderly is not something for which the market has any easy solution whether it concerns care or pensions? Deep financialisation and the provision of essential social solutions just do not mix in either case. But I expect the same old excuses to be rolled out this time as in the past.
One day we might have a government with the courage to admit that this is a problem for all of us. Until the problems will keep on coming.
The potential bankruptcy of Four Seasons (we have absolutely no idea what their financial situation is at all, we're only going on the evidence provided by Murphy) is in no manner an outsourcing disaster. It may not be all that much fun for either shareholders or bondholders but it will make very little difference to anyone else, including those elderly people currently living in those homes.
For we've seen this movie before, when Southern Cross went down. Management messed up their financing, the company went bust. But the homes carried on existing, those elderly people carried on living in them, being cared for by the same staff as before. For capitalism is a system which describes who owns things. And bankruptcy is the method by which transfer of such assets (ie, care homes, contracts with people to live in them, with staff to aid them in doing so) are transferred from one group of owners who screw up to others who may do better.
As far as anyone knows there wasn't even a case of one single cup of nice hot tea not being served as a result of that Southern Cross bankruptcy. And there's not a shred of evidence that anything different will happen in any other future such event. Simply because investors who choose the wrong management lose their money. This is how it should be, this is how the system works. And bankruptcy is the process by which we ensure that it does.
Quite why the transfer of a group of assets from possibly erroneous or not very good management to that of some other group of people is a disaster we're really not sure. Perhaps Jezza, with the aid of his adviser, will be able to explain it all to us one day from the Dispatch Box.