We’re not going to believe this report, sorry, we’re not

We have the latest salvo in the barrage about how bad foods, those ones that we enjoy, must be taxed and those good foods, the ones we don’t so much, must be subsidised. That is, tax sugar and carbohydrates, subsidise fruit and veg. The argument today being that the bad foods have fallen relative in price to the good ones sand that this is very bad, not good.

The report’s authors found that fruit and vegetables had risen in price by up to 91 per cent in real terms between 1990 and 2012, a bigger increase than for other any other food group. “In high income countries over the last 30 years it seems that the cost of healthy items in the diet has risen more than that of less healthy options, thereby encouraging diets that lead to excess weight,” said Steve Wiggins, one of the authors of the report.

The report itself is here.

There’s a few things being missed. Weight is a function of calories in, calories expended. We don’t gain weight simply because we eat cheaper calories. So this cannot be an explanation for rising obesity levels. Further, all food has become cheaper relative to incomes, so if price really is determining what we eat then we might expect the diet to have become healthier. Whatever budget constraints we had on eating that “good” food have still been relaxed, whatever has happened to relative prices.

But perhaps more importantly than this we’re not sure that we believe the price indices themselves. They appear to be looking at the prices that people actually pay for the goods, not at prices for a constant form or type or quantity. Thus it’s “prices of fruit” or “prices of vegetables” as they appear in the average consumer basket. And there’s a few changes in the composition of that consumer basket over those 30 years.

1) Around the year availability of alomst all fruits and vegetables. This is going to make the average price rather more than what it was when we relied upon the local and seasonal gluts. We also get very much more choice of very much more exotic fruits and vegetables and these are, not surprisingly, more expensive as well.

2) The rise of prepared foods. 30 years ago you could not wander into a supermarket and purchase a prepared salad, not a punnet of sliced fruit etc. Now one can and many do. This is obviously more expensive per unit of salad or fruit but we all seem happy enough to pay it.

3) The rise of organic and fair trade. These are both, by design, premium products at premium prices. And while they’re not a vast portion of the food market they are significant enough to influence a price index composed in the manner this report seems to.

So, the price index seems to be composed not of what we actually want to know (are apples more expensive than they used to be?) but of what we actually buy (are we buying more expensive foods, of greater variety and exotica, all year rather than seasonally, in a more prepared state?). So we’re afraid that we don’t actually believe the stated statistic, whatever problems we’ve got with the theory that they’re trying to push.

Comparing apples to apples: NHS still ranks below average

Most healthcare reporting is deeply biased. From blogs to papers to policy, most people have strong preferences for different kinds of healthcare systems that they believe to be ‘the best’, often based on what they view the role of the state to be. Obviously some beliefs are grounded in more facts and stats than others, but given how complicated healthcare systems are, it’s possible to come up with all different kinds of conclusions that appear, at least on the surface, like they’re grounded in fact.

Compare, for example, The Commonwealth Fund 2014 report to the 2014 European Health Consumer Index: two studies that compare international healthcare systems. Both published within one year of each other, The Commonwealth Fund ranked the NHS the best healthcare system out of 11 countries, while the EHCI threw it down the list, ranking it 14th after all your obvious competitors, including The Netherlands, Switzerland, Germany, but also after your less obvious contenders, like Portugal.

Both reports appear to be thoroughly researched and have lots of numbers to back them up. So who do you believe? Well, if you favour single-payer health systems, you’re probably going favour the Commonwealth Fund’s report, which inherently favours centralised systems. (For example: out-of-pocket costs and insurer rejection of full cost reimbursement were considered a black mark against a healthcare system, regardless of access to treatment.) If you rank results higher than the principles around who delivers healthcare or who makes a profit, you’re probably going to favour the EHCI’s report, that gives more weight to things like waiting lists.

I personally give more credit to the EHCI report because my primary concern when it comes to healthcare systems is patient outcomes. That’s my bias.

Which is why the OECD’s healthcare efficiency reports are so important. The OECD’s stance is that “there is no “one-size-fits-all” approach to reforming health care systems. Policymakers should aim for coherence in policy settings by adopting best practices from the many different health care systems that exist in the OECD and tailor them to suit actual circumstances.” So while the OECD does make some comparisons of countries across the board, it also intentionally group countries together based on different kinds of healthcare systems in order to compare like with like.

Specifically, they break countries down into six groups to compare the efficiencies of similar healthcare institutions to each other, in an attempt to identify where the most improvement can be made within specific systems:

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The UK falls into Group 6, which is characterised as:

Mostly public insurance. Health care is mainly provided by a heavily regulated public system, with strict gate-keeping, little decentralisation and a tight spending limit imposed via the budget process

Seven countries fall into this category: Hungary, Ireland, Italy, New Zealand, Norway, Poland, and the UK. The OECD uses nifty radar charts (click on links) to illustrate how each country compares to both the OECD average as well as Group 6’s average in different areas including efficiency and quality, amenable mortality, prices, resources, consumption, financing and policy. The final chart ranks each country’s to measure its comparative efficiency. The results:

High DEA Score: Norway, Italy
Above Average: Poland
Average: New Zealand
Below Average: UK
Low: Hungary, Ireland

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The OECD’s analysis: “The quantity and quality of health care services (in the UK) remain lower than the OECD average while compensation levels are higher. Reinforcing competitive pressures on providers could help mitigate price pressures, e.g. by increasing user choice further and reforming compensation systems.”

On Tuesday I noted that the UK is one of the OECD countries that could do the most to improve its efficiency in public healthcare spending . But breaking that down even further, the UK doesn’t come close to topping the charts in its own group.

Perhaps the UK should be looking to make improvements to resemble Norway, which tops the ranks for public health services. Or maybe it should be looking towards other categories that focus on social insurance systems. Either way, it’s time for the UK to start looking beyond the NHS.

Myth busting: NHS not so efficient after all

The NHS has long coasted on the widely held belief that it is one of the best healthcare systems in the world because it is so efficient. While European systems boast better patient outcomes, and the United States points to its excellent pre-emptive care measures, NHS loyalists cast that all aside, because unlike any of those other countries, the UK is able to keep its healthcare spending below 10% of GDP, free at the point of use, with relatively good outcomes. No other country can beat that efficiency.

Well, it turns out most of them do.

In 2010, the OECD published multiple papers that specifically looked at the efficiencies of different health care systems. In its report “Health care systems: getting more value for money”, the OECD found that there was “room in all countries surveyed to improve the effectiveness of their health care spending.” Some countries, however, could see significant efficiencies gained. And the top three countries that could benefit the most: Greece, Ireland, and the United Kingdom.

By improving the efficiency of the health system, public spending savings would be large as compared to a no-policy-change scenario, amounting to almost 2% of 2017 GDP on average in the OECD. It would be over 3% for Greece, Ireland and the United Kingdom.

Potential savings

Breaking with myth, the UK is one of the countries that could do the most to improve its efficiency in public healthcare spending. Even more than the United States.

What the loyalists don’t seem to realise is that efficiency can’t simply be determined by how much money a country puts towards healthcare. The real question is how efficiently those monetary resources are being used to obtain better health outcomes.

And according to the OECD, both the UK and the US still have a long way to go:

Australia, Iceland, Japan, Korea and Switzerland perform best in transforming spending into health outcomes

In more than one third of OECD countries, exploiting efficiency gains in the health care sector would allow improving health outcomes as much as over the previous decade while keeping spending constant (Figure 2, Panel B). Germany, the United Kingdom and the United States fall into this group.

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I’m not predicting the end of this health care tale. Perhaps, if the right reforms were made to the NHS to drastically improve efficiencies, the UK would have a system that not only demands less public spending, but also creates better health outcomes too. To compare apples with apples, Norwegian healthcare is ” is mainly provided by a heavily regulated public system, with strict gate-keeping” and grouped together with the UK in the OECD’s categorisations for healthcare systems; yet Norway‘s system is ranked much better for efficiency (more details to come in next blog…).

I just thought I’d flag up that, as things stand, the NHS under-performs on just about everything that matters.

Non magister sed mendax

Once again we’ve the, umm, interesting assertion that it’s sugar that is really causing the outbreak of obesity. That this is not true doesn’t seem to bother those pushing the tale. For here they are again:

Sugar and carbohydrates are the real culprits in the obesity epidemic – and the public has been falsely told that couch potato lifestyles are to blame, a new report has claimed.

Writing in the British Journal Of Sports Medicine, they said poor diet now generates more disease than physical inactivity, alcohol and smoking combined.

The editorial, by a group of cardiologists and sports experts, says that while obesity has rocketed in the past 30 years there has been little change in physical activity levels.

“This places the blame for our expanding waistlines directly on the type and amount of calories consumed,” they write.

Here is that editorial:

A recent report from the UK’s Academy of Medical Royal Colleges described ‘the miracle cure’ of performing 30 min of moderate exercise, five times a week, as more powerful than many drugs administered for chronic disease prevention and management.1 Regular physical activity reduces the risk of developing cardiovascular disease, type 2 diabetes, dementia and some cancers by at least 30%. However, physical activity does not promote weight loss.

In the past 30 years, as obesity has rocketed, there has been little change in physical activity levels in the Western population.2 This places the blame for our expanding waist lines directly on the type and amount of calories consumed.

So, what’s actually wrong with this analysis?

What’s wrong with it is that it’s simply factually wrong. As Chris Snowdon has been manfully pointing out all along, calorie intake in both the US and UK has been falling over the decades. As has, remarkably, sugar consumption. To the point that, for the UK today, average calorie consumption is lower than the minimum recommended during WWII rationing. Actually, today’s average consumption is below where our grandparents started to lose weight on such wartime rations. It simply cannot be an increase in consumption to blame as there’s not been an increase, there’s been a reduction.

Given that weight does work on calories input minus calories expended, this means that calorie expenditure must be down. But our magisters here are telling us of a study that shows that exercise levels have not fallen, might even have risen. So, what is happening here?

Quite simply, they are looking at formal exercise, not calorie expenditure. Perhaps more people do go for a shuffle around the block than used to. But that’s not going to outrun the effect of us all having central heating these days upon calorie expenditure.

It’s getting very difficult indeed to think that magister is the appropriate word here, our opinion is leaning ever more to the word mendax.

Universal healthcare and market-based systems aren’t mutually exclusive

An op-ed published last week in the New York Times laments Americans’ decline in support for government involvement in the redistribution of wealth – or, as the Times author Thomas Edsall calls it, ‘sharing’.

Edsall analyses a bunch of polls throughout the article, but what he finds troubling I find to be good common sense. For example, most Americans aren’t incredibly trusting of their government:

Even worse for Democrats, the Saez paper found that “information about inequality also makes respondents trust government less,” decreasing “by nearly twenty percent the share of respondents who ‘trust government’ most of the time:”

Smart thinking.

Furthermore, most Americans aren’t convinced that Obamacare is going to be the shining, efficient, cheaper, all-inclusive beacon of hope it was promised to be:

An earlier New York Times poll, conducted in December 2013, found that 52 percent of those surveyed believed that the Affordable Care Act would increase their medical costs; 14 percent said it would reduce costs. Thirty-six percent believed that Obamacare would worsen the quality of health care compared to 17 percent who thought it would improve it.

Also probably wise.

On the whole Edsall appears to understand people’s perceptions of government care (to my relief and his dismay) quite well – except for in one area.

Esdall claims the “most dramatic” change in public opinion has been people’s perception of the ‘right’ to healthcare. He cites the two Gallup polls in an attempt to claim that majority support for guaranteed access to health coverage has dropped radically over the past six years:

The erosion of the belief in health care as a government-protected right is perhaps the most dramatic reflection of these trends. In 2006, by a margin of more than two to one, 69-28, those surveyed by Gallup said that the federal government should guarantee health care coverage for all citizens of the United States. By late 2014, however, Gallup found that this percentage had fallen 24 points to 45 percent, while the percentage of respondents who said health care is not a federal responsibility nearly doubled to 52 percent.

But Esdall isn’t comparing apples with apples. The belief that in a developed society everyone should have access to basic healthcare provisions is not the same as believing that healthcare is a federal responsibility – especially in the United States.

The debate is not – and has not been for a long time – whether or not people should have access to healthcare, but rather how that care should be provided. What kind of delivery of healthcare will create the cheapest prices and best outcomes, and what safety net for those at the bottom will provide the most comprehensive care?

There is huge demand in the States for healthcare reform, and most people want this reform to focus on cheaper access to care. But that can be achieved without fully handing healthcare provision over to the federal government or adopting something that resembles the NHS.

Both the US and the UK should be looking to countries that rank highest for healthcare provisions internationally, which have almost all settled on systems where the central government funds healthcare but does not directly provide healthcare.  The Netherlands, Denmark, Switzerland, and Germany all have healthy relationships with private companies, ranging from insurance companies and charities, that provide better outcomes than those in the UK and in a cheaper, more efficient manner than in the US.

Support for universal access to healthcare and support for market mechanisms in healthcare are not mutually exclusive; there’s plenty of evidence to suggest a combination of the two creates the best healthcare systems in the world.