Can National Pay Bargaining in the NHS Kill?

Pay for NHS clinical staff (nurses and physicians) is set nationally, with very little variation to take into account local labour market conditions. This is a problem because in the UK regional pay differences are high, even when you control for things like education and skills. As a result, there are large differences in the UK between wages inside and outside sectors where pay is strictly regulated like the NHS. In some regions NHS clinical staff are overpaid relative to local labour market conditions, while in others (London and the South East) clinical staff are underpaid and would get higher pay if they left the NHS for the private sector.

This leads to worse outcomes for patients according to a 2010 paper from Propper and Van Reenen. Looking at the hospital death rate for heart attacks alone, they find that national pay setting for NHS clinical staff (nurses in particular) leads to 366 extra deaths every year.

In effect, national pay setting in the NHS for nurses acts as a price ceiling in high wage regions, which in the absence of other countervailing factors should generally lead to an undersupply.

There are two major predictable effects of this defacto price ceiling.  First, we should expect nurses to move from areas where their wages are relatively low (London and the South-East) to areas where their wages are relatively high (South-West and the North-East). Second, we should expect nurses in London and the South East to leave the regulated sector (NHS) for the unregulated sector (private nursing homes) where they can expect higher pay. Put simply, we should expect the NHS to get better in low wage regions, and get worse in high wage regions. 

Now this alone doesn’t really tell us much about the overall effect of setting pay nationally in the NHS. Perhaps the benefits of better service in the North-East outweigh the harm of worse service in London.

However, the data implies that regulating pay leads to worse outcome across the NHS on balance. Part of the problem is that people have strong area-based preferences: they aren’t willing to just up sticks and move across the country unless they’re getting a serious jump in wages. So instead they’ll be more likely to stay in the high wage region and just leave the NHS altogether to move into the nursing home sector where pay isn’t set nationally. 

On balance, this leads to 366 extra heart attack deaths each year across the NHS. But the authors suggest this figure might, if anything, be understating the harms of national pay setting:

If we were able to calculate the fall in quality across a much wider range of illnesses (deaths and more minor loss of quality of life), we would scale up the social loss by a very large amount.

If we devolved pay negotiation and hiring powers to trusts, we could raise standards across the NHS and most importantly, save lives!

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:

From the press release:

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.

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.

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.

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.

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.

Miliband's attack on profit is an attack on patients

Either Ed Miliband is struggling to understand the basics or his ideology is spiralling out of control. The latest Labour pledge:

Labour would cap the amount of profit private firms can make from the NHS, Ed Miliband will say as he launches the party's election campaign.

He will pledge to halt the "drive to privatisation" he claims has taken place in the health service since 2010.

The future of the NHS is "on the ballot paper" and only Labour can guarantee the funding it needs, he will say.

Under his plans, private firms will have to reimburse the NHS if they exceed a 5% profit cap on contracts.

Companies make profit by keeping costs as low as possible while producing a product or service that people want (and ideally choose) to consume. Apologies for the simplicity, but apparently Ed needs it.

Pledging to fix levels of profit that a company can make ruins any motivation for the company to bring costs down. Given the NHS’s current financial situation, Miliband should not be so quick to toss aside the importance of efficiency gains.

Nor should he be ignorant of private firm’s impacts on patient outcomes.

Private firms are hardly private when working for the NHS; they are still under the jurisdiction of NHS bureaucracy and are often dependent on public funds for their operations. But where private firms and independent sector treatment centres do differ from the public sector is in their record on patient outcomes. Research from 2011 showed that ISTC surgery patients are healthier and experience less severe recovery conditions than patients undergoing the same surgeries with NHS providers.

Furthermore, Circle's management of Hitchingbrooke Hospital turned a failing trust into one of the highest ranked hospitals for patient happiness and cut waiting times drastically; their recent failings were not a result of bad healthcare but rather bad business.

One of the reasons Circle reneged on its government contract is because it’s a struggle to make efficiency gains under NHS regulations as they currently exist; if Labour gets its way, this will become nearly impossible.

Miliband's attack on privatization and profit is an ideological attack on buzzwords; unfortunately, his crackdown could have real affects on patient outcomes.

Keep Politicians out of the NHS

In the run-up to the election, politicians are trying to out-bribe us with our own money to pay for escalating NHS expectations. Democracy has a dark side. Doctors are telling politicians to: “stop messing with NHS to win votes.” (The Times, 17th February, p.15). Demand will always outstrip capacity for a free good such as health. The questions are simply two: how much money should be allocated to the NHS and how should those resources be best managed to maximise welfare?  The former question is essentially political but the latter should not be. The budget should be set annually and not agonised over every day.

As every government IT project demonstrates, government does not do management well. One can blame either politicians or civil servants but it is the combination that is fatal. Apparently the present Secretary of State for Health assembles his entire team every Monday morning to micro-manage NHS issues in Darlington, Taunton or wherever. Or rather to attempt to micro-manage. This may improve media coverage but it builds confusion and disheartenment throughout the NHS.

All the best-run large businesses know that those at the top should lead, not manage. The first level of management should be empowered to deal with the micro-stuff and thereafter the next level of management should deal with matters the lower level cannot sensibly address. Because the NHS is so very large, that lesson is the more important.

How can politicians be removed from NHS management? Simple. We have a relatively new, well experienced, NHS England Chief Executive. He seems excellent and a great improvement on his predecessor. NHS England and the other national NHSs should be converted into public corporations, like the BBC, i.e. a stand alone operations funded and responsible to government but managed, day to day, independently. Whether to close, say, a cottage hospital would be a matter for NHS England. Politicians will still, rightly, lobby but they should not be making the decision.

Our political leaders should lead, not second guess local NHS doctors and managers. In addition to setting the budget, politicians should agree the budget and the strategy, i.e. what, overall, we should expect for our money. Then they should get out of the operating theatre.

A neat solution to the vaccine problem

A bit of free riding is inevitable in a free society. But sometimes you get so much that it ruins things for everyone. To stop the spread of infectious diseases, you need a certain number of the 'herd' to be immune to protect unvaccinated people from the disease's spread. In some parts of the US, after years of (baseless) scaremongering about the MMR vaccine against measles, mumps and rubella, so many parents have now chosen not to vaccinate their children that this herd immunity no longer exists. Until recently they were able to free ride on vaccinated children and avoid the disease, but now measles is staging a comeback.

If it were only the children of these parents who were at risk, we might judge that risking their lives was a price worth paying for parental autonomy, depending on how lethal the disease was. But some children (and adults) cannot be vaccinated for medical reasons or because they are too young, so there is a clear external cost to others.

Because of that, depending on the lethalness of the disease, there is a case for government intervention, but it would still be nice to minimise coercion if possible. KCL academic Nick Cowen suggested one elegant way of doing that:

Modest proposal: pay parents of new borns about £2,000 ($3,000) on completion of all vaccines on a standard schedule, or on submission of a medical exemption certificate (just to be fair to children with genuine vulnerabilities to vaccines).

That should get everyone enrolled apart from the truly rich and stupid, and bring herd immunity (the public good we are looking for) up to scratch. If that doesn't do it, double it. It functions as a good excuse to channel more money to families with young children - think of it as an upfront capital grant. The distribution is so broad that it will have few dead weight losses.

I imagine this would probably work, and it avoids having to put anyone in jail or take anyone's children away from them.

The NHS is meant to be for patients, not staff

Jeremy Hunt has annoyed people today by refusing to give NHS workers a blanket 1% pay rise on top of the incremental pay rise they were already supposed getting. That’s hardly a surprise: the NHS is a religion, and Hunt’s decision is the equivalent of giving the finger to the Pope. But he’s got a point.

According to the BBC’s Nick Triggle, “all NHS staff will be getting at least a 1% pay rise. Just over half receive incremental pay rises each year - determined by their length of service and performance. Those whose incremental increase is less will have their pay rise made up to 1%, but many will get more. Last year, the average incremental pay rise was 3.5%.”

In other words, today’s announcement means that NHS staff won’t be getting an additional 1% pay rise over their existing agreed pay increases. That’s a real terms drop, but lots of the coverage I’ve seen has suggested that this means that nurses won’t be getting any rise at all.

Remember that real private sector wages have fallen every year since 2010. Public sector workers already have greater job security than private sector workers, so it's difficult to see why they should be regarded as being automatically entitled to pay rises that most private sector workers aren’t getting.

Obviously, there’s no ex-ante reason NHS staff should get a pay rise. The point of the NHS is to provide care for patients, not to provide welfare to NHS staff. Since the NHS's budget is limited, a pay rise to staff means foregone spending elsewhere.

It’s worth noting that, at least according to the government, this pay rise would be equivalent to 6,000 nurses. Now, I don’t know how the NHS should spend its money – it may well be the case that NHS patients are better served by additional staff or more investment in medical equipment than they would be by this wage increase. Maybe a pay rise is the best way to improve patients’ outcomes, maybe not.

I’m left wondering why NHS pay should be a political issue at all. In the end, this story just underlines the need for devolution of pay bargaining to NHS trusts. National pay bargaining makes little sense given differing labour markets and patient needs across the country. In other words, a pay rise that makes sense for patients in Suffolk may not make sense for patients in Sunderland. We don’t want Whitehall to determine supplies of medical equipment or the allocation of labour hours between staff. Why should pay negotiations be any different?

An alternative ‘Agenda for Hope’

Owen Jones has written a nine-point ‘Agenda for Hope’ that he argues would create a fairer society. Well, maybe. I’m not convinced by many of them. Then again, it would be quite surprising if I was.

But it got me thinking about what my nine-point agenda would be — not quite my 'perfect world' policies, but some fairly bold steps that I could just about imagine happening in the next couple of decades. Unlike Owen’s policies, few of these are likely to win much public support. On the other hand, most of the political elite would think these are just as wacky as Owen's too.

Nine policies to make people richer and freer (and hopefully happier):

1) The removal of political barriers to who can work and reside in the UK. Removing all barriers to trade would increase global GDP by between 0.3% and 4.1%. Completely removing barriers to migration, though, could increase global GDP by between 67% and 147.3%. Those GDP benefits would mostly accrue to the poorest people in the world. We can’t remove these barriers everywhere but we can show the rest of the world how it’s done. Any step towards this would be good – I suggest we start by dropping the net migration cap and allowing any accredited educational institution to award an unlimited number of student visas.

2) A strict rule for the Bank of England to target nominal GDP instead of inflation, replacing the discretion of the Monetary Policy Committee. Even more harmful than the primary bust in recessions is what Hayek called the ‘secondary deflation’ that comes about as people, fearing a drop in their future nominal earnings, hold on to more of their money. That reduces the total level of nominal spending in the economy which, since prices and wages are sticky in the short run, leads to unemployment and a fall in economic output. NGDP targeting prevents those ‘secondary deflations’ and would make economic busts much less common and harmful. In the long run, we should scrap the central bank altogether and replace it with competition in currencies (see point 9, below).

3) Significant planning reform that abolished the Town and Country Planning Act (which includes the legislation ‘protecting’ the Green Belt from most development) and decentralised planning decisions to individuals through tradable development rights (TDRs). This would give locals an incentive to allow new developments because they would be compensated by the developers directly, allowing for a reasonably efficient price system to emerge and making new development much, much easier. The extra economic activity from the new home building alone would probably add a couple of points to GDP growth.

4) Legalisation of most recreational drugs and the medicalisation of the most harmful ones. I think Transform’s outline is pretty good: let cannabis be sold like alcohol and tobacco to adults by licensed commercial retailers; MDMA, cocaine and amphetamines sold by pharmacies in limited quantities; and extremely dangerous drugs like heroin sold with prescriptions for use in supervised consumption areas. The sooner this happens, the sooner producers will be answerable to the law and deaths from ‘bad batches’ of drugs like ecstasy will be a thing of the past. Better yet, this would bring an end to drug wars like Mexico's, which has killed around 100,000 people in the past ten years.

5) Reform of the welfare system along the lines of a Negative Income Tax or Basic Income Guarantee. As it is, the welfare system disincentivises work and creates dependency without doing much for the working poor. A Negative Income Tax would only look at people’s incomes (not whether they were in work or not in work), reducing perverse incentives and topping up the wages of the poorest earners. This would strengthen the bargaining position of low-skilled workers and would remove much of the risks to workers associated with employment deregulation. Of course, the first thing we should do is raise the personal allowance and National Insurance threshold to the minimum wage rate to give poor workers a de facto 'Living Wage'.

6) A Singaporean-style healthcare system to replace the NHS. In Singapore, people have both a health savings account and optional catastrophic health insurance. They pay a portion of their earnings into the savings account (poor people receive money from the state for this), which pays for day-to-day trips to the doctor, prescriptions, and so on. The government co-pays for many expenses but the personal cost disincentivises frivolous visits to the doctor. For very expensive treatments, optional catastrophic health insurance kicks in. This is far from being a pure free market system but it is miles better (cheaper and with better health outcomes) than the NHS. (By the way, if you really like the NHS we could still call this an ‘NHS’ and still get the superior system.)

7) A school voucher system and significant reform of the state education and free schools sectors. This would include the abolition of catchement areas and proximity-based admission, simplification of the free schools application process, and expansion of the free schools programme to allow profit making firms to operate free schools. These reforms, outlined in more detail in two ASI reports, would increase the number of places available to children and increase competition among schools to drive up standards.

8) Intellectual property reform. As both Alex Tabarrok and Matt Ridley have pointed out, our IP (patent and copyright) law is too restrictive and seems to be stifling new innovation. Firms use patents as barriers to entry, suing new rivals whose products are too similar to their own. In industries where development costs are high but imitation costs are low, like pharmaceuticals, patents may be necessary to incentivise innovation, but in industries like software development where development can be cheaper than imitation, patents can be a terrible drag on progress. Tabarrok recommends that we try to tailor patent length in accordance with these differences; as a sceptic about our ability to know, well, anything, I’d prefer to leave it to private contracts and common law courts to discover.

9) Last but not least, the removal of the thicket of financial regulation and the promise of bailouts for insolvent banks. Known as ‘free banking’, this system of laissez-faire finance has an extremely strong record of stability – though bank panics still occurred in free banking systems, they were much less severe and rarely systemic. Only once the government started to intervene in the financial system to provide complete stability did things really begin to go wrong: deposit insurance, branch-banking restrictions, and other prudent-seeming regulations led to extremely bad unforeseen consequences. The financial crisis of 2008 probably owes more to asset requirements like the Basel accords, which heavily incentivised banks to hold ‘safe’ mortgage debt over ‘risky’ business debt, than anything else. Incidentally, the idea that having a large number of local banks is somehow better than having a few large banks is totally wrong: during the Great Depression, 9,000 of America's small, local banks failed; at the same time not one of Canada’s large banks failed. The small banks were more vulnerable because, unlike the big banks, they were undiversified.

Now, if only there was a think tank to try and make these dreams a reality.