Healthcare

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!

The NHS is not investment, it is current spending

We'd like to leave aside our well known biases on the subjects of the European Union and the NHS and make a still important point. Brexit itself is going to make no difference at all to domestic policy: what will is the policies adopted once the UK is again free to adopt whichever policies it wishes. And the NHS, sure, we're not wholly in favour of the current form of the organisation and think the same provision can be done better. But leave those both aside and consider this statement:

Norman Lamb, the Liberal Democrat MP and former health minister, backed Hunt’s EU stance.

He said: “I don’t agree with Jeremy over the current funding of the NHS.

“I’ve been very clear that I’d like to see the government investing more in the NHS and social care. But we could not even have that debate if we vote to leave the European Union.

Spending upon the NHS is not investment. Yes, parts of such spending are: building a hospital which will still be there in 30 years' time is investment. But by far the vast majority of NHS spending is upon wages and consumables and is thus current spending. We could, of course, just dismiss this as being pedantry, a symptom of "investment" to a politician being public spending upon anything said politician approves of. But sadly the issue goes deeper than this.

It is not just an apocryphal story that the original founders thought that after the backlog of problems had been cured then spending upon the NHS would go down: they really did think that it was investment. Get over the hump of untreated disease and costs would decline even as tax revenues from the newly again healthy would rise. That could indeed have been described as investment: if it had actually happened. It didn't of course, that nascent NHS went from consuming 3 to 4% of GDP to the current 9 to 10% and more (all figures are a bit hazy as exactly what is NHS spending is a bit hazy).

We're not going to get to a proper and rational discussion on what amount should be spent on the health of the nation, nor how that should be raised nor allocated, until we get over that 70 year old delusion that health care spending is an investment. It isn't: it might be just, moral, necessary, better organised in another manner, just perfect the way it is. But it's most definitely current spending and must be recognised as such before we can have a proper discussion about it.

For example, the correct question is, at heart, how much of current production of the economy should be devoted to health care? No, not how much should we borrow to "invest" in it, but what portion of current income should be devoted to it? That's what that essential division into capital and current spending aids us in seeing: and given that that's what we must see before we decide thus we must see it. Further, the insistence upon seeing it as current spending aids us in viewing that "how much" question in its proper light: what other things are we not going to have as a result of having health care?

Or as an economist would put it about everything, there are always opportunity costs. Thus the true price of something is what we give up to get it. There is no cute let out by calling it investment and thus that is the correct lens through which to view health care spending whether it's done through the NHS or not. What won't we get as a result of more NHS and is more NHS worth more or less than what we must give up?

After all, we can only find the right answer if we ask the correct question in the first place.

How we end up with absurdities like the sugar tax

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Quite how we end up with absurdities like the sugar tax is an odd one. From Osborne's point of view it is of course just pandering to whatever he thinks the chatterati are wibbling about this week. Rather than considering the economics of his action it's a bone thrown to the political dogs. Not really how we do want our economic policy to be determined. On the other side, from those pushing the policy in the first place, it seems to be simple and pure ignorance of the subject under discussion. Here is the leader of the campaign itself, Dr. Aseem Malhotra on the subject of sugar:

Sugar is NOT a “nutrient” so let’s not pretend it is

That's rather news to any- and every- one who has ever studied the subject of diet and what it is necessary for human beings to ingest.

For years spokespeople for the food and soft drinks companies have defended arguments calling for the regulation of sugar by saying we shouldn’t be singling out one “nutrient” when it comes to tackling Obesity. This was again repeated by the corporate affairs director of the Food and Drinks Federation in a debate I had with him on Channel 4 News last week. I pointed out that sugar has no nutritional value, has no biological requirement and therefore cannot be a “nutrient.”

No nutritional value? What?

Just to be clear the definition of nutrient is “a substance that provides nourishment essential for the maintenance of life and for growth”

Sugar contains calories. That's rather the point of the campaign that Dr. Malhotra is leading: the consumption of sugar leads to many calories being ingested. And we are really rather sure that it is necessary for human beings to ingest calories, they are indeed nourishment essential for the maintenance of life and for growth.

A crowd pleasing Chancellor listening to the gibberings of the grossly ill-informed. Now you know how we end up with absurdities like the sugar tax.

Osborne's disastrous sugar tax decision in the Budget

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George Osborne made a truly horrible decision in the Budget yesterday: the one about a sugar tax.

So today I can announce that we will introduce a new sugar levy on the soft drinks industry.

Let me explain how it will work. It will be levied on the companies. It will be introduced in two years’ time to give companies plenty of space to change their product mix.

It will be assessed on the volume of the sugar-sweetened drinks they produce or import.

There will be two bands – one for total sugar content above 5 grams per 100 millilitres; a second, higher band for the most sugary drinks with more than 8 grams per 100 millilitres.

Pure fruit juices and milk-based drinks will be excluded, and we’ll ensure the smallest producers are kept out of scope.

We will of course consult on implementation.

We’re introducing the levy on the industry which means they can reduce the sugar content of their products – as many already do.

It means they can promote low-sugar or no sugar brands – as many already are.

They can take these perfectly reasonable steps to help with children’s health

Of course, some may choose to pass the price onto consumers and that will be their decision, and this would have an impact on consumption too.

We understand that tax affects behaviour. So let’s tax the things we want to reduce, not the things we want to encourage.

It's not that taxing sugar is a particularly bad thing to do. There's other nice and desirable things that we tax like booze and insurance. Hey, got to get the revenue where you can.

Rather, what worries us is the monumental mountain of lies that the campaign for this tax has been built upon. Sugar consumption has been falling in recent decades even as the country gets ever porkier. It is therefore not sugar consumption driving the fact that we're all becoming lardbuckets. If that is so the tax won't achieve the stated goal.

However, what will happen as a result of giving in to the misinformation being shouted from the rooftops is that every Single Issue Fanatic will now be concocting plans to bombard us, and more crucially the government, with demands for whatever absurdities they can conceive of imposing upon us. Whatever the actual merits of a sugar tax (none, but that's by the by) the caving in to the fanatics has just made future public policy worse.

Just not a good idea.

Why are people so illogical about vaping?

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There're certain subjects that seem to turn people into drooling idiots. Those subjects often involve people enjoying themselves so we can at least construct some clues as to why the idiocy. Vaping seems to be one of those subjects. The basic point is really easy enough for anyone to understand: human beings rather like the effects of nicotine and vaping is about 5% as dangerous or less as a manner of ingesting nicotine as the other popular method, smoking tobacco. Being able to abolish 95% of the damage done to health by a product seems like a pretty good idea to us but there are those out there who disagree:

Legislators across the country are bringing bills to statehouses to raise the vaping age in line with the smoking age to a new high of 21 in some states. Politicians and public health activists argue e-cigarettes could hook kids on nicotine and lead to them to transition to tobacco and, therefore, need to be more tightly regulated.

It's obviously true that that is possible: but what we need to know is whether it is true. Is vaping a substitute or a complement to cigarette smoking?

“We should regulate tobacco products proportionate to their risks, and e-cigarette evidence suggests they’re less risky products,” said the Cornell study’s lead author Dr. Michael F. Pesko. “While there’s some risk, it would be a mistake to regulate them the same way we regulate cigarettes.”

The study backs up research published in 2015 showing the drive to ban the under 18s from buying and using e-cigarettes had the exact opposite effect that policy makers intended.

Smoking rates among 12-17-year-olds actually rose in states that banned e-cigarette sales to minors, according to the study by Abigail Friedman of the Yale School of Public Health, published in the Journal of Health Economics found.

“Such bans yield a statistically significant 0.9 percentage point increase in recent smoking in this age group, relative to states without such bans,” Friedman said. The study controlled for smoking rates within states and statewide cigarettes.

It's a substitute so far from making it more difficult, or taxing it more, if we're seriously concerned about human health we should be subsidising it.

In other news the European Union has started discussions on raising the taxation level on vaping to equal that on cigarettes. As we note, there's something about some subjects that just turn people into drooling idiots.

In praise of profiteering on vaccine prices

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The scandale du jour seems to be that people are raising the price of something that is in short supply. Quite what anyone is supposed to do other than that is not detailed but it's definitely a scandal:

Private clinics have been accused of “cashing in” on the increased demand for meningitis vaccinations by charging up to £750 for a child’s treatment. This is more than 12 times the cost of the same three-dose course on the NHS, which is around £60.

Parliament are expected to discuss reversing a controversial decision to limit the meningitis B vaccine to babies under nine months after MPs acknowledged that a record-breaking online petition had to be "taken seriously".

The petition, which has been signed by more than 800,000 people maing it the most signed in parliamentary history, calls for all children under the age of 11 to be given the vaccine.

Vaccination is of course a good thing in general: it's one of the great advances in public health of the past few centuries, ensuring that ever fewer of us die of the common childhood diseases. It also leads to that public good of herd immunity which is a very good reason indeed for there to be state intervention and possibly state subsidy. That is, after all, one of the major reasons for having government, to gain those public goods which we cannot gain in any other manner.

Sadly, meningitis vaccines tend not to produce herd immunity but that's a slightly different matter. Dependent upon the sub-type it is possible to be personally protected and yet still carry and possibly infect.

Yet this is simply wrong:

Sue Davie, head of the charity Meningitis Now, told The Daily Mail: "It would clearly be wrong for anyone to profiteer from this situation. This vaccine should not only be available to those who can afford it."

Ian Liddell-Grainger, a member of the All Party Parliamentary Group for Child Health and Vaccine Preventable Diseases, said: "For clinics to profiteer on something which is affecting people's health and lives is disgraceful.

"People's lives are being played with. To charge £250 a dose really is disgusting. I will bring this up in Parliament if I can."

Because that isn't the situation at all. Those wise people at NICE and elsewhere in the health service have done their best to look at the costs and benefits of this particular vaccine. It's part of the regular childhood set now. And that part is entirely unaffected:

Due to unexpected global demand for Bexsero during 2015, we are experiencing supply constraints during the first half of this year.

Although vaccination through the NHS childhood programme has been prioritised and is unaffected, we have unfortunately had to ask private clinics temporarily to not start new courses of vaccination.

Children who have already started their course of the vaccine privately should still be able receive their follow up doses.

So, where it is considered medically appropriate this vaccine is available in the usual manner, through the NHS. For others who desire this vaccine there is a shortage of supply. There is, quite literally, nothing at all that can be done to increase this supply in the short term. In the medium term there will be increased supply.

What then should anyone be doing to allocate that very limited (in fact, the drug company itself is indicating no further supply at all to the private market)? Who, where and how, should be making the decision as to who gets that limited supply and who does not?

Note again, all the actions to increase supply are already happening. Even a Manhattan Project style program isn't going to increase that supply before the summer.

Clearly, what should be happening is what is already happening. Supply to those with medical priority, the 9 month old babies, is already both prioritised and ensured. The remaining supply is being allocated to those who value it most: as it should be, on the basis of price. There is no other sensible manner of doing this.

Just what is the solution that anyone else would offer?

We regard this as something of a victory actually

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People are throwing around the latest global mortality statistics to show that we've got some grand problem that we've got to deal with. And we're certainly amenable to the argument that things could be better. However, we would also still insist that this is a victory, not a defeat:

Now new research has found that air pollution is the leading environmental risk factor for disease, and the fourth highest risk factor for death. The data is the newest addition to the Global Burden of Diseases, Injuries, and Risk Factors Study, the most comprehensive international effort to measure epidemiological trends worldwide.

Yes, a victory:

According to the Global Burden of Disease Study, air pollution causes more deaths than malnutrition, obesity, alcohol and drug abuse, and unsafe sex. Cardiovascular and pulmonary diseases, as wells as respiratory infections, account for the majority of deaths from air pollution.

Historically human beings have died either from infectious disease or malnutrition. They're the two that have carved great swathes through the population repeatedly. Both are, while not entirely solved, at least under control to a great extent.

Which leads to two further things: the first being that if we don't die of one of those two then we're obviously going to die of something else. And given that life expectancies do keep on growing we are indeed living long enough to die of those other things. But much more specifically to this point, the pollution that is being complained about here is that air pollution. That air pollution which is the result of having a modern economy that is able to be clean enough not to be rife with infectious disease and which also produces enough food that we don't all starve. The poor world has a slightly different problem, in that it's indoor air pollution killing them, from wood cooking fires mostly, something we stopped doing many generations ago.

So, yes, we do regard this as a victory, even if not a complete one. Sure, we could and we will make things rather better as technology improves but that we are all living long enough to die of the side effects of the system that allows us all not to starve to death earlier is indeed a victory.

Delusions on the NHS

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Sadly, one of the reasons that the political conversation about health care in the UK is so difficult is that a number of people taking part in it simply do not know of what they speak. And example here in the Guardian:

Four flawed beliefs have dominated the actions of UK governments on healthcare over the past 25 years: personal responsibility for health supersedes government responsibility; markets drive efficiency; universal healthcare is ultimately unaffordable; and it is entirely legitimate to view healthcare as a business.

Responsibility is a moral argument and not really our point here: no one at all says that universal health care is unaffordable, only that all healthcare that everyone would conceivably like to get is unaffordable. But of course it is legitimate to regard healthcare as a business: there're inputs, there're outputs, there are people in the middle doing the transformation, that's a business. But that point about markets not driving efficiency is drivel: because this is the same NHS which is now separate organisations, NHS England, NHS Wales and NHS Scotland. And NHS England has had rather more of that market stuff applied to it. And NHS England has been getting more efficient more quickly than NHS Wales and Scotland too. The very subject under discussion disproves that assertion about markets.

But there's more too:

The 2014 Commonwealth Fund report on 11 wealthy countries shows that the UK spends least but ranks first in healthcare performance; the US spends most but ranks bottom.

Actually, no. Healthcare performance was only one of the things measured. Things like equitable access and so on were also measured and the NHS did very well on some of those measures (that the Commonwealth Fund agitates for single payer health care in the US is not a result of such studies, it is the cause of their measurement methods). On actual healthcare performance, mortality amenable to healthcare, it came near last. And oddly, we do think that how well a healthcare system is able to treat things that healthcare systems can treat is a pretty good measure of how good that healthcare system is. Or, for the NHS, not very.

In the US, one in six citizens has no health cover and inability to pay healthcare bills is the primary cause for personal bankruptcies, yet we are witnessing extraordinary, deliberate moves towards a failed US-style healthcare model.

Absolutely no one at all (and we are ourselves one of those voices shouting loudly for NHS reform) is calling for a US-like system. Instead we're calling for a system rather more like that of France, or Switzerland, or Singapore, all of whom have rather better healthcare systems than either we or the Americans do.

So why is this a problem if piffle like this appears in The Guardian?

Neena Modi is professor of neonatal medicine at Imperial College London, and president of the Royal College of Paediatrics and Child Health

Because this piffle is being spouted by people who really should know better.

Reminder to CDC: Women are more than baby-portals

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No one likes to receive unsolicited advice; and government recommendations are no exception to this. But the United States’ Centers for Disease Control and Prevention didn’t heed that warning when on Tuesday it released a new alcohol advisory, aimed at child-carriers (who we in the 21st century have started to call ‘women’).

The CDC has recommended that women of a childbearing age who are not using birth control completely abstain from alcohol intake to avoid an accidental, alcohol-exposed pregnancy.

From the CDC's Principal Deputy Director Anne Schuchat, M.D.:

Alcohol can permanently harm a developing baby before a woman knows she is pregnant...About half of all pregnancies in the United States are unplanned, and even if planned, most women won’t know they are pregnant for the first month or so, when they might still be drinking. The risk is real. Why take the chance?

Why take the chance? In the off-chance that a woman could get pregnant during 3-4 decades of her life, why wouldn't she abstain from alcohol (and while she’s at it, cut out raw fish, cured meat and soft cheeses, stop skiing, avoid overheating and sign up to antenatal courses too.)

Those outside the- 4-decade span haven't been excluded fully from the press release either. While the CDC mainly addressed the effects of alcohol on pregnant women, their infographic suggests far more ambitious plans to cut down on women's alcohol consumption alltogether. Keep in mind "heavy drinking" is defined by the CDC for woman as "consuming eight drinks or more per week".

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Fear-mongering much?

Quite rightfully, the Internet went ballistic over the insinuation women should be prioritizing the biological possibility of pregnancy over their daily activities, which include drinking habits.

These recommendations in the States come just weeks after here in the UK the Department of Health changed its alcohol guidelines, lowering maximum unit intake to 14 a week for both men and women, making the UK’s recommendations some of the most restrictive in Europe.

The CDC's and DoH's recommendations are different, but the recommendations of both government bodies were created with the same, faulty assumption: individuals can’t be trusted to their own lifestyle choices, and if left to make up their own minds, will engage in risky behavior.

There is indeed an appropriate way to advise women about the potential consequences of drinking while pregnant, but terrifying non-pregnant women out of a glass of wine because of ‘what might be’ falls short of providing an education tutorial.

We can't help but think that numbers are important

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We find ourselves somewhat ticked off. Not because people are trying to persuade us of something, that's just normal. But that they're willing to, umm, brush over perhaps, the numbers in order to convince us of their desired course of action. And that's not the way it should be: numbers are important, the proper appreciation and quotation of them allows us to actuallly work out what is the truth of any matter. Yes that isn't how they are being used. On the NHS and the exploding livers brought about by booze:

The recent report into life on the liver ward makes sobering reading. John has alcohol-induced dementia (Korsakoff’s syndrome) and doesn’t know where he is. Rita has cirrhosis of the liver and is homeless. Her life has spiralled downwards as a wine habit segued into damaging dependence. It’s easy to feel sorry for the Johns and Ritas, though most of us think it’ll never happen to us.

But will it? Are we becoming a nation of drinkers and drunks? The UK death rate from liver disease has increased fourfold in the past 30 years as cheap alcohol has flooded our shores and our gullets.

In the rest of the piece it actually says nothing at all about possible other causes of such cirrhosis or liver disease. Which is odd:

Common causes of cirrhosis are long-term alcohol abuse, hepatitis B and C infection, and fatty liver disease. Of those, hepatitis B and C together are said to be the leading cause of cirrhosis (WHO).

Agreed, that second number is not coming from the UK but there's obviously some amount of those other causes going on. That someone wants to persuade us to drink less, well, go ahead. But can't you do it using the actual and real numbers? And then of course there's Bill McKibben:

I’ve spent much of my life chronicling the ongoing tragedies stemming from global warming: the floods and droughts and storms, the failed harvests and forced migrations. But no single item on the list seems any more horrible than the emerging news from South America about the newly prominent Zika disease.

Spread by mosquitoes whose range inexorably expands as the climate warms,

Or as implied, Zika is caused by climate change. Well, no. This is the spread of a virus into the extant mosquito populations of the areas affected.

And yes, we do think this is important. Because numbers are the secret to science and science is how we make sense of the world. Rather than rejecting the Demon Rum or worshipping Gaia. as the sign says, "Down With This Sort Of Thing". If we want to discuss what we should do about the world let us do it on the basis of facts: as represented by actual numbers, not incantations pulled out from who knows where.