Isn't this the point of the NHS in the first place?

We're sure it is you know, the point and purpose of the NHS. At least, whenever we suggest introducing a bit more competition into the system we're told that this is the reason we shouldn't. For, you see, if we avoid the chaos and inefficiencies of competition, of the wasted capacity that must be there to allow competition, then the NHS will be a cheaper method of providing health care than alternative systems. And when we've looked at comparisons like those done by the Commonwealth Fund we find that the NHS is rated very highly because it's cheap, despite the fact that it's not all that good at actually curing people. But then we get this complaint from King's Fund:

Britain’s spending on its health service is falling by international standards and, by 2020, will be £43bn less a year than the average spent by its European neighbours, according to research by the King’s Fund.

The UK is devoting a diminishing proportion of GDP in health and is now a lowly 13th out of the original 15 EU members in terms of investment, an analysis for the Guardian by the thinktank’s chief economist shows.

But isn't that the point? The NHS is the Wonder of the World precisely because of its method of organisation? The one that allows us to have equitable and above all cheap health care as the state simply provides it? So how can lower funding than in other countries, with their less efficient systems and structures, be a problem? Isn't this supposed to be a sign of how marvelous the NHS is? That it does better on less?

Then again, we're not sure all that many arguments about the NHS are all that informed by logic: hysterical emotionalism seems to be par for the course.

Why we need to reform the NHS

The Guardian is running a month-long series to tell us about that Wonder of the World, the National Health Service. Somewhat inadvertently they've also told us why it needs reform. That reason being that the NHS just isn't actually very good. As they say:

Maligned for long waiting times and disrupted by endless reorganisation, the NHS may not sound like an international benchmark. But the respected US Commonwealth Fund health thinktank ranked the UK first in its most recent study of healthcare in 11 rich countries (June 2014).

The UK came out best in eight of the 11 areas studied, including safety and effectiveness of care and for overall efficient use of resources. However, it was placed only 10th out of the 11 nations for health outcomes and overall death rates.

It's rather worse than that actually, that report is here.

Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives— mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

We ourselves would think that how well a health care system manages to cure people, given the current state of medical technology, is a pretty good indicator of how good or bad that health care system is. The American system has its own problems, that employer paid insurance being one of them, it isolates consumers from the cost of their health care almost as much as the NHS's tax paid model does. It's also true that that system doesn't cover everyone.

Yet the NHS is also an outlier by this crucial measurement: all the other systems which have more diversity in both funding and supplier, including some measure of that dread market competition, perform better. Thus we must reform the NHS so that it performs better: by, presumably, having more of that market competition.

A simple guide to us all being fatty lardbuckets

Allister Heath has picked up on the excellent work that Chris Snowden has been doing over at the IEA on the obesity issue. Weights are indeed rising but it is not because we are all eating more. The reason that's not the reason is that we're not all eating more: calorie consumption is falling as it has been for a century. The current median diet is today well below the level at which people would lose weight under WWII rationing. Something else has changed and it's actually the amount of energy we expend, not what we consume, which has. As regular readers will know we think that it's central heating which is the big issue here, not in fact exercise. Which, given that the main energy expenditure of mammals is temperature regulation makes a lot of sense to us.

However, Heath makes clear something that can be used as a very useful little tell tale:

We aren’t addicted to high fructose corn syrup either. For reasons relating to tariffs and agricultural policy, Americans consume 25 kilograms a year, against less than half a kilogram for us.

If anyone starts going on about how it's fructose which is the problem, or HFCS, then we can immediately dismiss them as a crank. Or at best, woefully misinformed. Because people are turning into fatty lardbuckets at similar rates in the US and UK. And across Europe too, where HFCS consumption rates vary. So, given the huge variance in fructose consumption, but the same problem everywhere, then it cannot be the fructose causing the problem.

This is not, obviously, a startling revelation, but it is a handy little mnemonic. Warbling on about fructose just doesn't cut it we're afraid.

We're afraid that it's true, maternity leave does contribute to the gender pay gap

This might not be quite what people want to hear but it is in fact true:

Women's careers can nosedive if they take more than a year off after having a baby, experts warned yesterday. New mothers may struggle to get back into the workforce, earn less and be passed over for promotion in what has been described as a ‘motherhood penalty’. A panel of women representing the teaching, legal, medical and recruitment professions told MPs that mums who spent more than 12 months on maternity leave were ‘penalised’. Dr Sally Davies, of the Women’s Medical Federation, said: ‘Anything more than 12 months is a detriment – you will not be looked at quite in the same way, sadly, when you return.’ Amanda Fone, chief executive of F1 Recruitment, said she would discourage women and men from taking more than a year off to care for children because it was ‘so difficult’ to return to a role equivalent to the one they left. She claimed legislation had ‘got in the way’ of women being able to have honest discussions with their employers about their plans to have a family.

As we've pointed out many a time before we don't in fact have a "gender" pay gap any more. What we do have though is a motherhood pay gap. And this is made up of two rather different things. The first is simply the general societal background to the process of child rearing. Whether it should be this way or not (not that it is a surprise in a mammal species) it is true that in general women take on more of the child rearing work than men do. Thus things like careers, on average, take a bit more of a back seat for women than they do for men. Perhaps that should change: but a goodly part of the distinction between male and female average wages comes from that deep rooted fact of our society, not from any discrimination by employers.

The other cause is the actual process of having the children themselves and that associated maternity leave. Some part of the pay gap is not because of that lesser desire for the cut and thrust of business, but because of that time taken out of the workforce. Imagine, say, two years paid maternity leave: and the possible average of two children per woman who has any children at all (about right) that would be four years out of the labour force, or well over 10% of the average working life. Climbing that greasy pole is simply going to be more difficult with that disadvantage.

There isn't in fact a solution, at least not a legal or governmental one, to either of these points. whatever ones' views on this, or indeed innumerable other possible problems, it simply is just true that some conundrums just don't have solutions.

I'm afraid the doctors have this the wrong way around about the NHS

One of the joys of a market in things is that it's clear and obvious who it is who is the supplicant and who it is that is the boss. You check which way the money is flowing and you can tell easily: the person handing over the cash is the one whose wants, needs or desires are being catered to. That we don't have a market in the NHS is what causes logical failures like this:

Feckless patients who fail to take proper care of their health are to blame for a growing NHS crisis, doctors say. GPs said the public needed to take more responsibility for “managing their own health” instead of always turning to their local surgery. Rising patient demand means soaring numbers are struggling to even get through to their GP surgery to make an appointment, a recent National Audit Office report found. In total, around 6 million patients a year turn to Accident & Emergency department and walk-in centres because they have struggled to see a family doctor.

There's something Brechtian about this demand: that the doctors would like to elect a different population to cure and treat. But that's not actually the way that the treating should be going on. It might be masked, in that we pay taxes which then pay for the NHS, but it is still true that we are disposing of our cash on a service which we need, desire or want. The NHS is thus supposed to be at our disposal, not us at its.

What this means is that if we like the grape so much that our livers explode, well, treat us. Sure, tell us that our livers might explode if we do have that second bottle of port with lunch every day, but that's all you do get to do. Similarly with smoking and lung cancer, hamburgers and diabetes and so on. We are hiring you, keeping you in bedpans and nurses, with our money. We are the bosses and you, the medical professionals are, or should be, at our beck and call.

This is rather what Hayek was on about in the Road to Serfdom. That taxation as the method of payment is going to lead to that Brechtian position: that we the population should accord with the ideas of the bureaucrats rather than the proper relationship which is that the bureaucrats gain their salaries by serving us.

No, no one does want the US system of health care: but something more like the French or other European ones, where this relationship is properly pointed out would be an advance.

The NHS is there to treat us, not for us to live up to the standards of the NHS.

Five facts that undermine the junior doctors' strike

1. The maximum hours doctors can be made to work is actually decreasing. The British Medical Association is claiming that today’s strikes, in part, are about delivering safeguards to protect patients against the consequences that can arise from tired, over-worked doctors. While there is evidence that intervention into medical working hours can have mixed - and sometimes even negative - results, let's agree that no one wants a tired doctor attending to them. But maximum hours doctors are allowed to work are actually decreasing under the new contract. From the Telegraph:

The Government says the new deal would have an absolute limit of 72 hours in any week, lower than the 91 hours that the current arrangements allow. Doctors will not have to work for more than 48 hours on average due to the European Working Time Directive (ETWD), but they can opt out and work more hours - up to 56 - if they wish.

It appears EU law has limited the number of hours doctors can work per week, quite significantly. Furthermore, the BMA has already come to an agreement with the government regarding "safety issues" around "maximum working hours". The issue has been sorted.

2. This strike is over pay; not patient safety. Point one leads us nicely into point two; this strike is not about overworked doctors, and it’s not about patient safety. It is openly about pay.

Specifically, it is about how much doctors will get paid for working on the weekends. Both the BMA and government reps came to an agreement on 15 of the 16 points of contention the BMA had with the new contracts, but the discussions were ended over this last point on weekend pay.

The BMA should be honest about this. It might well be the case that junior doctors deserve higher salaries; but the money to fund that pay raise comes from the public’s purse. If the BMA wants to secure higher salaries for those in the profession, it needs to ask the taxpayer to foot the bill.

(Update, 10 February 2016: the "key sticking point" of today's strike "appears to be payments for working on Saturdays.)

3. The NHS is the only healthcare most Brits can access. The NHS in not unique in its delivery of universal healthcare. As Kristian Niemietz has noted, almost every developed country (apart from the United States) provides comprehensive healthcare services for its citizens.

What is unique about the NHS is that is provides care through one system that is both publicly funded and publicly run. There is no real market for healthcare in the UK, which keeps the cost of private healthcare sky-high.

It is simply not the case that when NHS doctors go on strike, Brits can turn to private provisions; most people have been regulated out of the market, and for them this has been made financially impossible.

4. Patient safety is at risk. Some folks out there are claiming that strikes are beneficial for patient safety because mortality rates actually decrease during strikes.

If this sounds wildly misleading, that is because it is wildly misleading.

On the one hand, studies have found that, in some cases, mortality rates do decrease during a strike; but this is only because risky operations and elective surgeries, which bump up mortality rates, are cancelled.

Putting off these kinds of operations can have very dangerous medium-term effects. Making patients wait for important surgeries is not simply an inconvenience; it can hurt their health.

On the other hand, there is evidence that health strikes can seriously increase mortality rates. Over at the Telegraph, Asa Bennett has highlighted a study from the States, where a nurse strike in New York increased morality rates at the hospital by almost 20%:

US academics Jonathan Gruber and Samuel Kleiner recently looked at what happened when nurses went on strike in New York in what they billed as the "first analytical evidence on the effects of health care strikes on patients". The professors, from MIT and Cornell University respectively, discovered in their paper – "Do Strikes Kill? Evidence from New York State" – that the rate of in-hospital mortality rose by 19.4 per cent among the 38,228 patients admitted during a strike, and the rate of patient readmissions increased by 6.5 per cent.

Only the aftermath will reveal how today’s strike has impacted on mortality rates; but one is certainly within their right to ask if the potential for increased death tolls at hospitals is ever worth the risk.

5. The British Medical Association is not a neutral body; it is a pressure group. The BMA is not an impartial medical association; it is a union for doctors, and their job is to negotiate the best deal for their members that they can get.

But the BMA isn’t negotiating. Despite coming to agreement on 15/16 issues with the government, they have still decided to hold the public to ransom over one issue, jeopardizing the quality and quantity of services the only healthcare provider in the country can perform.

When a country operates under a healthcare monopoly, its citizens are fundamentally at the mercy of the provider. That provider has an ethical responsibility to show up to work every day and look after its patients; if they don’t, no one else will

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One final point: British patients are becoming increasingly aware that the NHS isn't all it's cracked up to be; some are starting to look look fondly across the channel to Europe, where patients are getting better treatment and experiencing better outcomes.

What is often neglected from these discussions is how doctors are treated by the NHS. Indeed, there is good reason to believe it is both patients and doctors who are getting the short end of the stick. Jeremy Hunt's new contract doesn't solve this issue, but neither do the BMA's demands. If the BMA is truly intent on bettering the working environment for doctors, it should look to reforming a system that only allows them to negotiate with one provider: a highly bureaucratic, government body.

That tricky point about competition in the NHS

One of the more ridiculous pieces of wibble in the public discussion these days is the idea that competition inside the NHS is a bad idea. The likes of Polly keep on about how cooperation, rather than that competition, is the right way to go. To which there are two responses: the first being that competition is actually how you decide who you are going to cooperate with. We might think that Pepsi competes with Coke, but neither are competing with Tesco: they are competing to decide who cooperates with Tesco. The second is that cooperation is indeed good: it's just that in groups of more than perhaps 3,000 or 4,000 people (derived, not entirely accurately, from Elinor Ostrom) we find that it's not really possible to have central control of peoples' cooperation. We need to use the market to organise that cooperation. All of which brings us to this lovely experiment:

NHS hospitals in England are rarely closed in constituencies where the governing party has a slender majority. This means that for near random reasons, those areas have more competition in healthcare – which has allowed the authors to assess its impact on management quality and clinical performance.

The answer? More competition improves the health care service.

We know the same from other sources as well. NHS England is, as Polly would put it, more accursed with competition than NHS Wales or NHS Scotland. NHS England has been, by all the usual measures (whether financial, patient satisfaction, health outcomes) getting better faster than NHS Wales or NHS Scotland. And that's what we would predict too: for we do't in fact say that competition is necessarily a better way of running something. We do however shout very loudly that it's a good way of making something better over time. Competition incentivises productivity improvement that is.

So, every time we go out to test this we find that competition makes the NHS better. The case for not having more competition in the NHS is therefore what?

The Junior Doctors Row: Striking Won't Help

Rumour has it that, after the controversy surrounding Andrew Lansley’s NHS reforms, his successor Jeremy Hunt was instructed to do one thing: keep his head down. Instead, it’s wanted on a plate. As talks between the Government and junior doctors again break down once more, one of this Parliament’s most persistent political stories just won’t go away. The health secretary hasn’t helped himself: he came under fire over his misrepresentation of the “weekend effect” (the link between weekend hospital admissions and poorer patient outcomes including higher rates of mortality). He has been rightly criticised for his subtle suggestion that the increase in basic pay is an 11 per cent increase in overall earnings, when in reality most doctors’ salaries are substantially reliant on additional money from working evenings and weekends – which will be cut.

Nonetheless, you may start to feel some pity for Hunt – after all, he’s inherited a ticking time bomb, an obsolete behemoth that works neither for its consumers nor its staff. As Kate Andrews has suggested, the successes of market-based systems in Europe can’t be ignored much longer, as the NHS staggers towards its breaking point.

And doctors have long used collective protest to shape the NHS and their role within it. In 1947, doctors contested plans for the new NHS, looking to retain their independent contractor status rather than becoming salaried employees. In 1975, both consultants and junior doctors engaged in partial strikes over hours and overtime. This ties in neatly with Peter Hoskins’ blog this week. In it, he examines all disputes going back to the 1930s.

Time lost to strikes, he finds, was much higher in the 1970s and 1980s than previously or since. The overall peak came in April 1980, when around 32 million working days were lost to industrial action in the 12 months up to and including that date. He says:

“Industrial action is consistently low, nowadays. In fact, the average 12-month total for the Labour years is about 613,000. For the Cameron years, so far, it is 658,000. This suggests not just that incidences of industrial action are much lower than they were before the 1990s, but also that they have remained consistently low. The unions have been defused by a combination of Margaret Thatcher’s reforms and wider, historical forces. The industrial strikes of the 1980s are unlikely to be repeated in a de-industrialised nation.

“None of this is to downplay or excuse the industrial action that’s being planned by the British Medical Association and junior doctors. Each strike must be judged according to its own facts.” Are doctors paid enough? It depends on whether you believe anyone “deserves” a particular salary. But junior doctors must resist the urge to back a strike, one that would compromise the safety and wellbeing of NHS patients.

Since the resumption of talks in November, there has been significant movement on almost all outstanding issues on the contract. As Sir Robert Francis QC pointed out yesterday, continued negotiations must proceed: both sides have a duty to continue exploring all avenues, including conciliation and meditation.

Can National Health Sense Be Dawning?

A trio of former health ministers has called, on 6^th January, for a cross-party commission to be set up to review the future of the NHS and social care in England. An epiphany indeed. Alan Milburn (Labour), Stephen Dorrell (Conservative), and Norman Lamb (Lib Dem) should be congratulated.  The NHS has never been a strong card for the Tories and they should be particularly delighted to take this opportunity to remove the rod from their back. This call could be the first step to taking politics out of the NHS and should be welcomed.  Once again we have the prospect of a junior doctor strike brought about by ministerial meddling.  Yes the BMA is intransigent but the lesson of history is that there are no bad soldiers, only bad generals.  Politicians, who know nothing about management, should get out of trying to micro-manage the biggest employer in Europe.

This has nothing to do with privatization: as discussed before, the public corporation should resource internally its core functions and whatever it can do efficiently and economically and outsource the rest.  It should not run blast furnaces to make steel for its own surgical instruments.

Three more strategic changes need to be made and the cross-party review should consider which should take priority: the links with social care, removing bureaucracy and dividing the NHS into right-sized units.  Taking the last first, it is absurd that the NHS Scotland and NHS Wales should both be considered “right-sized” in terms of taxpayer value when one is 60% larger than the other.  Either one is too big or the other is too small.  And Northern Ireland?

And it is still more absurd that NHS England, covering a population 10 times the size of Scotland’s as to be a uniform, standardized organization providing the same uniform standardized service everywhere.  In this logic, Truro is identical with Newcastle but Newcastle is totally different from Edinburgh.

The NHS is too big and needs to be divided into managerially feasible units achieving their own goals in their own ways.

Much of the NHS bureaucracy has been created over the last 70 years in response to ministerial meddling.  Remove the latter and we could have the first ever purge of the time wasters.  A neighbour provided a neat vignette the other day.  “Have you ever wondered,” he said “why it is impossible to find a parking space in the King’s Lynn hospital car park during the week but the car park is empty at weekends?  The number of patients and their visitors are much the same and medical staff not that much reduced.  The bureaucrats have all gone home.”  We should send most of them home permanently.

Finally, as also discussed before, the NHS should focus on “cure” and with “care” managed separately.  They have quite different objectives and need different skills albeit the transition between the two should be seamless.  Keeping those who should be in care in far more expensive NHS hospital beds is bad for everyone.  We need a National Cure Service working closely with a National Care Service.

Well, that didn’t take long did it?  Let’s hope the cross-party review can report and its recommendations implemented before this bright new year concludes.

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.