September 23, 2010
Thursday
Replacing the NHS with a system which works better
The NHS has been a much-loved institution all my life. I and members of my family have been treated by it, sometimes wonderfully well.
My elderly mother was treated at Winchester Hospital and I remember a staff nurse there who went extra miles to make sure my mother got the care she needed. I know what it is to feel intensely, emotionally grateful to an NHS nurse.
There are certain phrases that capture powerfully the appeal of the NHS idea: ‘free at the point of delivery’ is probably the most potent. Naturally many people are reluctant to consider anything that goes near to giving up on it.
But I think most people want a health service that provides two things: one, a top class service and, two, one which means we don’t have to worry about the cost when we are ill.
The NHS – in general – is indeed free at the point of delivery. But unfortunately, it is not successful at providing a top class service. The data shows again and again that compared to other advanced countries, Britain is seriously below average.
Eurocare, which is funded by the European Union, records how many people are still alive five years after first being diagnosed with cancer. Let us take one of the most difficult cancers: lung cancer. Survival rates are quite low. In England, only 8.4 people out of hundred survive this cancer for five years after diagnosis. In Germany, 14.7 do – more than half as many again.
In stomach cancer we have a particularly poor record. In England, 17 people survive for five years. In Italy, 33 do. To put this another way, 16 people out of a hundred die in England who would not die if they were using the Italian medical service instead of the British. I am afraid that in every single major cancer, the chances of survival in Britain are lower than in other advanced European countries.
How does this happen?
The NHS often has delays. In France, it would be unacceptable to have a cancer patient wait more than a week between diagnosis and treatment. In Britain, much longer waits are not unusual. On the continent, the latest drugs are used far more quickly. In Europe, the average use of drugs introduced in recent years is three times higher than in Britain. This is according to a survey by the Karolinska Institute in Sweden.
We also have a shortage of up-to-date radiotherapy equipment. In a survey of radiologists, they said that three out of four patients who would have benefited from the use of most advanced radiotherapy technology were being treated, instead, with old machines. This is according to a survey in the leading cancer journal, Clinical Oncology. The use of older technology means more damage to healthy tissue.
The below-standard treatment of cancer patients in Britain is something we have a lot of evidence for. But there is plenty of reason to think it is representative of relatively poor treatment of other diseases, too.
On pretty well every measure you can make of a medical service, Britain is well below the average of other advanced countries. Overall, it is probably right at the bottom.
We have fewer doctors per thousand of population than other advanced countries. We have fewer hospital beds for acute care. Germany has twice as many. We have far fewer CT scanners. We have far fewer MRI scanners, too, – a mere fraction of the numbers in Austria, and Finland and fewer even than Slovakia or Greece.
But there has also been a wasting away of the services that do not hit the headlines - the ‘Cinderella’ services. My late elderly mother needed regular physiotherapy on a continuing basis. The NHS in her local authority paid for six weeks and then it stopped. These things don’t usually get measured. But they matter.
An important thing to note about the NHS is that it is patchy. You could be a woman who suspects you have a lump in your breast, sees a GP and immediately finds yourself referred on to a cancer specialist who has you scanned within a day or two and in the operating theatre within a week. It can happen. But there can also be delays at any stage. These delays give your tumour the chance to grow and to make it more difficult for you to be cured.
But what about the second part of what we really want from a health service: not having to worry about the cost?
The most common system in Europe is called ‘social insurance’. Each country operates in a slightly different way. In Switzerland, for example, you need not worry about the cost because you are compulsorily covered by the social insurance scheme.
Those who are less well-off, have their contributions made up to the full amount by the government. Each person can choose which insurance institution to use. It could be one connected with their particular line of work or run by a trade union. These insurance organisations, in turn, choose which hospitals to make arrangements with to provide you with your care.
France has a government insurance company which covers most of the cost of treatment and the vast majority of people take out further insurance to cover the rest. In the German system, you can choose your insurer. Again, everyone is covered.
Singapore has a highly successful system which is a combination of compulsory health savings and insurance. There are plenty of different models around the world.
Ever since the government took over our hospitals in 1948, politicians have been claiming that they have some changes up their sleeves will make the NHS work better. But after 6o years of ‘improvements’, the results are still inferior to those of other countries. It is now reasonable to suggest that the system is inherently flawed.
The simple point is that it is a government monopoly. We know from experience that such monopolies are prone to waste. To give just one example, one survey asserted that in operating theatres less than half the time scheduled for operations was actually used for surgery. The nursing unions say they have to spend a vast amount of their time doing administrative jobs instead of frontline work.
The number of administrative and support staff employed by an NHS hospital compared to the number of nurses is five times what it is in a private hospital.
In countries such as France, Belgium and Germany, there are hospitals and doctors who have to compete on price and quality. One in five hospital beds in France is in a commercial hospital. Two out of five beds in Germany are in a voluntary hospital. The effect of competition on standards is dramatic. In Britain, there have been attempts to create fake markets and competition within the NHS but they have not worked. It seems it is not easy to create phoney competition.
To get a better system than we have now, we need not give up something we value a great deal: the absence of worry about cost. But we should look around the world at other systems. We should then move to one which would still leave us without financial worry but which bring a higher, international standard of care for ourselves and those we love.
This is an unedited draft of an article which appeared in the Daily Express on Tuesday. The article was based on the opening talk I gave in the BBC Radio 4 programme 'Iconoclasts' on 15th September.
Posted by James Bartholomew • Indexed in NHS • Reform
Comments (3)
TrackBack (85)
As a nurse who has worked in the NHS for 21 years, I listened with interest to this programme.
Given that you propose to completely rebuild our health care system along social insurance lines, with all the disruption and expense that that implies, it seems fair to me that you should demonstrate beyond reasonable doubt that the existing model has failed. I don’t believe that you have done this.
Your argument seems to hinge on various “facts and figures” produced at the beginning of the programme as evidence of the failure of the NHS. To recap: that it is a monopoly, a lack of doctors, specialist equipment, and acute beds, cancer outcomes, poor use of operating theatre time, patients not being fed properly, “vast” amounts of nursing time devoted to admin, and NHS hospitals having four times the administrative staff of private hospitals.
The central point you have to deal with, and appeared to evade when it was put to you in the programme, is the historically very poor level of funding of the NHS, since its inception right up until the last few years, as compared to the health systems of other developed countries. Thus, even the doubling of funding in recent years has left UK health spending in 2008 at *less than the OECD average*.
http://www.oecd.org/document/11/0,3343,en_21571361_44315115_45549771_1_1_1_1,00.html
Many of the ills you cite flow in large part from this simple fact, unless you are suggesting that the amount of resources available to an organisation is completely unrelated to the service it is able to deliver. You have to pay, *a lot*, for MRI and CT scanners, radiotherapy equipment, doctors, nurses and acute beds.
It sometimes seems that, in the eyes of people like yourself, public services are exempt from the conventional wisdom that “you get what you pay for” and that adequate resource are something which they are expected to be able to perform well without.
The same standards don’t seem to apply to, say, the independent schools sector, for what *is* a private education, other than a means to secure increased resources for the education of your child in the form of more and better teachers, equipment, premises, facilities, class sizes etc? Michael Gove now apparently expects kids to be educated in disused shops, whilst over at Eton I understand that a new cricket pavilion, hockey pavilion, organ for the lower chapel, biology teaching laboratory, and beagle kennels are in the pipeline. I imagine the parents who pay for these things would be disappointed if their outlay weren’t reflected in an improved *outcome* in terms of their child’s education. When you go out for a meal, are you mystified as to why it costs more to eat at a Michelin 4 star restaurant than it does at a KFC? This is pretty basic stuff, but it seems you have (a wilful?) difficulty in grasping the simple relationship between what you put in and what you get out.
The RCN report you (partially and misleadingly) cite actually recommended increased spending on ward clerks and secretaries to reduce the time spent by nurses on admin. Incidentally, my sister is a hospital pharmacist in Antwerp – she tells me that in Belgium ward nurses have to complete forms individually detailing *all* the medications and medical equipment used by each patient throughout their stay in order that this information can be sent to the insurance company. This must be a hugely time-consuming job which simply doesn’t need to be done under the NHS model.
Problems with operating theatre use are not evidence of a failure of the NHS model. What you neglected to point out was that these issues were identified *by* the NHS who then recommended changes to practice, just as a private company might identify a better and more cost-effective way of doing things. The idea that the NHS is not mindful of the need to use resources efficiently, when it is faced with a dire ongoing shortage of those resources combined with continual growth in demand pressures is not credible. All NHS staff have heard from management for years is the need to do “more with less”.
Furthermore your comments on cancer outcomes citing data from Eurocare 4 are either ignorant, disingenuous, or both.
http://scienceblog.cancerresearchuk.org/2008/10/05/ncri-public-lecture-international-survival-trends-and-comparisons-impact-on-uk-cancer-care/
So despite chronic under funding, it seems the performance of the NHS in cancer isn’t quite as bad as you make out, and the figures you cite are based on survival during a period prior to the recent increases in funding. As in many areas of health care the reality is often a bit more complicated than a simple glance at some statistics might suggest.
I’m not a scientist, but I know enough about the scientific method to know that you should not attribute a particular finding to one particular variable, in this case the model of health care delivery, whilst ignoring other confounding variables.
In this case, how confident can you be that cancer outcomes are not better *because* of the NHS model rather than *in spite* of it? How do you know that they wouldn’t be a lot better had the NHS not been chronically starved of resources for decades, or had to suffer relentless and expensive marketising interference and reorganisation since the 1980s? Furthermore, a diagnosis of cancer does not exist in isolation. On what basis do you discount the complex social, economic, and cultural determinants of ill-health which will impact on the success of diagnosis and treatment, and for which the Eurocare figures do not control?
I would be very interested to learn the source of the statistic that NHS hospitals had 5 times the admin staff of private hospitals. Could you provide it?
When asked about funding you said that recent increases had not made any significant difference. This is quite simply untrue. A few examples:
http://www.kingsfund.org.uk/current_projects/progress_made_by_the_nhs_in_the_last_13_years/index.html#findings
The Kings Fund found that considerable progress had been made whilst identifying areas requiring further improvement.
From Wikipedia:
http://en.wikipedia.org/wiki/Healthcare_in_England#Experiences.2C_perceptions_and_reporting_of_the_NHS
“An independent survey conducted in 2004 found that users of the NHS often expressed very high levels satisfaction about their personal experience of the medical services they received. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied.”
Interestingly, those who had experience of the NHS were far more satisfied with the service than those who hadn’t, whose opinions were presumably formed second hand from stories in the media. Looks like all those leader columns you wrote for the Telegraph and the Mail didn’t fall on stony ground, eh, James?
According to the Economist Intelligence Unit, Britain performs well in the delivery of End of Life care.
http://www.lifebeforedeath.com/qualityofdeath/highlights.shtml
This is something I know something about from my own practice and which is notoriously difficult to get right. It requires continuity and integration of care from, and communication between, multiple services and disciplines. These include: specialist secondary care services, GPs, district nurses, specialist nurses (for example COPD or heart failure nurses), palliative care teams, and social services, all motivated by a common goal: that the patient have a peaceful, dignified death in the place of their choosing. The unified NHS model is ideally suited to coordinating this type of care.
Interestingly, this is relevant not just to care of the dying patient, but also to the complexities of caring for elderly patients with multiple long term conditions, whose numbers are set to increase inexorably as the population ages. In the future they will absorb most health care activity, not the discrete, uncomplicated, low-risk, profitable, elective procedures carried out on the otherwise-well “consumers” so beloved of private “providers”.
Given the expected demographic changes I’m not sure that the model the government is currently moving us towards; that of fragmentation of the health service into myriad competing units driven by a need first and foremost to make profits, is the right one.
In my own area the abolition of the PCTs has meant that private providers are bidding to run our heart failure nursing service. So far we have had expressions of interest from Tesco, Virgin, and various multinational corporations based in the Far East, US and Europe. Maybe you think that’s great – I don’t.
The NHS has never been a monopoly. There has always been a private sector – the reason it has been small is that, because of the NHS, most people didn’t need it. What was to stop the affluent Middle Classes voting with their feet and deserting the NHS and its appalling quality of care in their droves in accordance with the workings of the market?
In your blog post above you dismiss The Commonwealth Fund’s report because it partially uses survey data and mostly doesn’t look at outcomes, but of course properly conducted surveys can provide meaningful information, otherwise people wouldn’t conduct them, and polling and market research organizations wouldn’t exist.
The authors were trying to investigate the actual *delivery* of care in terms of efficiency, equity, access, etc via an analysis of doctors’ and patients’ experiences and official data – are you saying these things aren’t important and unworthy of investigation? There isn’t in fact much room for subjective interpretation of many of the survey questions in any case – for example: “patient did not spend any time on paperwork or disputes related to medical bills or health insurance” , “Patient had serious problems paying or was unable to pay medical bills”, or “practice routinely uses written guidelines to treat chronic diseases”.
In any case many of the indicators were based not on survey data at all but on objective official statistics, such as those for efficiency. Interestingly the UK came out top for efficiency and, according to OECD data, of the countries studied spent the least on health care as a % of GDP, and spent the least on administration and insurance as a % of overall spending. How exactly does this square with the constant mantra from people like yourself and The Daily Mail et al of a “bloated”, “wasteful” and “expensive” NHS?
“The emails coming in ran 3 to 2 in favour of abolition. It seems possible that the NHS does not retain the almost religious respect and love that it once did.”
If you believe that some emails from a few self-selected listeners to a radio programme represent an accurate measure of public opinion, why do you have difficulty accepting the results of the Commonwealth Fund’s far more rigorous methodology? Similarly, if you don’t deem survey data valid as evidence of health service quality, can you also tell me why you were happy to cite a survey on the programme regarding patient feeding? Is it that survey data *is* valid, but only if it appears to back up your position?
Implicit in your remarks about patients getting help with feeding is the belief that the NHS model produces poor nursing care at the bedside. I’m not sure how you arrive at this conclusion, I presume it stems from the dim view that free-market theorists appear to take of their fellow human beings: that they are generally incapable of working well, efficiently, or creatively unless they, or their manager, are motivated by profit and commercial competition. My experience of the NHS is that nothing could be further from the truth. People do things, very well, for all kinds of reasons not least of which are the very human motives of compassion, the desire to help their fellow man, and the satisfaction of doing a good job for its own sake.
On the occasions as a nurse where I have seen care fall short it is invariably due to a lack of staff and unmanageable workloads. This is because good health care is extremely labour intensive and is not amenable to being industrialised or commoditised. It relies on millions of individual tasks done well, diligently, with thought and care, and therefore depends on adequate staffing levels.
As a nurse on the wards you frequently find yourself in a position where you are confronted simultaneously by several jobs which ideally ought to be done immediately, for example: speaking to a distraught relative, getting the commode for a patient, giving someone a pain-killer, washing an incontinent patient and changing their sheets, checking the vital signs of an acutely unwell patient, and feeding a patient. As a nurse you are then placed in an impossible situation and have to prioritise, and that is when helping someone with feeding will take second place to, for instance, attending to a very sick patient. I am convinced that it is scenarios like this that lead to the vast majority of cases where patients do not get the help they need. Patients and relatives observing this may not always appreciate what else is happening on the ward.
I am not saying that the NHS is perfect, far from it, but contrary to your analysis of the NHS as a model which has been tried and failed, I see it as a model which has done remarkably well *when you consider how much we spend on it* compared to other advanced countries. What the NHS needs is to be given the resources it needs (say, the 11.2% of GDP spent in France in 2008, compared to the 8.7 % we spent, or the less than 6% in 1997), and then for the government to leave the staff alone to get on with their jobs.
You are an ideologue. You presume to be able to recommend sweeping changes in a field, health care, in which you have no professional knowledge or experience, which would affect the lives and deaths of millions. I don’t suppose Stalin knew much about agriculture when he collectivised the farms of the Ukraine, but he just knew it was the “right thing to do” and would be better for everyone in the end. I wouldn’t presume to pronounce so confidently on national radio and in the national press about something I didn’t have long experience of from the inside, because life and work have taught me that that is the only way you can make informed judgements.
Posted by: PH at September 27, 2010 01:21 PM
The problem with PH's big waffle (above) is that he/she omits to mention that the difference in funding (as a % of GDP) between the UK and most European countries is principally accounted for by the difference in PRIVATE medical spending. Public funding is very similar in the UK, Germany and France. The reason why private funding is so low in the UK is that if you choose not to use the NHS, then you have to pay 100% of the cost - and few people can afford to do this once they've paid taxes for the NHS. In most European countries mixed provision and funding is normal.
James Bartholomew is not an idealogue - do you see him argue for one particular system as superior to all others? Do you see him advocate imposing one system on everybody? It seems to me that 'PH' is the idealogue - defending the monopoly (and it is a monopoly) NHS as the best system to be imposed on everybody, regardless of whether they'd prefer to have a choice about how their money is spent.
Posted by: HJ at October 2, 2010 10:23 PM
“The problem with PH's big waffle (above) is that he/she omits to mention that the difference in funding (as a % of GDP) between the UK and most European countries is principally accounted for by the difference in PRIVATE medical spending.”
You seem a little confused, HJ.
The whole point of JB’s piece was to make a direct, unfavourable, comparison between the NHS and other countries’ health care systems, to support his thesis that the NHS model has irredeemably failed.
In this context, the proportion of private and public spending is entirely irrelevant, since we would expect a country that spends more (from whatever source) on health care to do better, all other things being equal (which they are not, incidentally – see the US).
Insurance systems simply involve greater private contributions than the NHS model. People still have to pay for their health care, whether in taxes, insurance premiums, co-payments, deductibles or coinsurance.
Now, as it turns out, much of JB’s “evidence” for this unfavourable comparison between the NHS and other countries’ health systems consisted of an ill-thought-out hatchet job, seemingly cobbled together from a very hasty Google News search using the term “isn’t the NHS crap?.”
Much of my waffle above was of necessity a lengthy point by point rebuttal of this, and I note that you have absolutely nothing to say in response to any of the arguments put forward.
“Public funding is very similar in the UK, Germany and France. The reason why private funding is so low in the UK is that if you choose not to use the NHS, then you have to pay 100% of the cost - and few people can afford to do this once they've paid taxes for the NHS”.
But there are plenty of health insurance schemes available in the UK, and subscribers would not have to pay 100 % of the cost of treatment if they became ill, because it would be covered by their insurance. As you said yourself, public expenditure is similar to the UK (actually higher in most OECD countries), so it would seem that the citizens of France, Germany, Austria etc *can* miraculously afford the (higher) taxation to pay for public expenditure on health as well as their private insurance contributions. Funny that!
The NHS isn’t a monopoly. There are millions of people in the UK who could afford to take out private insurance on top of paying their taxes. They don’t do it because they don’t need to.
“James Bartholomew is not an idealogue - do you see him argue for one particular system as superior to all others. Do you see him advocate imposing one system on everybody?”
JB ideologically favours a small state, private enterprise and deregulation. He advocates abolition of our health service, massively reducing state involvement and handing over a large proportion of services to private companies - all the models he lauds have this in common. Unfortunately he doesn’t present a shred of real evidence that the current model has failed (apart from a few re-heated Daily Mail headlines). He is an ideologue.
“It seems to me that 'PH' is the idealogue - defending the monopoly (and it is a monopoly) NHS as the best system to be imposed on everybody, regardless of whether they'd prefer to have a choice about how their money is spent.”
But we do have a choice about how our money is spent. It’s a little thing called democracy – if we don’t agree with the way the government is spending our money we are free to vote them out.
The increased spending on the NHS over the last 10 years was extremely popular, because the NHS remains, despite the best efforts of certain sections of the press, a hugely popular institution. This is why all the attempts over the last 30 years to undermine its public service ethos and character have had to be conducted in an underhand and indirect way using weasel words such as “reform”, “modernisation” and now “liberation”, for fear of an electoral battering.
Also, the people of, for example, Germany, pay more in taxes for their health service than we do. I presume these taxes aren’t voluntary.
All together now: the NHS isn’t a monopoly – you are still free to take out private health insurance, although I personally don’t feel the need to. I would, however, be more than happy to pay more in taxes to bring our health spending up to 11% of GDP if it means that my fellow countrymen and women, old and young, rich and poor, get properly looked after when they’re sick.
Posted by: PH at October 6, 2010 08:59 PM
Add a Comment
Warning: file(http://63.247.138.2/~bartholo/randomquotes.dump) [
function.file]: failed to open stream: No route to host in
/home/bartholo/public_html/archives/2010/09/abolishing_the_1.php on line
433
Warning: implode() [
function.implode]: Invalid arguments passed in
/home/bartholo/public_html/archives/2010/09/abolishing_the_1.php on line
433
As a nurse who has worked in the NHS for 21 years, I listened with interest to this programme.
Given that you propose to completely rebuild our health care system along social insurance lines, with all the disruption and expense that that implies, it seems fair to me that you should demonstrate beyond reasonable doubt that the existing model has failed. I don’t believe that you have done this.
Your argument seems to hinge on various “facts and figures” produced at the beginning of the programme as evidence of the failure of the NHS. To recap: that it is a monopoly, a lack of doctors, specialist equipment, and acute beds, cancer outcomes, poor use of operating theatre time, patients not being fed properly, “vast” amounts of nursing time devoted to admin, and NHS hospitals having four times the administrative staff of private hospitals.
The central point you have to deal with, and appeared to evade when it was put to you in the programme, is the historically very poor level of funding of the NHS, since its inception right up until the last few years, as compared to the health systems of other developed countries. Thus, even the doubling of funding in recent years has left UK health spending in 2008 at *less than the OECD average*.
http://www.oecd.org/document/11/0,3343,en_21571361_44315115_45549771_1_1_1_1,00.html
Many of the ills you cite flow in large part from this simple fact, unless you are suggesting that the amount of resources available to an organisation is completely unrelated to the service it is able to deliver. You have to pay, *a lot*, for MRI and CT scanners, radiotherapy equipment, doctors, nurses and acute beds.
It sometimes seems that, in the eyes of people like yourself, public services are exempt from the conventional wisdom that “you get what you pay for” and that adequate resource are something which they are expected to be able to perform well without.
The same standards don’t seem to apply to, say, the independent schools sector, for what *is* a private education, other than a means to secure increased resources for the education of your child in the form of more and better teachers, equipment, premises, facilities, class sizes etc? Michael Gove now apparently expects kids to be educated in disused shops, whilst over at Eton I understand that a new cricket pavilion, hockey pavilion, organ for the lower chapel, biology teaching laboratory, and beagle kennels are in the pipeline. I imagine the parents who pay for these things would be disappointed if their outlay weren’t reflected in an improved *outcome* in terms of their child’s education. When you go out for a meal, are you mystified as to why it costs more to eat at a Michelin 4 star restaurant than it does at a KFC? This is pretty basic stuff, but it seems you have (a wilful?) difficulty in grasping the simple relationship between what you put in and what you get out.
The RCN report you (partially and misleadingly) cite actually recommended increased spending on ward clerks and secretaries to reduce the time spent by nurses on admin. Incidentally, my sister is a hospital pharmacist in Antwerp – she tells me that in Belgium ward nurses have to complete forms individually detailing *all* the medications and medical equipment used by each patient throughout their stay in order that this information can be sent to the insurance company. This must be a hugely time-consuming job which simply doesn’t need to be done under the NHS model.
Problems with operating theatre use are not evidence of a failure of the NHS model. What you neglected to point out was that these issues were identified *by* the NHS who then recommended changes to practice, just as a private company might identify a better and more cost-effective way of doing things. The idea that the NHS is not mindful of the need to use resources efficiently, when it is faced with a dire ongoing shortage of those resources combined with continual growth in demand pressures is not credible. All NHS staff have heard from management for years is the need to do “more with less”.
Furthermore your comments on cancer outcomes citing data from Eurocare 4 are either ignorant, disingenuous, or both.
http://scienceblog.cancerresearchuk.org/2008/10/05/ncri-public-lecture-international-survival-trends-and-comparisons-impact-on-uk-cancer-care/
So despite chronic under funding, it seems the performance of the NHS in cancer isn’t quite as bad as you make out, and the figures you cite are based on survival during a period prior to the recent increases in funding. As in many areas of health care the reality is often a bit more complicated than a simple glance at some statistics might suggest.
I’m not a scientist, but I know enough about the scientific method to know that you should not attribute a particular finding to one particular variable, in this case the model of health care delivery, whilst ignoring other confounding variables.
In this case, how confident can you be that cancer outcomes are not better *because* of the NHS model rather than *in spite* of it? How do you know that they wouldn’t be a lot better had the NHS not been chronically starved of resources for decades, or had to suffer relentless and expensive marketising interference and reorganisation since the 1980s? Furthermore, a diagnosis of cancer does not exist in isolation. On what basis do you discount the complex social, economic, and cultural determinants of ill-health which will impact on the success of diagnosis and treatment, and for which the Eurocare figures do not control?
I would be very interested to learn the source of the statistic that NHS hospitals had 5 times the admin staff of private hospitals. Could you provide it?
When asked about funding you said that recent increases had not made any significant difference. This is quite simply untrue. A few examples:
http://www.kingsfund.org.uk/current_projects/progress_made_by_the_nhs_in_the_last_13_years/index.html#findings
The Kings Fund found that considerable progress had been made whilst identifying areas requiring further improvement.
From Wikipedia:
http://en.wikipedia.org/wiki/Healthcare_in_England#Experiences.2C_perceptions_and_reporting_of_the_NHS
“An independent survey conducted in 2004 found that users of the NHS often expressed very high levels satisfaction about their personal experience of the medical services they received. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied.”
Interestingly, those who had experience of the NHS were far more satisfied with the service than those who hadn’t, whose opinions were presumably formed second hand from stories in the media. Looks like all those leader columns you wrote for the Telegraph and the Mail didn’t fall on stony ground, eh, James?
According to the Economist Intelligence Unit, Britain performs well in the delivery of End of Life care.
http://www.lifebeforedeath.com/qualityofdeath/highlights.shtml
This is something I know something about from my own practice and which is notoriously difficult to get right. It requires continuity and integration of care from, and communication between, multiple services and disciplines. These include: specialist secondary care services, GPs, district nurses, specialist nurses (for example COPD or heart failure nurses), palliative care teams, and social services, all motivated by a common goal: that the patient have a peaceful, dignified death in the place of their choosing. The unified NHS model is ideally suited to coordinating this type of care.
Interestingly, this is relevant not just to care of the dying patient, but also to the complexities of caring for elderly patients with multiple long term conditions, whose numbers are set to increase inexorably as the population ages. In the future they will absorb most health care activity, not the discrete, uncomplicated, low-risk, profitable, elective procedures carried out on the otherwise-well “consumers” so beloved of private “providers”.
Given the expected demographic changes I’m not sure that the model the government is currently moving us towards; that of fragmentation of the health service into myriad competing units driven by a need first and foremost to make profits, is the right one.
In my own area the abolition of the PCTs has meant that private providers are bidding to run our heart failure nursing service. So far we have had expressions of interest from Tesco, Virgin, and various multinational corporations based in the Far East, US and Europe. Maybe you think that’s great – I don’t.
The NHS has never been a monopoly. There has always been a private sector – the reason it has been small is that, because of the NHS, most people didn’t need it. What was to stop the affluent Middle Classes voting with their feet and deserting the NHS and its appalling quality of care in their droves in accordance with the workings of the market?
In your blog post above you dismiss The Commonwealth Fund’s report because it partially uses survey data and mostly doesn’t look at outcomes, but of course properly conducted surveys can provide meaningful information, otherwise people wouldn’t conduct them, and polling and market research organizations wouldn’t exist.
The authors were trying to investigate the actual *delivery* of care in terms of efficiency, equity, access, etc via an analysis of doctors’ and patients’ experiences and official data – are you saying these things aren’t important and unworthy of investigation? There isn’t in fact much room for subjective interpretation of many of the survey questions in any case – for example: “patient did not spend any time on paperwork or disputes related to medical bills or health insurance” , “Patient had serious problems paying or was unable to pay medical bills”, or “practice routinely uses written guidelines to treat chronic diseases”.
In any case many of the indicators were based not on survey data at all but on objective official statistics, such as those for efficiency. Interestingly the UK came out top for efficiency and, according to OECD data, of the countries studied spent the least on health care as a % of GDP, and spent the least on administration and insurance as a % of overall spending. How exactly does this square with the constant mantra from people like yourself and The Daily Mail et al of a “bloated”, “wasteful” and “expensive” NHS?
“The emails coming in ran 3 to 2 in favour of abolition. It seems possible that the NHS does not retain the almost religious respect and love that it once did.”
If you believe that some emails from a few self-selected listeners to a radio programme represent an accurate measure of public opinion, why do you have difficulty accepting the results of the Commonwealth Fund’s far more rigorous methodology? Similarly, if you don’t deem survey data valid as evidence of health service quality, can you also tell me why you were happy to cite a survey on the programme regarding patient feeding? Is it that survey data *is* valid, but only if it appears to back up your position?
Implicit in your remarks about patients getting help with feeding is the belief that the NHS model produces poor nursing care at the bedside. I’m not sure how you arrive at this conclusion, I presume it stems from the dim view that free-market theorists appear to take of their fellow human beings: that they are generally incapable of working well, efficiently, or creatively unless they, or their manager, are motivated by profit and commercial competition. My experience of the NHS is that nothing could be further from the truth. People do things, very well, for all kinds of reasons not least of which are the very human motives of compassion, the desire to help their fellow man, and the satisfaction of doing a good job for its own sake.
On the occasions as a nurse where I have seen care fall short it is invariably due to a lack of staff and unmanageable workloads. This is because good health care is extremely labour intensive and is not amenable to being industrialised or commoditised. It relies on millions of individual tasks done well, diligently, with thought and care, and therefore depends on adequate staffing levels.
As a nurse on the wards you frequently find yourself in a position where you are confronted simultaneously by several jobs which ideally ought to be done immediately, for example: speaking to a distraught relative, getting the commode for a patient, giving someone a pain-killer, washing an incontinent patient and changing their sheets, checking the vital signs of an acutely unwell patient, and feeding a patient. As a nurse you are then placed in an impossible situation and have to prioritise, and that is when helping someone with feeding will take second place to, for instance, attending to a very sick patient. I am convinced that it is scenarios like this that lead to the vast majority of cases where patients do not get the help they need. Patients and relatives observing this may not always appreciate what else is happening on the ward.
I am not saying that the NHS is perfect, far from it, but contrary to your analysis of the NHS as a model which has been tried and failed, I see it as a model which has done remarkably well *when you consider how much we spend on it* compared to other advanced countries. What the NHS needs is to be given the resources it needs (say, the 11.2% of GDP spent in France in 2008, compared to the 8.7 % we spent, or the less than 6% in 1997), and then for the government to leave the staff alone to get on with their jobs.
You are an ideologue. You presume to be able to recommend sweeping changes in a field, health care, in which you have no professional knowledge or experience, which would affect the lives and deaths of millions. I don’t suppose Stalin knew much about agriculture when he collectivised the farms of the Ukraine, but he just knew it was the “right thing to do” and would be better for everyone in the end. I wouldn’t presume to pronounce so confidently on national radio and in the national press about something I didn’t have long experience of from the inside, because life and work have taught me that that is the only way you can make informed judgements.
Posted by: PH at September 27, 2010 01:21 PM