No excuses, no nannying (well, maybe just a bit….)

1950

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Shadow Health Secretary Andrew Lansley unveiled his public health agenda at an event with centre-right think-tank Reform this morning. Key amongst his proposals was introducing a separate budget for public health, more evidence-based practice and the appointment of local directors of public health.

He also acknowledged the role that individuals must take in their own health with the mantra ‘No Excuses, No Nannying’. Building on Cameron’s earlier comments around the “moral neutrality" of society, the Conservative approach to healthcare would be to ask us (or at least ‘nudge’ us) to take more responsibility for our lifestyle choices.

Putting aside the debate over whether how much we eat and how little we move has anything to do with the state, we are left with the question whether, in a taxpayer funded system, any amount of ‘nudging’ can galvanise patients into taking more responsibility for their health? Indeed, a system that makes no direct link between what a patient pays in and how much they get out is one that will, perhaps inevitably, promote irresponsible attitudes on the part of individuals.

One way to encourage more responsibility would be to roll out individual budgets on a wider scale, giving patients a sense of ownership over their health and well-being by allowing them to manage and control their healthcare spending. This, I am told, is something that Mr Lansley is very keen on.

But, with the cost-pressures mounting on the health service perhaps we need to start thinking about radically different approaches to the way that healthcare is delivered and funded? To this end, medical savings accounts could be a model well worth considering. By placing money spent on medical services directly in the hands of the consumer patients are encouraged to become more actively involved in their own health. And, both by making preventative expenses eligible for coverage and by allowing people to keep the money they don’t use, medical savings accounts contain an in-built mechanism that promotes public health without the need for government regulation and interference. ‘No Excuses, No Nannying’ required.

The false generalizations about obesity

1925

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Surging healthcare costs in developed countries and increasing numbers of hefty people are happenstance – not evidence that both phenomena are strongly connected. Of course we always reckoned that some thin people can develop heart disease and some fat people don’t. But that millions defy the stereotypes is something which runs against everything the media have been reporting for some time. A new study from the university of Michigan has put that issue straight. It is the first national estimate of its kind:

In the study, about 51 percent of overweight adults, or roughly 36 million people nationwide, had mostly normal levels of blood pressure, cholesterol, blood fats called triglycerides and blood sugar. Almost one-third of obese adults, or nearly 20 million people, were also in this healthy range, meaning none or only one of those measures was abnormal. Yet about a fourth of adults in the recommended-weight range had unhealthy levels of at least two of these measures. That means some 16 million of them are at risk for heart problems.

But there is a cautionary tale to be observed because the Michigan scientists actually did not collect data of millions. They have only analyzed nationally representative government data involving 5,440 people age 20 and over and extrapolated their findings to the general population. Further studies of this kind are certainly necessary. However, this data should warn government bodies worldwide to abstain from hasty measures for tackling obesity with the expectation of curbing health expenditures.

Ration or reform?

1861

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In Monday’s Times, Libby Purves suggests that NHS rationing is something that we should all get used to. Purves plucks examples out of the air as to where further rationing could be employed:

- IVF should be funded because it is not life-threatening.
- Drunkards, smokers and addicts should be required to get clean before any emergency treatment.
- Stomach-banding should be subject to co-payment in arrears since you’ll be eating less.
- Life-extending (as opposed to palliative or Alzheimer’s) treatments should cease at 85.
- Breadwinners and parents of young families should get formal priority with cancer drugs.
- An age should be introduced beyond which heart surgery is not offered.

Purves does not suggest that any of these policies should be introduced, but is showing that these are areas in which we could potentially ration healthcare. I’m not surprised she is vague in her policy suggestions. People being denied treatment -  who have paid in taxes throughout their life for the inefficient and failing NHS - but happen to smoke, be fat, have chosen not to have children or be past a certain age, is simply unfair and frankly missing the point of the problem.

Given that this is the state of healthcare in this country, is it not therefore time for us to think about healthcare reform instead of rationing? As Michael Tanner argues in The Grass Is Not Always Greener. A Look at National Health Care Systems Around the World:

Those countries with national health care systems that work better, such as France, the Netherlands, and Switzerland, are successful to the degree that they incorporate market mechanisms such as competition, cost-consciousness, market prices, and consumer choice, and eschew centralized government control.

Just to be clear. Tanner does not include the British healthcare system in this list.

Health targeting in obesity

1863

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Japan has introduced new legislation that requires everyone between 40 and 74 years of age - almost half of the country's population - to have their waist measured. The waist limits are set at 33.5 inches for men and 35.4 inches for women. People who exceed this measure are supposed to run high risks of diabetes and heart disease. Those with larger waist have only three months to get in to shape; after that compulsory health re-education kicks in and their employers have to pay penalties.

This is absolute amazing, given that Japan still has the world’s skimpiest and longest living population. It has only recently faced an increase of obese people. 1997 figures from a WHO task force show Japan has got only 3% obese people (defined by body mass index of over 30) which has changed little in the preceding forty years. Even more upsetting is that the Japanese have actually cut their energy intake (from 2104 kcal/day to 1967 kcal/day) during these 40 years. So what happened? Well it’s all about policy targets. The Japanese obesity task force (JASSO) has simply decreased the obesity cut off for their generally lean subjects to BMI=25, which in the West only counts as overweight. This trick exploded Japanese obesity to 30% in the group of men over 30 years and made them the suitable target for draconian health policies.

Now the link between diabetes and waist measurement is still very contentious. Two large studies, one in Britain the other in the US, by Naveed Satter of Glasgow Faculty of Medicine, published in Lancet, have plainly rejected it because the evidence supports rather the opposite. In fact, men and women with large waist sizes had lower risks for CVD (heart disease) mortality than the thinner-waisted. Moreover, these were Americans, who generally have larger waists than the Japanese. Certainly, in Japan the number of diabetics has doubled in the last 15 years. Yet as this study suggests, the link to obesity is weak and in sharp contrast to the dramatic reaction of the Japanese lawmakers.

The price of life

1837

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"How can the NHS put a price on life?" – that the Daily Mail's take on the news that four life-prolonging drugs are to be denied to kidney cancer patients on the grounds that they are not "cost-effective". It's hard to disagree with the Mail (or Cancer Research UK, for that matter), especially when you hear that these drugs can double a patient's life expectancy, and are considered "the biggest advance in the field for 20 years".

Unfortunately though, putting a price on life is precisely what Britain's National Health Service does. It is simply the nature of the beast. Taxpayer funding puts a budget ceiling on healthcare, and with rising life expectancy, technological advance, and no constraint on demand, that budget ceiling is never going to be high enough. As a result, a tax-funded system like the NHS inevitably and unavoidably rations care, either through waiting lists or through not offering particular services.

Clearly, this presents a problem. The best solution would be to allow the market to take over healthcare, letting the price mechanism match up supply and demand, and using taxpayers' money only to subsidize those unable to pay their own way. But there seems to be no political appetite for that.

Nonetheless, there are a couple of things which could make the current system more tolerable. Firstly, introducing limited user charges for NHS services (as in Sweden) would constrain demand for services and free up capacity. Secondly, allowing patients to pay privately for additional services (like new medicines or treatments) without losing their entitlement to NHS care would be fair, humane, and would encourage the development of an affordable 'NHS-plus' private insurance option – giving many more people access to the very best care.

Fight the fat

1824

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Yesterday The Guardian reported on the Department of Health's plan that starting next month parents will be sent letters that contain their children’s heights, weights and whether they are underweight, a healthy weight, overweight or very overweight. This plan is an attempt to address England’s expanding obesity problem. 

If you were visiting friends and noticed that their little Sally was a couple stones heavier than your little Billy you most likely wouldn't say, "Harriet, Sally is looking a little heavy. Don't you think you should put her on a diet?" It is not your job, and certainly not the government's job to tell parents when their child is fat, mainly because it is an issue of personal responsibility for the parents to look after a child's health. They should not rely on public services to alert them to when their child is overweight, nor should we encourage that behaviour by providing the service.

The initiative is also frustrating because how could parents not notice that their 8-year-old child outweighs comparable children by 10 kg. It seems suspect if the child in question seems to be carrying around almost 2 bowling bowls in extra body weight. The Department of Health is basically giving parents an easy way out by allowing them to plead ignorance to their child's rotundness.

Putting the creation of the program aside – if the letters are going to be sent they might as well be to the point and forceful. Ministers are worried about stigmatising children and so have decided to avoid the words "fat" and "obese". If you want parents to react to these letters they need to be convinced or otherwise the children will become stigmatised because they'll hear it everyday in the playground. And the 4 categories that ministers did approve of aren’t convincing at all. By combining "obese" into "very overweight" it softens the message parents receive and it won't make them notice or be more proactive, especially if they haven't noticed the obesity in the first place.
 

An apple a day

1779

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It’s been 1-2 days: you’ve a temperature of 38.5/39^oC, a cough (not dry), sore throat, and paracetamol is all that keeps your temperature normal (37^oC). What do you do?

Your options: visit the GP (though you may not get in on short notice), visit an NHS walk-in centre, or call NHS direct and talk to a nurse. Say you’re lucky enough get into your GP, who prescribes you antibiotics. Problem solved! Or is it…?

Now, let’s say you didn’t get antibiotics, but were instead told you had a virus — go home, rest and come back if it gets much worse.

Which would you choose?

These days, antibiotics are being over-prescribed in the UK. Taking antibiotics for a virus will not cure the infection. In fact, £270 million, put forth by Health Secretary Alan Johnson earlier this year, will be spent to advertise this simple fact.

So who is to blame: GPs for being uninformed, or patients for being too demanding and pushy?

Last year, 38 million prescriptions for antibiotics on the NHS cost taxpayers £175 million. New guidance has been issued to GPs to try and reduce this level, to help prevent building immunity. MRSA, for example, is antibiotic resistant, as are other superbugs plaguing hospital wards. But — more interestingly, this call is coming from the NHS drugs rationing body, the National Institute for Health and Clinical Excellence (‘NICE’).

Notice — the body in charge of drugs for NHS is asking for fewer drugs to be prescribed. Yes, this will have some effect against superbugs, but nearly TWICE as much money is being spent telling people they don’t need the prescriptions than is spent filling them. Perhaps, financial motives taking precedent over health? It’s a little hard to believe taking penicillin a few more times than necessary will make you susceptible to MRSA.

According to the General Medical Council GPs have a responsibility to patients to, “provide effective treatments based on the best available evidence; take steps to alleviate pain and distress whether or not a cure may be possible." GPs should be upholding this and letting the rest cure the virus.
 

It's their money

1771

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A study suggests that most "international experts" (whoever they are) think that people should be prevented from having IVF if they have lifestyle factors that damage their chances of conceiving, like smoking or obesity.

Since IVF is covered by NHS, but more than 70% IVF doctors work privately, it's hard to know what to do with this information.  On the one hand, if taxpayer dollars are spent on a non-critical procedure for people whose lifestyles are preventing them from conceiving, it is completely reasonable to refuse service unless they stop smoking or eliminate other negative behaviours.

On the other hand, if private individuals are willing to spend money to conceive, even with a lower success rate, they should be able to do so- it's their money.  They should of course be aware that it is less likely to be successful, and of any risks to themselves that they might incur.  But if the only relevant difference between obese smokers and healthy non-smokers is the success rate of treatment, then the people who are spending the money on treatment should be the ones to decide whether it's worth it.  If it doesn't work, who cares? It's their money.
 

Patients pick good doctors not bureaucrats

1738

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The government wants surgeons to receive extra pay for good performance when operating on their patients. State of the art quality of care is internationally getting ever more important but nobody has yet come up seriously with the idea of incentivising surgeons for good performance - measured in patient survival. For this is a very tricky thing to measure. You need a whole new layer of bureaucracy.

But even worse are the unintended consequences: as one consultant, responsible for cancer care, has put it:

We have got to ensure we don't create a dangerous precedent, that the surgeons doing the big complex cases aren't discouraged from taking them on.

It is obvious that the incentives would prod surgeons to focus on the patients with acute diseases rather than chronic ones because this delivers better survival scores. However, it would be absolutely counterintuitive,  as the NHS always was and still is by default biased heavily against the chronically ill. The reason for this is political meddling which is driven by short-term thinking glued to election cycles.

Patient outcomes are important as a standard between competing health care providers. But this is all about information for patients as consumers who can then compare quality and make choices. At present the performance information on hospitals in the NHS is almost useless and does not enable patients to choose on the basis of quality. This is the challenge the government strives to circumvent by reducing it to a contest between surgeons. But that won’t do. Only comprehensive outcome data reporting of all providers can extend competition to the hospital as a whole and enable them to address the worst problems first. Moreover, in times of ever rising healthcare spending, the best doctors should not be rewarded with bonus pay, but with more patients flocking to them and thus increasing their reputation and pay.      
 

Seppuku state

1693

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As the largely unwarranted festivities around the 60-year birthday of the National Health Service are dying down, the actual state of healthcare is once again hitting the headlines. Last week the British Medical Association (BMA) called for a thorough and independent review of NHS patients topping up their care. However, the report will not be ready until summer next year.

According to a BBC article on the issue, at present you have two choices. You can either pay for health care that would normally be free, or go without drugs that could help extend your life. They are in fact wrong. For many people the choice has already been made by the state because they cannot afford the first option. At present, lifesaving drugs are cut off from many who cannot afford to pay for healthcare outside of the state system.

Slowly, but too slowly, the ideological disgrace of denying top-up treatment is being realised. The BMA debate was a reaction to a woman dying of cancer who was denied free NHS treatment in her final months because she had paid privately for a drug to try to prolong her life. This is not a health service that that is the envy of the world.