Good sense on the NHS

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Harriet Sergeant's article in Saturday's Daily Mail said almost everything that needs to be said about the current state of Britain's National Health Service. I heartily recommend reading the whole thing. In the meantime, here are a few edited highlights...

On public sector inefficiency:

But how on earth will it cope with the exploding number of elderly patients and the costly new procedures and treatments coming on to the market? The answer, says the health think tank the King's Fund, is to increase productivity in the NHS. But over the past decade, it fell by almost 4 per cent. (Over the same time, it rose by almost 23 per cent in the private sector).

How could this be?

I had not realised how costly the actual structure of the NHS is until I sat in on a hospital board meeting. Making sure the hospital complied with the latest government initiatives dominated the agenda. We didn't discuss patients, improving care, saving money or any issue relating to the hospital. The focus was on the bureaucratic process. The initiatives did not come cheap. The board has to prove to the DoH it is complying. So, for nearly every new initiative, the hospital appoints a manager, often on £50,000 to £80,000 a year - not to mention a secretary - to collect the all-important data that must then be submitted to the Department of Health.

The result?

The effect of this is clear. One consultant calculated the proportion of managers, administrators and support staff to nurses in the NHS is 41/2 times greater than in private hospitals, which are not subject to the government initiatives.

Why doesn't someone do something about it?

I spoke to one non-executive director who has a career in trouble-shooting ailing companies and who was astounded by the attitude of his local hospital. With only a cursory look at the books, he announced he could save £200,000 just by good accounting. The response he got? 'It was as if I was speaking Ancient Greek.' His ideas were dismissed as not applicable in a service funded by the Government. Worse, the hospital's chief executive feared that an investigation might expose failings and leave him vulnerable to political interference.

The real problem:

The problems with NHS finances are bound up with the problems of the institution itself. It was designed to be state- owned, centrally planned, financed and run. Until we engage with that basic premise, the NHS will continue to be inefficient and expensive. And we'll see more hospitals closed and front-line staff cut. It is clear to me that we can no longer afford this top-down approach. But where do we go from here?

The solution:

I believe that instead of devising its own solutions to problems, the Government should cease to micro-manage our healthcare. Instead, it should be creating the opportunities for individuals and companies, inside and outside the NHS, to come up with the most efficient and cost-effective solutions, with the Government's role as strictly regulatory.

I really couldn't agree more...

Turning health into a zero sum game

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Health is an area where the gains of one would not normally come at the detriment of others. If one person is cured, it does not usually involve another person becoming ill. As society becomes wealthier and better educated, most of its members ought to have access to better health and greater longevity, without impeding the ability of others to do likewise.

Alas, the NHS has changed that. Given its universal provision and its necessarily finite resources, decisions have to be made about which treatments and procedures can be afforded and which cannot. In a recent case a leukemia sufferer was denied access to a possibly life-prolonging drug because the NHS regarded the £30,000 a year cost as an ineffective use of resources, given likely clinical outcomes.

The point is that within a closed system of finite resources, each treatment has to be assessed to see if it is worth denying funding to other treatments in order to supply it. Television reporters interview someone demanding extraordinary (and very costly) treatments for their brain-damaged premature baby, without ever alluding to the brutal fact that others must die if it is to be kept alive. In the NHS people have to ask if that extended life is worth more than the ten kidney patients who might otherwise have been saved. They have to ask if a drug which might offer a few extra years to one patient is worth the suffering to dozens of elderly patients who will not receive their hip replacements if the money is spent elsewhere.

The NHS has turned health into a zero sum game, in which the survival of some takes place at the expense of the death or suffering of others. The QALY, or quality-adjusted life year, was devised to facilitate these complex, and some would say repugnant, calculations. Many people also blanch at the way the NHS can withdraw all treatment if people obtain privately the drugs the NHS has refused to allocate to them. Gods might behave like this, but men and women shouldn't.

There has to be a better way, and it might involve encouraging charities and communities to rally round people who lose out on NHS allocations, and raise extra funds to support them. That breaks out of the fixed pie of the zero sum game, and brings in additional resources instead of taking them at the expense of others.

Caution: Government warnings can damage your health

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Those who hoped for a let-up in the blitz of government warnings that were so prominent at Christmas have been disappointed. Now government agencies try to ride the tide of New Year resolutions, urging behavioural changes upon the population, and giving grim warning of the consequences of not doing so. It has been a boon for the advertising industry and for the media which have benefitted from the bonanza of taxpayer cash funding these campaigns, but there are questions as to whether it achieves any good.

Since stress is regarded as a big killer, exacerbating many other conditions as well as causing its own problems, the wisdom of exposing us all to the stress of this relentless advertising has to be questioned. They want us to treat every meal as a minefield rather than as a source of relaxed pleasure. Is there too much sugar? Too many saturated fats? We are made to feel guilty about eating butter and cream, and made anxious that we might be exceeding our day's quota of salt. And so it goes on. That stress-reducing drink after work now has numbers of alcohol units mentally written upon it for us to fret about, and of course any smokers who want to relax and reduce their stress levels with a cigarette now have to do it in the snow, and feel outcasts as well as guilt-ridden.

Government environmental advertising is adding to stress levels as well. Now we are supposed to fret about ways of traveling five fewer miles a week, or turning thermostats down.

If, as is likely, we have a new government this year, one of its first moves should be to stop all such advertising. Instead of trying to make people feel miserable and guilty, especially at holiday times, it should allow them to relax and enjoy themselves, unbombarded by exhortations to worry about what they are doing. The theme should be lighten up, enjoy life, relax. There's much to enjoy about life, and we don't need killjoys to spoil it, especially those who waste huge quantities of public money in doing so.

NHS cash won't cure health inequalities

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David Cameron will pledge today to divert billions of pounds to healthcare in the most deprived parts of the country if he forms the next government.

This decision on health funding, I am told, is the first in a series of policy statements by the Conservatives aimed at countering claims that the party is intent on slashing core public services, and countering 'class war' claims that they are a party of the rich. So I can see why 'Dave' (as his spin-doctors prefer him to be called) wants to do this. I just think it will be an ineffective policy, and therefore a waste of our money – money that is pretty short right now, and could be used to better effect.

If health outcomes reflected the amount of money we spent in different areas, then the fittest, sprightliest, longest-living folk would be in the Calton area of Glasgow, and the sickest ones with the rottenest teeth would be in Wokingham. The fact is, of course that although residents of leafy Wokingham can expect to live comfortably longer than the national average (75 for men and 80 for women), a male in Calton cannot expect to see his 54th birthday. (That is 13 years shorter than Iraq, even after a decade of sanctions, and 16 years less than North Korea, likewise.)

In the Calton, a quarter of the population say their health is not good and over half smoke. Two-fifths are on incapacity benefit. Calton residents suffer from their drink, drugs, and poor diet. Alcohol abuse is far above the national average. Heart disease, diabetes, and hospital admissions with drug overdoses are high.

Would more money from the NHS change that? Not a chance. Of course, Dave's health supremo, Andrew Landsley, says that he is going to turn the NHS from a sickness service to a health service, concentrating more on prevention rather than cure. He would still have his work cut out to make an impact on statistics like these. No, Calton residents are already the victms of too much government spending – poor-quality public-sector housing, a social benefit system that encourages family break-up and makes it almost impossible for people to get back into work, and a state school system that leaves inner-city kids underqualified and devoid of any hope of improving themselves. Yet more of the same will not help. We need to think much more radically if we are to change ill-health – and the causes of ill-health.

Dr Butler's new book The Alternative Manifesto is published soon. Click here to find out more.

Making healthcare a human right a mistake

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The “right to health" is enshrined in several major international treaties, many national constitutions and forms the basis of policy for nearly every major aid agency and humanitarian NGO.

Unfortunately, treating health as an enforceable human right does not work.

Traditional human rights like free speech and the right to peacefully enjoy property have helped restrain the actions of authoritarian governments all over the world.

Since the Second World War, however, international human rights treaties have added positive rights such as health. These require government action, not just restraint.

Positive rights were intended as political aspirations. However, revisions by the UN’s International Covenant on Economic Social and Cultural Rights have made signatory governments legally obliged to “respect, protect and fulfil" the right to health for all individuals.

This new interpretation of the right to health is used as a political tool. The UN’s ideological commissars insist that human rights risk being infringed whenever healthcare is provided through the insurance market or other private means.

Canada’s 2005 Supreme Court decision to overturn Quebec’s ban on private health insurance was criticised by UN experts on the grounds that it interfered with the right to health. The health systems of Korea and Switzerland have similarly been criticised for having too much private involvement, despite delivering high quality services.

Meanwhile Brazil’s constitution recognises the right to health, but shortages are common in state pharmacies. Patients therefore sue the government, creating an intolerable burden on the judicial system. More than 1200 cases of judicial review are sought in the Rio Grande do Sul region alone each month.

The right to health is a blind alley. Traditional rights let people lift themselves out of poverty, giving them the resources to afford clean drinking water, good nutrition and the decent healthcare systems necessary to achieve good health.

Jacob Mchangama is head of legal affairs at the independent Danish thinktank CEPOS. He has written a paper that challenges the widespread acceptance of the existence of a human right to healthcare for IPN. It can be accessed through their website here.

The micro-politics of hospital privatisation

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Introduction
Mindful of a likely change of government in 2010, Nurses for Reform believes that the NHS should be renamed the National Health SYSTEM and that it should work through the universal supply of independent hospital care and treatment. Simply put, there should be no hospitals in this country owned by the state or managed by its agents.

Cheaper and Better
There was once a time before the industrial revolution when food production was onerous and costly. Many could not afford a nourishing, diverse or pleasurable diet and all too often people went hungry.

There was a time before the invention of the steam, internal combustion and jet engines when options for travel were limited and any significant distance remained the preserve of the rich.

There was also a time, not so long ago, when telephones were rationed and lengthy calls were beyond the means of most people.

Yet today, thanks to open and innovative markets, people can afford diverse food, extensive travel and outstanding telecommunications. What was once beyond the dreams of avarice are now part of every day life and taken for granted.

Universal Independent Hospital Provision
That is why the next government must liberate health provision from the rationed and expensive world of top-down of un-innovative state control. All NHS hospitals must be returned to the independent sector, not least so that such provision reflects actual needs and not the political whims of vote-motivated politicians. At a practical level this means the following key points:

• In the post-bureaucratic age the Secretary of State for Health must no longer have any say over when or where hospitals are built, opened or closed.
• Following the planned changes in education, local planning laws must be reformed so as to enable a much greater diversity of - and investment in - independent provision.
• The planned Independent NHS Board should oversee the return of all UK hospitals to diverse forms of independent ownership (for-profit and not-for-profit).
• Health censorship must be outlawed and patients must be empowered with greater access to information. In this context hospitals, doctors and other health professionals including pharmaceutical suppliers should be free to advertise and build trusted brands. Only by allowing reputations to be built openly from the bottom-up will the government be able to realise a lighter touch in regulation.
• To encourage openness, diversity and greater opportunity for staff, employers and patients, an incoming Conservative administration must also adopt the principle of subsidiarity when it comes to human resource management. Hospitals, care homes and all other health facilities should be able to set pay and conditions for staff as they think appropriate and take the lead in all medical and health training. National collective pay bargaining and professional monopolies should be abandoned in favour of a more post-bureaucratic approach.

By putting these key initiatives in place not only will there be a vast improvement in the provision of healthcare but, these changes will enable further micro-political changes to health funding. Overall, these reforms are necessary so that healthcare is pushed through the beneficial reforms that we now enjoy in so many other areas of our daily lives.

Dr Helen Evans is a fellow of the Adam Smith Institute, and the director of Nurses for Reform.

The NHS – Regulating the accounts

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Clearly, the next Government must address the issue of NHS expenditure – £102 billion has been allocated to the NHS in England for 2010 - and the priority is to maximize returns from such a vast annual outlay. With a work-force in excess of 1 million, it is simply not credible to argue that there is minimal scope for savings. But, assuming – in line with the opinion polls - that Andrew Lansley becomes the next Secretary of State for Health, how should he proceed?

Whilst clinical matters will obviously be handled by doctors and nurses, financial issues should be the priority for Lansley, especially as UK public finances are so dire. In particular, he needs to set common – and unambiguous - accounting criteria for each hospital. By doing so - and by using Monitor as the Financial Regulator - it will become abundantly clear where the most serious inefficiencies lie. Of course, in some cases, there will be valid reasons for above average expenditure. But there is clear evidence that some Foundation Hospitals – certainly not all – have outperformed those lacking this status.

Furthermore, the separation of accounts will enable particular activities within hospitals to become progressively more subject to competition. Within that grouping are both imaging and pathology, both of which have historically been under-funded. Whilst undoubted progress has been made in reducing the imaging backlog, there is a strong case for establishing a genuine competitive market in imaging - with the latest expensive radiography equipment being funded by the private sector on the basis of projected long-term revenues. Investment in pathology is also desperately inadequate. Similar efforts should be made to set up a competitive – and modernized - pathology market.

In time, a few key players should emerge, who hopefully would establish the UK’s leading role in these fields.

These proposals may sound radical – but are they?

NHS Bill

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A new NHS bill which aims to stipulate maximum waiting times will eventually be consigned to the dustbin of history as it will no doubt produce an endless array of fiddles, anomalies and counterproductive unintended consequences.

That said, its eventual downfall might nevertheless contribute to some beneficial policy advancements in the short and medium term. For example, if linked to an extension of the patient choice agenda such an approach might eventually pave the way to a welcome step change in UK health provision. For while ministers recently talked about establishing a legal right so that NHS funded patients could automatically go private if they waited more than 18 weeks for treatment, the time is fast approaching when we should ask why any NHS funded patient should have to go into a state owned hospital or clinic?

Today, I believe no NHS funded patient should have to go into a state owned facility. All hospitals, clinics and care homes should be provided by a diverse and open independent sector that competes for patients and in so doing builds trusted brands. If the new bills further sets the NHS up to fail and therefore heralds the input of ever more private sector know how and expertise then I say bring it on.

Dr Helen Evans is Director of Nurses for Reform.

Social Care Bill

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The current, means-tested system of social care penalises thrift and foresight. However, extending eligibility for ‘free’ personal care to people who are not in need is a myopic proposal. These plans will surely be popular with the prospective heirs of care-dependant elderly people. But against the backdrop of an ageing society, they will either have to be accompanied by sizeable tax increases – with all the economic side-effects that entails – or they will increase the tendency towards rationed state care. These plans neither enable the long-term care system to cope with the demographic challenges, nor do they encourage savings or promote fairness.

We should take the bull by the horns and move towards a system of private long-term care insurance, based on the capital cover method. This means that people would take out long-term care insurance when entering the labour force, and pay modest but regular premiums. Private insurers would gradually build up a capital stock on behalf of each policyholder. People would have free choice between insurers (their old-age reserves would be fully portable), coverage levels, and models of care delivery. Apart from commercial insurers, friendly societies and trade union schemes could play a vital role in this market.

Kristian Niemietz is the Poverty Research Fellow at the IEA.

Graduate nurses

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It is the mark of the increasingly backward system of healthcare that we practice in this country that the Department of Health has decided that all nurses need to be qualified up to graduate level from 2013.

The recommendation was made by the regulatory quango, the Nursing and Midwifery Council (NMC) with the Royal College of Nursing backing the move, On the one hand, NMC's defence of this move is certainly surprising in as much as the union are supporting the government determining the qualifications of nurses, circumventing the unions relations with hospitals, their direct employers. Yet on the other hand, the union may be banking on this restriction to nursing decreasing competition and thus increasing wages and the Union’s bargaining position vis-à-vis their indirect employer, the government.

UNISON takes a different line than NMC is worried about this move, for perfectly practical and sensible reasons:

Our concerns throughout have been to make sure that the profession, whether you're a nurse or a midwife, that we're actually reflecting the society that we care for and I think one of the concerns that colleagues have had is about making sure the right emphasis is placed on the care and compassion that nurses give and that shouldn't be solely based on their level of academia.

But for the big picture, Dr Helen Evans of Nurse for Reform articulates the attendant problems of grade inflation, increased costs and decreasing standards:

In further nationalising the labour market on the front line of patient care, ministers and the Royal College of Nursing will simply end up sucking in tens of thousands more ancillary workers and lowering standards on wards still further.

The next government has plentiful reform to undertake; it is looking increasingly unlikely that they are not up to the task, but given rising costs and slipping standards, their hand might well be forced.