There is no great stagnation

Given my advancing age and the near certainty that I'll have some form or amount of prostate cancer before I shuffle off this mortal coil, for almost all men do, I'm rather glad to see this little piece of technology. It's a robotic arse, doctors for the training of.

Dr. Lok: The image shows a medical student practicing a prostate exam on a virtual patient. The virtual patient prostate exam simulation is designed to help students practice and reduce anxiety with intimate exams. In the experience, the student talks to a virtual person and is able to practice their communication skills. The students can conduct a realistic prostate exam on the plastic mannequin. The mannequin is instrumented with force sensors that can measure where the student is examining and with how much pressure. This enables the system to provide a realistic encounter with a virtual patient that includes communication and physical exam components.

Intimate exams (including the clinical breast exam and prostate exam) are extremely high stakes and high impact scenarios for medical students. However, currently there are few tools to enable the practice and acclimation to what are very anxiety generating interactions. Currently, students receive minimal practice and interaction in intimate exams due to the high cost for training and high anxiety nature of the exams.

So our research group has spent the past 4 years exploring whether we can improve medical students preparation and performance in intimate exams using simulations, such as the one seen in the photograph.

Now you might think that I'm posting about this just so that we can all have a good snigger and you would, of course, be correct.

But there is an economic point here which is that GDP isn't the be all and end all of our economic system. Having medical students trained so that they can indeed perform these intimate examinations with some modicum of empathy is not something that turns up in GDP figures but we can reasonably assume that said training makes the world a better, happier place.

And there's one more little bit too: the difference between how much better off we are as measured by GDP and how much better off we really are increases over time. Simply because the two methods of measurement are diverging. Looked at purely by GDP the English lifestyle got about 8 times better in the 20th century. But there are entirely sensible and serious economists who would argue that life as it is lived got 50 to 100 times better in this same country over this same period of time. All as a result of the improvements in things that just don't get measured by GDP.

So, does competition work in health care or not?

We can all refer to theory about whether competition, markets, works in health care or not. There are still those who insist that competition and markets never work at all (yes, sadly, still some antediluvians out there) and even I will agree that there are areas of life where markets, pure and unadorned, are not the optimal solution. The question is though, well, do markets improve heatlh care provision or not?

Fortunately, we've an answer. This is the final version of a paper that looks at what happened in NHS England a few years back, at a time when NHS Wales and Scotland did not take the same market opening path. We can thus compare and contrast what happened in England against the other two, further we can look at those areas where there was more competition in England and see what happened. Interesting results:

The effect of competition on the quality of health care remains a contested issue. Most empirical estimates rely on inference from nonexperimental data. In contrast, this paper exploits a procompetitive policy reform to provide estimates of the impact of competition on hospital outcomes. The English government introduced a policy in 2006 to promote competition between hospitals. Using this policy to implement a difference-in-differences research design, we estimate the impact of the introduction of competition on not only clinical outcomes but also productivity and expenditure. We find that the effect of competition is to save lives without raising costs.

That seems pretty clear, doesn't it? Lives saved with no more money expended simply by bringing in a bit of market discipline?

We'd probably better have some more of that market discipline, hadn't we?

Institutionalised abuse of whistleblowers

A few weeks back I wrote about the criteria used by the Care Quality Commission (CQC) for inspecting dentists and their complete irrelevance to patient experience and assessing tooth maintenance.  The CQC inspectors do not see what matters and if they do see evil, they do not correct it.  Three brass monkeys preside over the CQC boardroom table: Speak no evil, hear no evil and CQC.

The Orchid View Care Centre is the latest example. According to this week’s reports Orchid View was opened in 2009 and by 2010, when the CQC first inspected, abuse was already rampant.  The CQC did find fault in 2011 but then took no steps to deal with the malefactors before the Care Centre closed four months later.  19 residents died in these two years and the coroner attributed five of the deaths to neglect.

As well as the residents and patients, the whistleblowers in care homes and NHS facilities also suffer from institutional abuse. That needs urgent attention too.  Andrea Sutcliffe, CQC Chief inspector of adult social care, was interviewed on the Today programme on Saturday about the Orchid View case. She was asked if she thought it unfair that the whistleblower, Lisa Martin, not only had to endure all the stresses of whistleblowing and its workplace consequences but had been unable to find a job in the three years since.  Sutcliffe agreed that it was unfair.

She was asked what should be done about that. After a pause which seemed to indicate that she had never previously considered the matter, she replied that a change of culture was required.  Unfortunately the interviewer failed to press the point.  What change? How could it be achieved? What is the CQC doing about it?

Every whistleblower in care homes and the NHS suffers the same abuse from the CQC and the other institutions involved: obstruction and putting on the frighteners to ensure nothing gets out and then, when it does, platitudes followed by a complete absence of practical help.

Lawyers and the compensation culture are part of the problem.  Managers are not allowed to admit fault, malpractice or negligence in case victims and their families sue. Funding shortage contributes to care failures in the first place and paying compensation further reduces available funding. When the facts do finally become public, not via the CQC which has its own tracks to cover, platitudes are followed by a complete lack of support. Abandoning whistleblowers to their own fate is as much an abuse as failing to tend the elderly.

Yet the CQC needs whistleblowers and should be motivating and supporting them.

Every whistleblower, whether in a care home or hospital seems to suffer the same fate: The anguish of being disloyal to workmates and employers, legal obstruction followed by joblessness.  After all, who would want to employ a troublemaker?  So who would want to be a whistleblower?

This has a simple solution.  Apart from those few cases where the whistleblower is crying wolf, the whistleblower should always be offered a job by CQC as an inspector.  Who else is better qualified for the job?  And if the CQC needs to sack some of its current dozy inspectors to make room for whistleblowers, so much the better.

Does the Dental Regulator know the meaning of quality care?

My dental surgery presented me with a two page medical history questionnaire to complete before being allowed to see the dentist.  You know the form. As nothing had changed since the last one, I offered to sign and date a copy.  That was not an option because (a) their technology didn’t not permit extracts or copies (a likely tale) and (b) completing a new form was a legal requirement.  They meant it was a Care Quality Commission (CQC) requirement.  “May I see at least last year’s as a prompt?  At my age, memory is imperfect: I cannot remember my medications when the tablets are at home.”  “No.  You have to complete the form unaided.”

The Adam Smith Institute has long drawn attention to regulators failing because they descend into box-ticking.  The financial crash of 2008 was one example. The CQC is a new regulator but this descent is already apparent.  Ensuring primary care achieves and maintains high standards is clearly important and was given impetus by the Harold Shipman tragedy.  But that is my point: whilst Shipman was good at the paperwork and complying with regulations, he was also killing his patients.  The Mid Staffs Hospital is not a primary care unit but the issue is the same: they could have been ticking all the boxes and still killing their patients.

The CQC’s 2nd Annual Report sets out five criteria for establishing dental care quality:
(a) Do the dentists treat their patients with respect and discuss their proposed treatments?
(b) Do they fully assess patients’ needs and deliver the care and treatment they need?
(c) Do they protect patients from the risk of abuse and treat them in a clean surgery without risk of infection?
(d) Do they recruit staff effectively and conduct thorough checks on them?
(e) Are patients’ records up to date and kept safe and confidential?

Incidentally, there is nothing here banning the use of copies of prior records. Item (c), however, is responsible for the new ban on coffee in dental surgeries.  According to my dentist, the CQC claims that this could give rise to cross contamination with medications even though there is no evidence that such a thing has ever happened. Harold Shipman would have passed these five criteria with flying colours.  

Patients visit dentists to retain their teeth as long as possible and, when that fails, have false teeth fitted, all in as agreeable and painless a manner as possible.  We want our teeth to look good too. The word “teeth” does not even appear in the CQC criteria and nor does the patient experience. “Quality”, in this context, means that we have teeth that work, avoid pain and look good. It would not be difficult to develop scales for these quality indicators.  Adjusted tooth loss rates could be measured in a similar fashion to Professor Sir Brian Jarman’s adjusted mortality rates for hospitals. The CQC does interrogate some patients but their conclusions rely mostly on what they glean from dental surgeries.  This is the wrong balance: patient experience, and especially the pain endured, is only known by the patients themselves.  When the care quality of each surgery, relative to equivalent surgeries, is established, its patients should be informed.  The aggregate scores in the CQC annual reports, all around 90%, tell us nothing.

Comment of the week

The point is that people who contract cancer or heart disease, (which are largely diseases of old age), suffer less than people who suffer the effects of malnutrition and poverty.

From the perspective of our prosperous and comfortable lives in the developed world, pollution-induced diseases seems like a terrible affliction. And they are, relatively speaking.

But from the perspective of somebody living in the developing world, the diseases associated with poverty are even worse, and that is the thing that environmentalists living their comfortable lives in the developed world never seem to get.

However bad you think industry is, the alternative is worse. Despite all those pollutants, when a country industrialises it's life expectancy and general healthiness climbs. That's why the global population increased. And when people without it get the chance to industrialise, they grasp it enthusiastically. We in the developed world have forgotten what pre-industrial poverty was like - thank heavens! - and have a tendency to romanticise it.

As it happens, the biggest health risks from pollution are in the form of water-borne disease - cured by the industrial production and distribution of clean water - and indoor smoke from wood/dung cooking fires - cured by the industrial production and distribution of cheap energy as electricity or gas. Are all the people who contract lung diseases from indoor smoke supposed to just shut up and suffer for the good of the environment?

We need to prioritise our resources on tackling the most pressing problems first, with the best benefit/cost ratio, and then move down the list once those are solved. I agree that we need to do something about the dimwitted claim that we "put profits before people". Trade and markets are about people - they are the way we collectively work together to solve other people's problems, they are about efficiently allocating our limited time and talents to addressing the problems people find most important, and "profit" is simply a statement that the benefit achieved doing something should be worth more than the effort put in. "Profit" is actually a "people" concept - it's opposite is "waste" and is anti-people. 'Waste' is about expending the resources that could have quietly helped a hundred on a (usually more obvious or media-friendly) handful. It is about what is seen and what is not seen. But it is a difficult point to get across.

- Nullius in Verba, commenting on "The environmental Kuznets Curve is alive and well in China"

Is the NHS really the kind of health service we want?

Half of Britain's family doctors, according to a survey this week, now believe that their patients should be charged to see them. Their workload, they complain, has become 'unmanageable', their waiting rooms clogged up by people who have very minor ailments and do not need to be there.

I write this from a car repair shop outside Cambridge. I had a problem with my car, so I called up yesterday and made an appointment, to suit my convenience, for 8am today. I rejected the offer of a courtesy car while mine was being looked at, but was invited instead to spend the intervening hour in their gleaming air-conditioned customer lounge and to help myself to coffee, tea, sandwiches, biscuits, fruit juice and lots more besides. So I have been reading the newspapers, watching the TV news, and I will shortly be sending this to the blog on the free customer wi-fi. Through the plate glass window I see the engineer plugging various computers onto my vehicle to find out exactly what is wrong. The fee for that hour of his time and all that customer service? £50 (including VAT). The difference between this and a doctor's waiting room could hardly be more stark. If I could pay a fee to get that kind of service from the NHS, I would be absolutely delighted.

Britain has a National Health Service that was constructed during the years of wartime austerity (which was real austerity, not the bogus 'austerity' we are told we are experiencing today), and it presumes that most of us are on the breadline. But there seems no shortage of people who, like me, are willing to pay £50 to sit in comfort while their car is fixed. Do we really think they would not pay £50 to get the health of their own body diagnosed? The first thing we need to do is to take the middle classes out of the free healthcare scam and focus our resources on people who genuinely can't afford a doctor.

As for them, just look round the world – there are innumerable ways of making sure that people who cannot afford the full cost of medical care still get it. In France you pay, but get a rebate if you are on low income – so you are aware of the cost, but do not suffer it. Other countries have insurance systems in which the state pays the premiums of the hardest-up. Britain's trouble is that nobody has the faintest clue how much medical care costs, so don't think about whether their sniffle is really worth the doctor's time and the taxpayers' cost.

I find myself visiting the doctor more, now that I have given up on the NHS and pay privately. Instead of fearing that I might be wasting the doctor's time on something minor, I know that the doctor is pleased to see me because I am a paying customer. It doesn't cost a huge amount, in fact – nothing like the £150 charge that the NHS doctors survey worryingly suggests. But like the car showroom, I get seen immediately in pleasant surroundings and get treated as a valued customer by someone who is not overloaded and stressed out. Isn't that the sort of health service we want?

The NHS is going to have a £30 billion a year funding gap apparently

Woes, woes unto us, eh?

The long-term crisis in NHS finances will be laid bare next week when the health service reveals it is facing a £30bn hole in its budget – as a prominent Lib Dem peer suggests charging people to see their GPs. Tim Kelsey, NHS England's information director and a former Cabinet Office adviser on data, said the health service faced a £30bn funding gap by 2020. In an interview with Health Service Journal he said: "We are about to run out of cash in a very serious fashion." He said that next week NHS England would be "publishing a call to action". The document – entitled The NHS Belongs to Us All – is expected to make the case for significant changes to the way hospitals operate. "The financial context is, and our analysis will disclose, that by 2020 there will be a £30bn funding gap in the healthcare system." NHS England's predictions appear to be based on work by the Institute for Fiscal Studies. Last year it calculated that if NHS spending was left to continue to soak up resources at its long-term rate and other on-health public spending is kept at 1% a year, then the funding gap would be about £30bn. When contacted NHS England confirmed that it would be publishing a report next week. "We are not in a position to say more at this stage," it said.

I'm not sure that I can take this. It will mean more Polly Toynbee columns about how the NHS is The Wonder Of The World, so fabulous that absolutely no one has ever tried to copy it.

Now unpack what they've actually said there. NHS inflation has been and is higher than the general inflation rate. This is partly because it's a protected State organism and partly because of Baumol's Cost Disease: services become more expensive relative to manufactures over time.

The solution to both of these problems is to introduce markets. Sure, they can be markets where the financing is still done by the State. But you need a variety of suppliers competing with each other for access to that cash stream in order to increase that productivity. This is obviously true of any organisation suffering from bureaucratitis: but it's also implicit in Baumol's writing on innovation. Yes, it's more difficult to increase productivity (and thus lower the inflation rate) in services but this is why services need to be subjected, even more than manufacturing, to the incentives of market competition.

That the NHS is going to suffer, as a result of its higher than general inflation rate, a £30 billion funding shortfall is why the NHS needs to be subjected to market competition. But do note that given that it is being subjected to market competition its higher inflation rate is going to be moderated: thus there won't be the £30 billion shortfall.

If you prefer, that identified shortfall is exactly why the current reforms must go through: because they're designed to beat that shortfall.

Now, if only we could get Polly to grasp this concept....

Why an opt out system for kidneys still won't work

Ben had an interesting idea yesterday: let's make organs the property of the State for them to allocate, as the State wishes, after our deaths. Even to the point that those who wanted the corpses of their loved ones buried intact would have to pay the State the value of those organs that would go unused. "Interesting" here includes the meaning of "how do I get a rise out of my readers" and by that measure it was indeed most interesting. However, by another, it's not so much. For the problem with the proposal it that it just won't solve the perceived problem. Not enough people die healthy enough for us to have enough organs to transplant.

Our basic problem is that people die as a result of our being able to perform organ transplants but there aren't enough organs available to perform such transplants. Not enough people carry organ donor cards and some of those that do their families demur when asked at that crucial moment. Thus it seems logical enough that we should move to a different policy in order to save those lives. We should have opt out systems: only those who feel strongly enough about rotting with their kidneys and have indicated that desire should be able to do so. Or even, as Ben intimates, that those who want to rot complete should pay the loss to the person whoi doesn't get the transplant as a result of said desire.

And yes, it's all ghoulish and yes there are considerable civil liberties implications: but we should indeed float such ideas to see where they go. The problem is that even if we did this we still wouldn't have enough organs for transplant. For you've got to die pretty healthy for it to be possible to use said organs: no one with any form of cancer can be used for example. No one with a variety of infectious diseases. By the time anyone's got dementia there's little point in trying to use parts of them and heart disease has its own problems: the process of dying this way can damage the organs that are desired.

Effectively we're left with that small group of people who die in accidents. There are certainly enough people who do to cover the simple number of organs desired even if some parts will be a little too squished (that being the cause of death) to be useful. But once you count in the necessity for blood type matching (and it's a lot more complicated than just O, A or AB etc) and tissue matching that's just not enough people to go around. Even if all organs of the deceased were indeed State property to be allocated: there still aren't enough.

So Ben's solution fails at the first hurdle: whatever the moral implications, it still doesn't work. Cadaveric transplant just isn't enough.

Which leaves us with two options. One would be to increase the number of cadavers. Perhaps abolishing the motorcycle helmet and car seatbelt laws. That would probably help, might even solve the problem. Plus we've the obvious benefit that this is an increase in freedom and liberty.

The other is that we should move to a paid market in live organ transplants. I've pointed this out a number of times before.

In terms of what we can transplant corneas we're fine with under the current system. Kidneys, lungs and livers can all come from live donors (no, really, you take a bit of the lung and a bit of the liver). And I've no problem with it being a very tightly controlled market, State controlled, but in order to get them to come forward we're going to have to offer cash rewards. About the only one we can't deal with at present in this manner is hearts. But then compulsory donation unless a fine is paid wouldn't solve this one either. And once we've solved as best we can this problem, through our paid market, then there's no need to go around thinking about making all corpses State property, is there?

Happy 65th birthday NHS, maybe it's time to retire?

65 years after the creation of the National Health Service, its fans say it's the envy of the world. But does it deserve that reputation, and could there be better alternatives?

We shouldn't just pay attention to the headline grabbing stories. You could point to the thousands of possibly needless deaths revealed by the Francis Report or the high costs of our NHS. The error of those who think we can deliver healthcare by committee is more fundamental. It's absurd that we trust politicians to know how to deliver something as important as our hospitals.

Imagine if the state supplied our food. Without prices, officials can't know when items run scarce. In the marketplace, a supermarket that runs out of food can raise the price for it. This prevents queues, and importantly alerts suppliers that they should divert resources to where there is scarcity.

Whenever governments have tried to control food production, this lack of co-ordination has seen people die in their millions. See the Great Chinese Famine. Governments can't tell if they're producing too much food or too little.

When it comes to the NHS, we're similarly ignorant about how well it's performing. Are we diverting too many resources into cosmetic surgery, too few into cancer drugs? There's no way of knowing, when patients have limited ways of indicating their preference, and we can't price the alternative uses of the NHS' resources.

There are good arguments to be made that we should be concerned by the high health costs that many incur due to conditions beyond their control, but this is an argument for systems that seek to reduce those costs.

Markets are a system that achieve just that. Health entrepreneurs can launch their ideas into the marketplace, and see if they work. Their success is easily gauged, will customers pay for them?

Letting us test health innovations against each other allows us to reveal the best ways to treat patients. Prices co-ordinate all of this information about what patients want, and without it NHS managers are flying blind, trying to make poorly informed guesses. After 65 years, the NHS experiment has been a failure, and we should put that system to rest.

Health inequality isn't all caused by income inequality

Chris Snowden has picked up on something that has long been a bugbear of mine. I shouted about it back when the Marmot Review on health inequality came out. It simple isn't true that all health inequality is as a result of income inequality: but that was the stance that the Review took.

Poor health will likely lead to low incomes, for example (reverse causation)

Absolutely: there are two effects going on. Getting some ghastly chronic disease in your 40s is obviously going to make you poorer in your 60s than if uyou'd been able to continue your meteoric rise up the career ladder to glory and a CEO's paycheque. I have no doubt that income inequality leads to some health inequality: I'd be surprised to find rich children suffering from vitamin deficiencies for example (assuming that Mother doesn't try all of the Mail's diet advice on her anklebiters) for example. But it's also true that health inequality leads to income inequality.

There's another effect going on as well. We're annually reminded (when the figures come out) about the geography of health inequality too. Men in Manchester or Glasgow die younger than those in Eastbourne for example. But again we're not being told a very important part of the story: people do move around you know. So it isn't true that someone born in Glasgow is destined for an early death: rather, it's those who don't climb the ladder up out of the slums who are. And the reason that lives are so long in Eastbourne or other retirement hotspots is that people only move to them when they are indeed retiring. And age expectations at 65 are very much higher than expected life span at birth. Simply because you've already survived, by definition, all of the things that were going to kill you before you got to 65.

Along with Snowden I tend to think that there are certain sets of statistics that are deliberately misrepresented in order to lead to a desired political conclusion. And those on health and age at death inequality are two sets of them.