Comparing apples to apples: NHS still ranks below average
Most healthcare reporting is deeply biased. From blogs to papers to policy, most people have strong preferences for different kinds of healthcare systems that they believe to be ‘the best’, often based on what they view the role of the state to be. Obviously some beliefs are grounded in more facts and stats than others, but given how complicated healthcare systems are, it’s possible to come up with all different kinds of conclusions that appear, at least on the surface, like they’re grounded in fact. Compare, for example, The Commonwealth Fund 2014 report to the 2014 European Health Consumer Index: two studies that compare international healthcare systems. Both published within one year of each other, The Commonwealth Fund ranked the NHS the best healthcare system out of 11 countries, while the EHCI threw it down the list, ranking it 14th after all your obvious competitors, including The Netherlands, Switzerland, Germany, but also after your less obvious contenders, like Portugal.
Both reports appear to be thoroughly researched and have lots of numbers to back them up. So who do you believe? Well, if you favour single-payer health systems, you're probably going favour the Commonwealth Fund's report, which inherently favours centralised systems. (For example: out-of-pocket costs and insurer rejection of full cost reimbursement were considered a black mark against a healthcare system, regardless of access to treatment.) If you rank results higher than the principles around who delivers healthcare or who makes a profit, you're probably going to favour the EHCI's report, that gives more weight to things like waiting lists.
I personally give more credit to the EHCI report because my primary concern when it comes to healthcare systems is patient outcomes. That’s my bias.
Which is why the OECD’s healthcare efficiency reports are so important. The OECD’s stance is that “there is no “one-size-fits-all” approach to reforming health care systems. Policymakers should aim for coherence in policy settings by adopting best practices from the many different health care systems that exist in the OECD and tailor them to suit actual circumstances.” So while the OECD does make some comparisons of countries across the board, it also intentionally group countries together based on different kinds of healthcare systems in order to compare like with like.
Specifically, they break countries down into six groups to compare the efficiencies of similar healthcare institutions to each other, in an attempt to identify where the most improvement can be made within specific systems:
The UK falls into Group 6, which is characterised as:
Mostly public insurance. Health care is mainly provided by a heavily regulated public system, with strict gate-keeping, little decentralisation and a tight spending limit imposed via the budget process
Seven countries fall into this category: Hungary, Ireland, Italy, New Zealand, Norway, Poland, and the UK. The OECD uses nifty radar charts (click on links) to illustrate how each country compares to both the OECD average as well as Group 6’s average in different areas including efficiency and quality, amenable mortality, prices, resources, consumption, financing and policy. The final chart ranks each country’s to measure its comparative efficiency. The results:
High DEA Score: Norway, Italy Above Average: Poland Average: New Zealand Below Average: UK Low: Hungary, Ireland
The OECD’s analysis: “The quantity and quality of health care services (in the UK) remain lower than the OECD average while compensation levels are higher. Reinforcing competitive pressures on providers could help mitigate price pressures, e.g. by increasing user choice further and reforming compensation systems.”
On Tuesday I noted that the UK is one of the OECD countries that could do the most to improve its efficiency in public healthcare spending . But breaking that down even further, the UK doesn’t come close to topping the charts in its own group.
Perhaps the UK should be looking to make improvements to resemble Norway, which tops the ranks for public health services. Or maybe it should be looking towards other categories that focus on social insurance systems. Either way, it's time for the UK to start looking beyond the NHS.
Myth busting: NHS not so efficient after all
The NHS has long coasted on the widely held belief that it is one of the best healthcare systems in the world because it is so efficient. While European systems boast better patient outcomes, and the United States points to its excellent pre-emptive care measures, NHS loyalists cast that all aside, because unlike any of those other countries, the UK is able to keep its healthcare spending below 10% of GDP, free at the point of use, with relatively good outcomes. No other country can beat that efficiency. Well, it turns out most of them do.
In 2010, the OECD published multiple papers that specifically looked at the efficiencies of different health care systems. In its report “Health care systems: getting more value for money”, the OECD found that there was “room in all countries surveyed to improve the effectiveness of their health care spending.” Some countries, however, could see significant efficiencies gained. And the top three countries that could benefit the most: Greece, Ireland, and the United Kingdom.
By improving the efficiency of the health system, public spending savings would be large as compared to a no-policy-change scenario, amounting to almost 2% of 2017 GDP on average in the OECD. It would be over 3% for Greece, Ireland and the United Kingdom.
Breaking with myth, the UK is one of the countries that could do the most to improve its efficiency in public healthcare spending. Even more than the United States.
What the loyalists don’t seem to realise is that efficiency can’t simply be determined by how much money a country puts towards healthcare. The real question is how efficiently those monetary resources are being used to obtain better health outcomes.
And according to the OECD, both the UK and the US still have a long way to go:
Australia, Iceland, Japan, Korea and Switzerland perform best in transforming spending into health outcomes
In more than one third of OECD countries, exploiting efficiency gains in the health care sector would allow improving health outcomes as much as over the previous decade while keeping spending constant (Figure 2, Panel B). Germany, the United Kingdom and the United States fall into this group.
I’m not predicting the end of this health care tale. Perhaps, if the right reforms were made to the NHS to drastically improve efficiencies, the UK would have a system that not only demands less public spending, but also creates better health outcomes too. To compare apples with apples, Norwegian healthcare is " is mainly provided by a heavily regulated public system, with strict gate-keeping" and grouped together with the UK in the OECD's categorisations for healthcare systems; yet Norway's system is ranked much better for efficiency (more details to come in next blog...).
I just thought I'd flag up that, as things stand, the NHS under-performs on just about everything that matters.
Non magister sed mendax
Once again we've the, umm, interesting assertion that it's sugar that is really causing the outbreak of obesity. That this is not true doesn't seem to bother those pushing the tale. For here they are again:
Sugar and carbohydrates are the real culprits in the obesity epidemic - and the public has been falsely told that couch potato lifestyles are to blame, a new report has claimed.Writing in the British Journal Of Sports Medicine, they said poor diet now generates more disease than physical inactivity, alcohol and smoking combined.
The editorial, by a group of cardiologists and sports experts, says that while obesity has rocketed in the past 30 years there has been little change in physical activity levels.
"This places the blame for our expanding waistlines directly on the type and amount of calories consumed," they write.
Here is that editorial:
A recent report from the UK's Academy of Medical Royal Colleges described ‘the miracle cure’ of performing 30 min of moderate exercise, five times a week, as more powerful than many drugs administered for chronic disease prevention and management.1 Regular physical activity reduces the risk of developing cardiovascular disease, type 2 diabetes, dementia and some cancers by at least 30%. However, physical activity does not promote weight loss.
In the past 30 years, as obesity has rocketed, there has been little change in physical activity levels in the Western population.2 This places the blame for our expanding waist lines directly on the type and amount of calories consumed.
So, what's actually wrong with this analysis?
What's wrong with it is that it's simply factually wrong. As Chris Snowdon has been manfully pointing out all along, calorie intake in both the US and UK has been falling over the decades. As has, remarkably, sugar consumption. To the point that, for the UK today, average calorie consumption is lower than the minimum recommended during WWII rationing. Actually, today's average consumption is below where our grandparents started to lose weight on such wartime rations. It simply cannot be an increase in consumption to blame as there's not been an increase, there's been a reduction.
Given that weight does work on calories input minus calories expended, this means that calorie expenditure must be down. But our magisters here are telling us of a study that shows that exercise levels have not fallen, might even have risen. So, what is happening here?
Quite simply, they are looking at formal exercise, not calorie expenditure. Perhaps more people do go for a shuffle around the block than used to. But that's not going to outrun the effect of us all having central heating these days upon calorie expenditure.
It's getting very difficult indeed to think that magister is the appropriate word here, our opinion is leaning ever more to the word mendax.
Universal healthcare and market-based systems aren't mutually exclusive
An op-ed published last week in the New York Times laments Americans' decline in support for government involvement in the redistribution of wealth - or, as the Times author Thomas Edsall calls it, ‘sharing’. Edsall analyses a bunch of polls throughout the article, but what he finds troubling I find to be good common sense. For example, most Americans aren't incredibly trusting of their government:
Even worse for Democrats, the Saez paper found that “information about inequality also makes respondents trust government less,” decreasing “by nearly twenty percent the share of respondents who ‘trust government’ most of the time:”
Furthermore, most Americans aren’t convinced that Obamacare is going to be the shining, efficient, cheaper, all-inclusive beacon of hope it was promised to be:
An earlier New York Times poll, conducted in December 2013, found that 52 percent of those surveyed believed that the Affordable Care Act would increase their medical costs; 14 percent said it would reduce costs. Thirty-six percent believed that Obamacare would worsen the quality of health care compared to 17 percent who thought it would improve it.
On the whole Edsall appears to understand people’s perceptions of government care (to my relief and his dismay) quite well – except for in one area.
Esdall claims the “most dramatic” change in public opinion has been people’s perception of the ‘right’ to healthcare. He cites the two Gallup polls in an attempt to claim that majority support for guaranteed access to health coverage has dropped radically over the past six years:
The erosion of the belief in health care as a government-protected right is perhaps the most dramatic reflection of these trends. In 2006, by a margin of more than two to one, 69-28, those surveyed by Gallup said that the federal government should guarantee health care coverage for all citizens of the United States. By late 2014, however, Gallup found that this percentage had fallen 24 points to 45 percent, while the percentage of respondents who said health care is not a federal responsibility nearly doubled to 52 percent.
But Esdall isn’t comparing apples with apples. The belief that in a developed society everyone should have access to basic healthcare provisions is not the same as believing that healthcare is a federal responsibility – especially in the United States.
The debate is not – and has not been for a long time – whether or not people should have access to healthcare, but rather how that care should be provided. What kind of delivery of healthcare will create the cheapest prices and best outcomes, and what safety net for those at the bottom will provide the most comprehensive care?
There is huge demand in the States for healthcare reform, and most people want this reform to focus on cheaper access to care. But that can be achieved without fully handing healthcare provision over to the federal government or adopting something that resembles the NHS.
Both the US and the UK should be looking to countries that rank highest for healthcare provisions internationally, which have almost all settled on systems where the central government funds healthcare but does not directly provide healthcare. The Netherlands, Denmark, Switzerland, and Germany all have healthy relationships with private companies, ranging from insurance companies and charities, that provide better outcomes than those in the UK and in a cheaper, more efficient manner than in the US.
Support for universal access to healthcare and support for market mechanisms in healthcare are not mutually exclusive; there's plenty of evidence to suggest a combination of the two creates the best healthcare systems in the world.
So, could the public health people please shut up?
Vaping, smoking, the great question is, is one a complement to the other (complement, meaning that more of one leads to more of the other) or a substitute (more of one leads to less of the other)? Evidence:
Electronic cigarette use among U.S. middle and high school students tripled in 2014 while cigarette use fell to record lows, according to provocative new data that is likely to intensify debate over whether e-cigarettes are a boon or bane to public health.
No, that's not provocative data, that's conclusive data. A substitute not a complement.
Every public health advocate should now be pushing vaping. Anyone who claims to be such and is not is simply a Puritan.
By their actions shall ye know them.
Lies, damned lies, and electioneering statistics: privatising the NHS
Now the election campaign is in full swing, there has been a sharp rise in questionable statistics used in public discourse. This is distressing, as there is a risk people vote on the basis of misinformation. It seems that by using the same bogus assertions repeatedly, politicians of all stripes are able to eventually change the ‘facts’. The debate around the NHS has been the most dishonest. “Reverse the tide of privatisation in our NHS”
There has NOT been a tide of privatisation in our NHS. Privatisation if the process of transferring ownership of an organisation from government to the private sector. No shares have been issued in the NHS, nor distributed as vouchers to citizens. The NHS remains publically owned and funded, resources have grown in terms of real cash and people, and services are free at the point of the use. They must still provide services to all, whilst a ‘privatised’ company could choose to only serve those who pay.
Outsourcing isn’t privatisation, and is slowing
The government has encouraged competitive tendering of services, and outsourcing has increased, but only from 4.4% under Labour to under 6% with the Coalition. The rate of outsourcing has actually slowed under the Coalition. Regardless, outsourcing isn’t privatisation, maintains free at the point of use access, and can result in better services.
What about Hinchingbrooke Hospital?
Hinchingbrooke Hospital is the closest example to privatisation, as it is now run (though not owned) by a private company. The tender process for the hospital happened in October 2009, under Labour, further exposing their hypocrisy. Regardless, its core assets are publicly owned, and it still delivers NHS services free at the point of use.
An honest debate would consider alternative models that would improve services
As an aside, it’s worth noting that Hinchingbrooke has gone from one of the worst ranked hospitals, on the verge of shutdown, to one of the best for patient happiness and waiting times.
A proper discourse on health care would focus on ways to improve the quality. We should examine the merits of private (profit and non-profit) providers, rather than being blocked by ideological labelling. We should explore how alternative models that don’t reply on as much government management, like in Germany or Singapore, could deliver better services for all.
Private parts of the NHS say the NHS should not be privatised
Just a small note. There's a letter in The Guardian insisting that the NHS should not be privatised in any form or manner. Hey, you know, election season. There's some 100 or more signatories to it. Of whom 46 are listed as being GPs. Yes, General Practitioner. That part of the NHS which has always been privately owned, run and managed, as contractors to the larger organisation.
46% of those shouting that there should not be private sector contracting to the NHS are themselves private sector contractors to the NHS.
It is, of course, possible that their own working experience leads them to believe that such contracting is a bad idea. In which case, of course, we should see the same people (including at least two past heads of the Royal College of General Practitioners) arguing that GP services must be nationalised and sharpish. We don't, so that cannot be their argument.
Which leaves us really with only one possible explanation: a gargantuan ignorance of their own situation. And a general piece of advice to the wise: pay not much attention to the opinions of those who prove themselves, publicly, to be gargantuanly ignorant.
Observe the naked cash grab by the tobacco control people
It's a general rule of UK taxation that we don't do hypothecation. On the very sensible grounds that how much we can raise by taxing on activity has absolutely no relationship whatsoever to how much we desire to spend on some other activity. Fuel tax is not all spent on the roads, national insurance does not pay for the NHS and so on. But we now have a proposal that we should have an explicity hypothecated tax: Pressure is growing for the introduction of an additional levy on cigarette sales in the UK, a move that campaigners say could help eradicate tobacco consumption within decades.
To tax tobacco more or less: an interesting question. Our supposition is that it's already taxed over the top of the Laffer Curve, given the percentage of the market currently supplied by smuggled and informal imports. But certainly, whether to tax more or not is something that can and should be discussed. But more tax in itself won't bring about that no smoking world simply because we do live in a free society with open borders. However, the idea is worse than that:
“The industry is one of the most profitable on Earth,” Burstow explained. “The two largest tobacco firms in the UK, Imperial and Japan Tobacco International, hold around four fifths of the UK market and achieve joint profits of about £1bn a year. Charging those firms to help clean up the damage their products cause is a rational and justified extension of the ‘polluter pays’ principle to public health policy.”
Stuff and nonsense, the polluters are those who smoke. Just as it is people driving cars who produce fossil fuel emissions, not the petrol companies. But it gets worse again:
Health campaigners say the introduction of a levy equivalent to 25p a pack could raise £500m a year, money that they say should be used to fund measures to help people quit and prevent the uptake of smoking. Health campaigners believe devoting greater resources to tobacco control will bring major benefits.
This is simply a naked cash grab. The various bureaucrats and prodnoses in the "public health" sector want to have an untouchable £500 million a year to spend upon themselves. Whatever happens at the election in a few weeks time this is an idea that must be rejected.
More tax on tobacco? Meh. A dedicated revenue stream for these people? Absolutely no way at all.
Blithering stupidity about electronic cigarettes
Sometimes we just despair for the human species. Perhaps it might be time for us to resign and make way for intelligent life. Such is our reaction to this latest report about electronic cigarettes:
E-cigarettes need to be more strictly controlled to stop teenagers using them, health professionals have argued.
The call was prompted by new research showing that 19% of 14-17 year olds have tried the products despite them only becoming available in recent years.
An analysis by researchers at Liverpool John Moores University found that the e-cigarettes were used by 5% of teenagers who had never smoked, 50% of former smokers and 67% of light smokers.
Or as the BBC reported:
Many teenagers, even those who have never smoked, are experimenting with e-cigarettes, researchers in north-west England say.
Questionnaires completed by 16,193 14 to 17-year-olds, published in BMC Public Health, showed one in five had tried or bought e-cigarettes.
The researchers said e-cigarettes were the "alcopops of the nicotine world" and needed tougher controls.
The truth is, of course, that these results show that electronic cigarettes are an entirely marvelous product that are likely to save many lives in the future. Yes, lots of teenagers are using them. But what is the effect of their using them? As one of us has pointed out elsewhere:
That halving of teen smoking rates coincides with the invention and introduction of vaping (overlaps at least, the first devices really came in 2007). And other studies show very much the same thing. People use vaping equipment instead of smoking, not as a gateway to it nor does vaping increase smoking prevalence. It is thus a substitute, not a complement. As such of course it is to be greatly welcomed.
Electronic cigarettes lead to less smoking of cigarettes. Thus, far from our wondering about whether we ought to regulate them more the actual discussion should be about whether they are quite so wonderful that we ought to be subsidising them.
Miliband's attack on profit is an attack on patients
Either Ed Miliband is struggling to understand the basics or his ideology is spiralling out of control. The latest Labour pledge:
Labour would cap the amount of profit private firms can make from the NHS, Ed Miliband will say as he launches the party's election campaign.
He will pledge to halt the "drive to privatisation" he claims has taken place in the health service since 2010.
The future of the NHS is "on the ballot paper" and only Labour can guarantee the funding it needs, he will say.
Under his plans, private firms will have to reimburse the NHS if they exceed a 5% profit cap on contracts.
Companies make profit by keeping costs as low as possible while producing a product or service that people want (and ideally choose) to consume. Apologies for the simplicity, but apparently Ed needs it.
Pledging to fix levels of profit that a company can make ruins any motivation for the company to bring costs down. Given the NHS’s current financial situation, Miliband should not be so quick to toss aside the importance of efficiency gains.
Nor should he be ignorant of private firm’s impacts on patient outcomes.
Private firms are hardly private when working for the NHS; they are still under the jurisdiction of NHS bureaucracy and are often dependent on public funds for their operations. But where private firms and independent sector treatment centres do differ from the public sector is in their record on patient outcomes. Research from 2011 showed that ISTC surgery patients are healthier and experience less severe recovery conditions than patients undergoing the same surgeries with NHS providers.
Furthermore, Circle's management of Hitchingbrooke Hospital turned a failing trust into one of the highest ranked hospitals for patient happiness and cut waiting times drastically; their recent failings were not a result of bad healthcare but rather bad business.
One of the reasons Circle reneged on its government contract is because it’s a struggle to make efficiency gains under NHS regulations as they currently exist; if Labour gets its way, this will become nearly impossible.
Miliband's attack on privatization and profit is an ideological attack on buzzwords; unfortunately, his crackdown could have real affects on patient outcomes.