What people don’t know about the NHS

… is that it is incredibly cheap. I was speaking recently with a British colleague, who asked how I liked being back in the UK after a year on sabbatical. I mentioned that there are things I really appreciate about living in California, but one of the things I like best about the UK is the NHS. Even without any significant health problems in the family, the incomparable irrationality of the US healthcare system (though even calling it a “system” seems overly generous) is palpably unnerving, at the very least since you’re occasionally confronted with the question of whether this or that problem is significant enough to go to the hospital for, and then you have to consider whether it’s worth entering into a multiyear negotiation over fictional bills for thousands of dollars.

Anyway, I remarked that I wish the UK would just raise its health spending to the European average, that it would be far and away the best in the world, as opposed to limping along as it does now, being the best for equality, but clearly overstretched, and not quite matching the top national healthcare systems. I thought this was simply a platitude, but he seemed genuinely surprised by the claim. On further questioning, he said that he would have thought the NHS was relatively expensive compared with healthcare in western Europe generally.

In fact, UK health expenditures are low, not just compared with the wealthy countries of western and northern Europe, but with respect to the EU generally — including the relatively poor countries of eastern Europe. They would have to spend an additional 6 billion pounds — about a 5% increase — to match the EU average. In 2011 the UK was below average healthcare spending for the OECD, and was still only average after removing the exceptionally high spending USA. (The US, despite the notoriously expensive private healthcare system of which its right-thinking populace is so proud, has considerably more public healthcare expenditure per capita than the UK, on top of the private system. And life expectancy is still several years shorter.)

I wonder if the public would demand more spending on the NHS, rather than accepting the government line about necessary efficiencies and the magic of privatisation, if they knew how efficient the NHS already is, and how little they are spending on healthcare compared with their European neighbours, not to mention the profligate Americans and Canadians.

 

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“Not infinite”

From The Guardian:

British nurses are planning to debate whether GPs should start charging patients for appointments.

The Royal College of Nursing’s (RCN) annual conference in Liverpool will discuss whether the union backs the idea of charging people a fee to see their family doctors.

Traditionally the RCN has stood behind the belief that the NHS should be free at the point of delivery. But nurses have put forward the motion, saying that NHS finances are “not infinite”.

“Not infinite” sounds like a sensible observation. Neither are the funds available to the police infinite, which is why we charge people a fee to report a burglary, with extra hourly charges for the investigation. And schools. And that’s why when the smoke alarm klaxons you out of bed, the first thing you need to do is grab enough cash to pay the firefighters who show up. Because their finances are not infinite.

Obviously, the RCN is just trying to make the point that healthcare workers are having their salaries squeezed up against the free-at-the-point-of-delivery. But this argument is made often, and it’s ridiculous. If you want to advocate patient fees, as opposed to all the other ways that the nation could increase funding of the NHS, it can only be because you think that the service that is now free is being overused, and you want to encourage ill people to do something else, besides visiting their GPs. In any case, the cost of administering the £10 fee would probably be more than the fee would bring in.

Here’s what charging for fire and rescue services looks like.

4p per household

According to today’s Times, the NHS has decided to link all the country’s medical data and then sell them off to vaguely specified third parties, including pharmaceutical companies, is being delayed for six months. Not because anything is wrong with the plan, mind you, but because of a failure to “build public confidence”. Most striking in this context was the report on confidence-building measures taken so far, consisting of £1 million spent to send a leaflet “to all households in the UK”. Since there are 26 million households in the UK, that would amount to less than 4p per household to print and deliver the leaflet. Thus I am not surprised that a survey found that most people said they had not seen the information. (I certainly didn’t.)

What is income?

A strange paradox has opened up in the magnificently cruel US healthcare system. The Affordable Care Act was supposed to subsidise people with modest incomes (above the federal poverty line) to purchase private health insurance. Those below the poverty line — in fact, 138% of the poverty line — were supposed to be moved onto free health insurance with Medicaid. But Medicaid is administered by the states, and quite unexpectedly many states with Republican governors have refused the Medicaid expansion, out of pure political spite, making a hash of this system: Now individuals in those states whose income is below the federal poverty line still don’t get Medicaid (unless they qualify for Medicaid under the old rules, which are much more restrictive), but they can’t get the health care subsidies because they don’t earn enough.

Ignoring the huge human suffering that is being intentionally inflicted, I find this situation fascinating, because it’s something that shouldn’t exist in the world imagined by quantitative finance. How can you have too little income to receive public assistance? After all, this isn’t about net income. They don’t have to do anything with the money. It just needs to be recorded as income. Someone can give me a cheque for $1000, in payment for “personal services”, and I can give it back to pay his bill for “financial services”. There. I’ve just gotten another $1000 in income. You’d have to put some extra organisational effort in to make sure that you don’t incur any tax obligations.

But the point is, in the world of high finance, there isn’t a category of “income”. There’s just money. And they don’t leave money on the table just because there’s not enough in one particular accounting category. But the poor don’t just lack money; they don’t have people to structure their transactions in beneficial ways.

Somebody to blame

Jonathan Cohn — one of the best-informed voices on healthcare in American journalism — has a new article in The New Republic about the reductions in provider networks that insurers are imposing, due to constraints in the Affordable Care Act. Except, as he points out,

Even before Obamacare, employers and insurers were already moving in the direction of limiting networks and penalizing costly hospitals like Cedars. Kominski notes that his employer, the University of California system, aggressively restricted its provider network two years ago. The change affected thousands of employees—and was one of many such decisions employers made around the country. But it didn’t generate a national controversy. The city of Los Angeles just took Cedars off the network for one large plan in order to keep premiums for city employees low. And while it’s possible Obamacare accelerated a trend toward limited networks for direct consumers, it’s also possible that insurers would have made that switch anyway—and that they’re introducing these changes now, in one big wave, because Obamacare gives them a convenient excuse.

This is a genuine bias, particularly in American democracy, toward leaving problems unaddressed, because as soon as you start trying to deal with the problem, voters will hold you responsible for any remaining defects.

I remarked on this shortly after I came to the UK, that it seemed to me that the British underrate the NHS, because any health problem that occurs anywhere in the country, whether it’s unhygienic conditions in a hospital, or GP surgeries not being open at sufficiently convenient hours, is blamed on “the NHS”. That is a strength, but it’s also a temptation for politicians to offload the responsibility onto “the market”. The political culture hasn’t  gone that far in this country, but that’s why there’s a major US political party whose political philosophy is, conveniently, essentially “There’s nothing we can do”.

(Physicist David Deutsch has written a book-length quantum-utopian manifesto whose main lesson seems to be that the fundamental criterion for the progress potential of a political system is the extent to which it makes it clear, when things go wrong, who is to blame.)

This is a well-known problem in torts law — a public danger that has never been touched is nobody’s responsibility. If you try to make it safer, but cannot eliminate the danger entirely, suddenly it has become your responsibility if someone is injured. I first encountered this many years ago, when The Economist published a somewhat surprising plea for a planetwide defence against rogue asteroids. Like (I think) most people, on the rare occasions when I do think about asteroid strikes, I generally do not consider the legal implications. The article pointed out, though, that while an unmolested asteroid that obliterates London is an Act of God, as soon as some government tries to divert it, it becomes a legal liability.

This is an issue that I’ve never seen raised in the famous trolley problems that moral philosophers love to natter about. If you’re the trolley driver then you have a real moral dilemma. If you’re a bystander who happens to see a switch that could be thrown, you’d best call your lawyer first. She’ll tell you, under no circumstances should you touch anything. If 5 people die, that’s not your fault. If you save the 5 but kill one — if you even hurt the one’s finger — his family will sue you.

Health selection bias: A choose your own preposition contest

Back when I was in ninth grade, we were given a worksheet where we were supposed to fill in the appropriate conjunction in sentences where it had been left out. One sentence was “The baseball game was tied 0 to 0, ——– the game was exciting.” Not having any interest in spectator sports, I guessed “but”, assuming that no score probably meant that nothing interesting had happened. This was marked wrong, because those who know the game know that no score means that lots of exciting things needed to happen to prevent scoring. Or something.

With that in mind, fill in the appropriate preposition in this sentence:

Death rates in children’s intensive care units are at an all-time low ————— increasing admissions, a report has shown.

If you chose despite you would agree with the BBC. But a good argument could be made that because of or following a period of. That is, if you think about it, it’s at least as plausible — I would say, more plausible — to expect increasing admissions to lead to lower death rates. The BBC is implicitly assuming that the ICU children are just as sick as ever, and more of them are being pushed into an overburdened system, so it seems like a miracle if the outcomes improve. Presumably someone has done something very right.

But in the absence of any reason to think that children are getting sicker, the change in numbers of admissions must mean a different selection criterion for admission to the ICU. The most likely change would be increasing willingness to admit less critically ill children to the ICU, which has the almost inevitable consequence of raising survival rates (even if the effect on the sickest children in the ICU is marginally negative).

When looking at anything other than whole-population death rates, you always have the problem of selection bias. This is a general complication that needs to be addressed when comparing medical statistics between different systems. For instance, an increase of end-of-life hospice care, it has been pointed out, has the effect of making hospital death rates look better. (Even for whole-population death rates you can have problems caused by migration, if people tend to move elsewhere when they are terminally ill. This has traditionally been a problem with Hispanic mortality rates in the US, for instance.)

In America everyone lives like royalty

Twice as well, actually, at least when giving birth. According to this article, the hyperluxury private hospital wing where the DoC gave birth to our new royal master, may have cost as much as £10,000, or $15,000. The average American woman gets twice as good a birth experience, worth $30,000 according to the bill, which must be a pretty goddamned awesome hospital suite. And then, because this is such an amazingly great country, she gets the price discounted so that only $18,000 has to be paid, on average. What a deal! It’s no wonder that Americans refuse to be reduced to the kinds of primitive, parsimonious conditions that even the future queen is subjected to in England.

Kate’s lucky she got out of there before they set the leeches on her.

Not the Lake Wobegon Hospital

From the front page of the West County Times:

Death rates at Bay Area hospitals vary widely, new report reveals

While some hospitals excelled at keeping patients alive, more than half of institutions around the Bay Area had worse-than-average death rates for at least one medical procedure or patient condition in 2010 and 2011, a new state report reveals.

Hospital advertisements

How to choose your emergency room
How to choose your emergency room

So, you’ve just been hit by a bus, and you’re lying bleeding in the gutter. Naturally, what you’re thinking about is, what would be the most convenient place to get a couple of pints of blood, and maybe have a ruptured spleen removed. Sure, the ambulance drivers might know the closest one, but I’m going to insist on being taken to the best, and what better recommendation could there be, when your life is at stake, than a placard on the side of a bus. (Anyway, the EMTs probably have a remunerative arrangement with some other hospital that will pad their incomes, regardless of whether you survive the trip.) And while I’m paying thousands of dollars a day just for being in the bed, I can think about how my money is being put to good use subsidising mass transit.

Seriously, isn’t this beyond bad taste? I’m used to a medical system that advertises to, you know, inform the public about medical matters. Not to drum up business for the ER.

Continue reading “Hospital advertisements”

Why don’t we throw people out of emergency rooms?

In discussions of market forces in health care, someone always points out that we don’t allow people to just die in the streets. Anyone who shows up in an emergency room must be treated (in the US this has been true since the Emergency Medical Treatment and Active Labor Act of 1986, I believe). Among the many other reasons why medical care does not respond to free market incentives, then, is the fact that the providers are not able to turn away customers who are unwilling or unable to pay.

But here’s what I’m wondering: This is always presented as an issue of basic humanity, or altruism. We can’t let the poor die of treatable injuries or illnesses because that seems too brutal. But is that the whole story, or even most of the story? My suspicion — and I’d have to go back to the debates on EMTALA to develop any clarity on this — is that the real reason we have a no-exceptions requirement that hospitals provide urgent care to the poor is that there’s a significant danger that the non-poor might be confused with the poor, particularly in times of medical emergency. Someone who has been hit by a car or has suffered a stroke and is disoriented is likely incapable of quickly identifying herself as an upstanding creditworthy citizen with health insurance. So the hospital is required to try to keep them alive long enough to allow them (or their relatives) to demonstrate that they are worth saving.

Which leads to a question: Supposing biometric databases become universal, and the hospitals are able to immediately ID anyone who comes through the door. Will we then relax the rules, and allow them to turn away the indigent, perhaps sending them off to some primitive alternative hospital for the poor?