Healthcare provision.
Feb. 8th, 2013 11:40 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
davywavyLike I should I expect most people, I've been watching with undisguised dismay the outcome of the inquiry into Mid Staffs NHS trust. In case you've not been keeping apprised of this, the short version is that at least 1200 avoidable deaths can be attributed to medical negligence at the hospital. What's more, at least five other hospitals are now being investigated under similar circumstances with at least another 3,000 additional deaths under consideration. That is, for sake of comparison, about 1500 more people than died in the World trade Centre attacks in 2001. If Osama bin Laden had infiltrated the NHS instead he could hardly have done a better job. What's more he'd still be alive, as the inquiry concluded nobody was to blame and nobody will be prosecuted, punished or even named.
To put the figures into perspective, in one single Staffordshire hospital more people died from medical negligence than in the entire Dutch healthcare system in the same year. When you get results like that, it starts being worth suggesting that maybe those Nederlanders know something we don't.
The details of the deaths make for depressing reading: nurses refused to bring patients water, reducing people to drinking from the vases containing flowers brought by their relatives. There are stories of people starving to death, and incontinents lying uncleaned in their beds.
I dunno about you, but I missed the bit in the Olympic opening ceremony with the pensioners starving to death in their own poo. Maybe I was making a cup of tea during that bit or something.
The problem is that any suggestion that there may be problems with the NHS immediately gets you labelled some sort of psychopath who wants to privatise the healthcare system and leave poor people to die like what happens in wicked America. Nigel Lawson once observed that the NHS had assumed the status of a new national religion, and he had a point. Criticise the good works and expect to find people queuing up outside demanding to find out if you weigh as much as a duck.
Anyway, despite this I got me to considering healthcare systems and how they work. The first thing to do when considering these things is to look at which ones work. It's difficult to get this sort of information as there are few comparitive studies which rank national systems. The most famous one is an World Health Organisation study from 2000, and going digging there is also an ACHI study from 2007 and one by the Economist intelligence unit from a couple of years ago which I have seen but don't have a link for. You can believe me or not as it pleases you regarding what I say about it.
Looking at these, there are some countries who names keep coming up as providing the best healthcare systems by outcomes in the world - France, Austria, Switzerland, Australia, Canada, Singapore, a few others. The UK doesn't tend to come into the list of top systems at all. The WHO ranked the UK 18th, and we didn't make the top ten in the EIU study either. As such it's instructive to look at what other, better placed, systems do.
In a broad brush sense, there are four structural models which can be said to be used by most national healthcare systems. These are:
1) The Beveridge system, as used in the UK.
This model involves the Government owning and operating the entire health care system, with all costs paid from general taxation and with no costs at point of use.
2) The Bismark model, used by places like France, Germany Switzerland and Holland.
This model involves healthcare being paid for by compulsory private healthcare strictly regulated and controlled by the government, with the government making insurance provision for the poor and unemployed.
3) The Douglas model, as used in Canada, Australia and South Korea.
This model involves most medical care being privately provided but paid for by general taxation from the government.
4) No effective public healthcare, as used in the United States, Somalia, and Chad.
If you can pay for your healthcare, good for you! Sucks to be you if you can't.
From looking at the studies, a few consistent features appear, these being:
1) That of the countries which regularly appear in the top ten best healthcare systems in the world, every single one of them spends more per capita on healthcare than the UK. That's unequivocal. Ranging from the marginally more, like Australia which spends maybe 1-2% more per capita on healthcare, to the significantly more, such as France which spends about 10% more per capita (it's worth noting that France seems to be regarded as the best healthcare system in the world fairly consistently). All of them spend more than the UK does.
It's worth noting that expenditure cannot be the only factor in improved outcomes - the US spends about 90% more per capita than the UK and whilst the NHS ranks about 18th globally on outcomes, the US comes in at 37th. So what other factors are there?
2) Of the ten best healthcare systems in large developed nations at least comparable to the UK, only one (Italy) uses the Beveridge structural model. The others are all either Bismark or Douglas models. What's more, the very best - France, Austria, Switzerland, Japan, Holland all use the Bismark model. For all the people who fear privatisation of the NHS, it's worth considering that the very best healthcare systems in the world all appear to be private operations and it's not like France is noted for being run by die-hard capitalists.
Chatting to the she-David, she observed that the great fear of private healthcare is that it stops being free at point of use, which is a legitimate fear, so I'd point out that all of the above listed systems ensure that their healthcare is insurance based and guarantee insurance coverage to the unemployed and poor.
3) All the best systems rely upon private provision of insurance and medical care, but they also rely upon strict government regulation and price controls.
Speaking as a die-hard market capitalist I've got to admit that I recoil from price controls, but I can't deny that in this case the evidence completely contradicts my ideological position. The best healthcare systems are based on having heavily regulated and price-controlled structures.
So, the conclusions we can draw from that are that:
1) If the UK wants a better healthcare system, it's gonna have to pay for it.
2) The funding structure used does not produce the best possible outcomes. I'd suggest that the problem is one of the government being both provider and regulator - player and referee. For why that's a problem, imagine if Manchester United employed, paid for, and regulated all the referees in the Premier League, and then ask yourself why nobody has been named or will face any punishment or sanctions for the deaths of 1200 people in Mid Staffordshire, or why the banks regulating themselves didn't work out so well.
3) Whilst the separation of provision and regulation appears necessary, regulation - strict regulation - and legally enforced price controls on the cost of procedures seems to be an essential part of the package.
So there you go. Ideologically speaking, I object to spending more on public services and price controls, but I've got to admit that I'd put that aside in return for fewer people dying in their own poo. The question is whether you have any ideological attachment to or dislike of the system of healthcare provision in the UK, and whether you'd be prepared to put that aside for the same goal. I'm looking at you, 'No private healthcare' people.
But hey, I might be wrong. What do you think?
To put the figures into perspective, in one single Staffordshire hospital more people died from medical negligence than in the entire Dutch healthcare system in the same year. When you get results like that, it starts being worth suggesting that maybe those Nederlanders know something we don't.
The details of the deaths make for depressing reading: nurses refused to bring patients water, reducing people to drinking from the vases containing flowers brought by their relatives. There are stories of people starving to death, and incontinents lying uncleaned in their beds.
I dunno about you, but I missed the bit in the Olympic opening ceremony with the pensioners starving to death in their own poo. Maybe I was making a cup of tea during that bit or something.
The problem is that any suggestion that there may be problems with the NHS immediately gets you labelled some sort of psychopath who wants to privatise the healthcare system and leave poor people to die like what happens in wicked America. Nigel Lawson once observed that the NHS had assumed the status of a new national religion, and he had a point. Criticise the good works and expect to find people queuing up outside demanding to find out if you weigh as much as a duck.
Anyway, despite this I got me to considering healthcare systems and how they work. The first thing to do when considering these things is to look at which ones work. It's difficult to get this sort of information as there are few comparitive studies which rank national systems. The most famous one is an World Health Organisation study from 2000, and going digging there is also an ACHI study from 2007 and one by the Economist intelligence unit from a couple of years ago which I have seen but don't have a link for. You can believe me or not as it pleases you regarding what I say about it.
Looking at these, there are some countries who names keep coming up as providing the best healthcare systems by outcomes in the world - France, Austria, Switzerland, Australia, Canada, Singapore, a few others. The UK doesn't tend to come into the list of top systems at all. The WHO ranked the UK 18th, and we didn't make the top ten in the EIU study either. As such it's instructive to look at what other, better placed, systems do.
In a broad brush sense, there are four structural models which can be said to be used by most national healthcare systems. These are:
1) The Beveridge system, as used in the UK.
This model involves the Government owning and operating the entire health care system, with all costs paid from general taxation and with no costs at point of use.
2) The Bismark model, used by places like France, Germany Switzerland and Holland.
This model involves healthcare being paid for by compulsory private healthcare strictly regulated and controlled by the government, with the government making insurance provision for the poor and unemployed.
3) The Douglas model, as used in Canada, Australia and South Korea.
This model involves most medical care being privately provided but paid for by general taxation from the government.
4) No effective public healthcare, as used in the United States, Somalia, and Chad.
If you can pay for your healthcare, good for you! Sucks to be you if you can't.
From looking at the studies, a few consistent features appear, these being:
1) That of the countries which regularly appear in the top ten best healthcare systems in the world, every single one of them spends more per capita on healthcare than the UK. That's unequivocal. Ranging from the marginally more, like Australia which spends maybe 1-2% more per capita on healthcare, to the significantly more, such as France which spends about 10% more per capita (it's worth noting that France seems to be regarded as the best healthcare system in the world fairly consistently). All of them spend more than the UK does.
It's worth noting that expenditure cannot be the only factor in improved outcomes - the US spends about 90% more per capita than the UK and whilst the NHS ranks about 18th globally on outcomes, the US comes in at 37th. So what other factors are there?
2) Of the ten best healthcare systems in large developed nations at least comparable to the UK, only one (Italy) uses the Beveridge structural model. The others are all either Bismark or Douglas models. What's more, the very best - France, Austria, Switzerland, Japan, Holland all use the Bismark model. For all the people who fear privatisation of the NHS, it's worth considering that the very best healthcare systems in the world all appear to be private operations and it's not like France is noted for being run by die-hard capitalists.
Chatting to the she-David, she observed that the great fear of private healthcare is that it stops being free at point of use, which is a legitimate fear, so I'd point out that all of the above listed systems ensure that their healthcare is insurance based and guarantee insurance coverage to the unemployed and poor.
3) All the best systems rely upon private provision of insurance and medical care, but they also rely upon strict government regulation and price controls.
Speaking as a die-hard market capitalist I've got to admit that I recoil from price controls, but I can't deny that in this case the evidence completely contradicts my ideological position. The best healthcare systems are based on having heavily regulated and price-controlled structures.
So, the conclusions we can draw from that are that:
1) If the UK wants a better healthcare system, it's gonna have to pay for it.
2) The funding structure used does not produce the best possible outcomes. I'd suggest that the problem is one of the government being both provider and regulator - player and referee. For why that's a problem, imagine if Manchester United employed, paid for, and regulated all the referees in the Premier League, and then ask yourself why nobody has been named or will face any punishment or sanctions for the deaths of 1200 people in Mid Staffordshire, or why the banks regulating themselves didn't work out so well.
3) Whilst the separation of provision and regulation appears necessary, regulation - strict regulation - and legally enforced price controls on the cost of procedures seems to be an essential part of the package.
So there you go. Ideologically speaking, I object to spending more on public services and price controls, but I've got to admit that I'd put that aside in return for fewer people dying in their own poo. The question is whether you have any ideological attachment to or dislike of the system of healthcare provision in the UK, and whether you'd be prepared to put that aside for the same goal. I'm looking at you, 'No private healthcare' people.
But hey, I might be wrong. What do you think?
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no subject
Date: 2013-02-08 12:43 pm (UTC)no subject
Date: 2013-02-08 01:01 pm (UTC)Looks like the US may well end up with a better system than us after all.
no subject
Date: 2013-02-09 05:40 am (UTC)There's a lot of other stuff in there too, but I'm hopeful (for my family's sake, since I'm rarely sick) that it's mostly for the good, or can be adjusted quickly where not.
no subject
Date: 2013-02-12 01:37 am (UTC)That said I think you have done some interesting research, I look forward to checking this out myself.
no subject
Date: 2013-02-08 01:53 pm (UTC)Beveridge was a proper liberal, and didn't hold with any of this Government decides everything nonsense, but was quite keen on the Govt paying for everything.
no subject
Date: 2013-02-08 01:54 pm (UTC)(oh, and you can't really talk about "The Canadian System", as it's all provincially based and some are closer to the NHS and have worse outcomes, etc)
no subject
Date: 2013-02-08 01:59 pm (UTC)What's interesting is the way that the model which bears his name has become such an article of faith in this country, irrespective of other people doing it better. Shame, really.
no subject
Date: 2013-02-08 04:13 pm (UTC)French hospitals are certainly ace; two patients to a room, no Wards, so no mass infections of all the other patients. Nice General also has a la carte menus and jolly nice views of the Med.(& Dad's surgeon looked & talked like a Gallic James Robinson Justice).
D
(agree about the Liberal Beveridge being had over by the Socialists also).
no subject
Date: 2013-02-08 05:32 pm (UTC)H
no subject
Date: 2013-02-08 06:02 pm (UTC)no subject
Date: 2013-02-08 06:07 pm (UTC)Just imagine how good the NHS would be if we used the same system?
no subject
Date: 2013-02-09 08:25 pm (UTC)I reckon we could run our hospitals better too.
no subject
Date: 2013-02-08 07:46 pm (UTC)no subject
Date: 2013-02-08 07:55 pm (UTC)Tho' Prof. Amiel's (the frog JRJ) menu was more "ah oui, I can remove ze pain by removing ur kidneys, zis will mean you weel be on zee machine for zee rest uf ur life, you may 'owever 'ave some 'eroin".
which apparently is jolly nice.
You do get billed for the hotel expenses.
D
(Of course the French are not better than us, they perhaps balance their commitments better - like when they invade a Country, it just happens to be the third largest GOLD producing state on the African continent)
no subject
Date: 2013-02-08 08:10 pm (UTC)Not seen the final report but I believe it was mostly due to lack of cover and poor staffing in A&E. I'm not sure who you feel would be to blame for that. It's usually systems, rather than individuals, which are at fault.
The pressure put on Trusts by the current government (to cut costs) often leads to the cutting of corners, especially when it comes to staffing. It shouldn't, but it does. The bigger the economic crunch, the more managers concentrate on economics rather than patient safety. I saw it happen. One of the reasons I retired and left the country.
OK, I'll put it bluntly... When I started out in Clinical Governance, our Medical Director told me that an important part of my work was to ensure that clinical staff did not 'cover up' their own or colleagues mistakes. To make sure that these were looked at openly, honestly and, rather than assigning blame, everyone agreed on systems to prevent recurrence of errors. By the end, I was being encouraged to help 'cover up' any and all kinds of failings.
This is a cultural thing and I don't think it's driven by the economic model on which the service is run...
no subject
Date: 2013-02-09 08:27 pm (UTC)People create the systems which create the problems.
People.
no subject
Date: 2013-02-09 11:10 pm (UTC)The individual people behind the systems that caused the problems at Mid Staffs went a long, long time ago. And often the systems themselves are good but the people in charge ignore the systems.... Protect the whistleblowers. Make the Board responsible for failures. Detect failures early. Make the Board responsible. And don't sacrifice patient safety for the Board's ambition to become a Foundation Trust. Oh, and quit making so many changes to the system that the entire staff become dizzy watching the goalposts rotate.
The whole concept of Foundation Trusts is faulty anyway. It's based on financial viability rather than any form of quality of patient care.
no subject
Date: 2013-02-12 09:11 am (UTC)Healthcare must be affordable, or we are simply taxing future electorates without their by your leave.
no subject
Date: 2013-02-09 08:32 am (UTC)no subject
Date: 2013-02-09 10:27 am (UTC)My post wasn't a suggestion of where we're going, it was a reaction to the widespread attitude the system is great and any suggestion of change is evil and driven solely by greed and malevolence. When I suggested the Bismarck system to someone the other day they told me the only reason I could possibly support it was because obviously I'm rich and I want poor people to pay for it and suffer.
This was someone who doesn't even know me, but that degree of intellectual shackling annoys me, and so really I'm reacting to that attitude.
no subject
Date: 2013-02-09 11:11 am (UTC)What he was saying was that the introduction over teh Beveridge system was a mistake and that other systems in Europe were far better, but it got reported as evil tory wants poor people to be denied healthcare.
When that's the level of debate, it's unsurprising that no meaningful improvements will happen forseeably.