More interestingly, can the US political system ever enable an evidence-based debate around it?
From the other side of the pond, it feels like debates end up being emotional rather than scientific.
(I’m a Brit and love the NHS with a passion but would not claim that it’s without flaw. Neither would I claim that we necessarily have more reasoned debates about issues here...)
I personally get the sense that it's quite easy for the NHS to look good when you compare it to America. When you compare to other western countries the results don't always seem so great and there are definately situations where as an outsider I think things are clearly pretty bad (like NHS IT system procurement).
I don't hold out much hope for reasoned debate to help things though - who can form a reasonable opinion about ~6% of GDP directly managed by the Department for Health? I certainly can't.
> More interestingly, can the US political system ever enable an evidence-based debate around it?
I honestly think the reason the US is slipping so much is because their political system never seems to have evidence-based debates around anything.
Worse, they have absolutely no interest what-so-ever in comparing their country and how it's actually functioning to other Developed Countries for the purposes of improvement. In fact, I genuinely don't think they care to improve anything, at all.
Funny how you you complain about evidence-based debates proceed to mischaracterize the U.S. based on your impressions.
Americans are not all of the same opinion. They do not all use the same arguments which have the same faults. In this they are like all people everywhere. Also, their political parties do not all employ the same arguments with the same faults. Arguing that everyone has the same faults is both-siderism. It is a counsel of despair. In fact, each party will use facts and international comparisons when doing so supports their preferred policy.
The Democrats have been quite fond of international comparisons in support of their efforts to improve healthcare. I struggle to find a topic on which Republicans prefer facts to mythology but they certainly grab onto a fact when it supports what they want to do. They can recognize and employ a good argument if it presents itself.
If you hear someone making a stupid argument, regarding health care or whatever, nine times out of ten it is not because they desire a worthy thing and are too stupid to get it but because they desire an unworthy thing and are crafty enough to recognize a plausible cover story. You can recognize this happening when someone drives for a constant goal but changes arguments as suits the moment. Republican arguments for lowering taxes fit this pattern as do arguments for not doing anything about climate change.
It isn't the stupidity of politicians, or even their voters, that explain American policy. It's disharmony within the nation mixed with political institutions that expect people to work toward a common purpose.
The US's problem is that things are massively inequal with income and wealth. And political power tends to follow the income and wealth. So for a significant (and over-represented politically) fraction of the US, we have better health coverage than what I can see about the NHS (I read Terry Pratchett's descriptions with despair and disbelief). Similarly, the problems the writer describes in the US system - those haven't happened with my health plans, despite costing them very large chunks of money at times. General doctor scheduling seems good in the article, but that's a pretty minor aspect of the complete care picture.
A more fair system could be quite a bit worse for people currently in positions of influence, and that's what's going to make it hard. That's how we got Obamacare in the first place - incremental improvement for some, trying not to screw it up for the most consistent voters - and even it's coming close to voter revolt-driven rollback.
If you want meaningful change I'm convinced it's going to have to come from the Sanders-style wing. The mainstream Democratic and Republican parties are too aware of how good they've got it, and at whose expense that comes, currently.
That's kind of where it loses me. We already have a system very similar to single-payer for our veterans and it is notoriously inefficient, bloated, and unpopular. What many are clamoring for in the US is already being tried in the US and failing exactly the way opponents claim it will.
Evidence that it works well in other countries is worth considering, but it in no way proves such a system would work well here. It'd probably work well in states that are similarly culturally homogenous (like Vermont or New Hampshire), but the discussion always seems to be at the federal level.
I think what we need is more freedom for experimentation. Pick maybe a city or county and make it eligible to sidestep all of the federal and state regulations and build/create their own. Some will undoubtedly shoot for a libertarian approach while others might imitate the NHS. See how the costs and outcomes compare. Gather more evidence in a more relevant way.
No, "the" NHS does not cover the UK. For one thing there are four seperate NHSs for each nation (Scotland, NI, Wales, and England).
It's incorrect to say that the English NHS is a monolithic thing. It isn't.
The NHS is regional. It's split into regions by "clinical commissioning groups". There are 32 CCGs in London. These are independent from each other, and from the rest of the UK.
> Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act (2012), replacing Primary Care Trusts on 1 April 2013. They are clinically-led statutory NHS bodies responsible for planning and commissioning health care services in their local area. There are currently 207 CCGs in England.
I’m aware. Per the very first line of its wikipedia page:
>
The National Health Service (NHS) is the name used for each of the public health services in the United Kingdom – the National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland – as well as a term to describe them collectively.
This is just getting boring as you argue pointlessly over semantics.
UK: Covered collectively by the NHS, which has its own branches.
England: A part of the UK that has 55 million people and its own branch of the NHS. It is racially 85% white and 7% Asian.
London: A big city in England with a population around 9 million.
The number of people in London is much smaller than the number of people in all of England, and all of the UK. Yet, England (as shown above) is quite racially homogenous (typically a good indicator for being culturally homogenous). That a single city exists in a sea that is culturally homogenous (that you feel like is "doing okay") does not mean that if all of England or the UK's population were more diverse, there would be no problems.
Nobody is arguing that the system would collapse the moment it encounters a single diverse area, so your point is irrelevant.
>So how does the US improve its healthcare system?
On both sides of the pond, we need to break the false dichotomy of UK vs US. Our systems are almost diametrically opposed, but they get vastly disproportionate mindshare and airtime. In any debate about NHS reforms, people will inevitably hold up the US as a cautionary tale and vice-versa, but hardly anyone raises Germany or Australia as a workable middle ground. This false dichotomy also dominates the debate over gun control.
Healthcare Triage did an excellent series of videos summarising the strengths and weaknesses of various international healthcare systems. I can highly recommend it to anyone on either side of the pond who is thinking about how their healthcare system could be reformed.
one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls (please no anecdotes). The US essentially funds medical innovation for the entire rest of the world. If the US goes socialized you will see almost a complete halt to medical innovation over time.
Here are 3 (not evidence based) reasons why medical care costs more in the US:
1) more administration (too many rules/regulations)
2) higher costs for the base goods (people get paid more, pharma, medical devices, etc) due to lack of price controls
3) people get more care, potentially even when it isnt going to help
Do you not consider the billions of dollars which the U.S. government puts into basic medical research socialized innovation? It was only last year that the U.S. government spending dropped below 50% of the total following years of federal cuts:
Your starting assumption that price controls are incompatible with innovation is a political belief, not a fact. There's no reason why that precludes funding bounties for improvements / cost reductions (e.g. why Japan's MRIs are so much cheaper than the U.S.), using different funding models for R&D than manufacturing, etc. Individual systems could choose not to fund research but that's a choice rather than a universal truth.
> one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls
This is a strong claim presented with no evidence. It is clear that the US is, by far, the global leader in this area. But to say there is no other innovation at all is going a bit far.
Indeed, it is easy to see that communist China is the world's second in this area, whether you go by papers published, clinical trials, or whatnot.
Even the libertarian Cato Institute doesn't go so far as to say that no one but the US innovates.
I strongly disagree with your first statement. The US definitely has a high rate of innovation in medical procedures, but by no means is it Atlas, carrying the world on its shoulders. Canada which is just a single socialized healthcare system has systematically produced fantastic innovations in drugs and therapy over the last 100 years. We have dozens of research hospitals who innovate regularly. I don't have the time to spend researching every single innovation, but a small sample is included below.
There is a lot of donor money and government grant money in medical research around the world.
This is even untrue in the US. My SO works at a system of donation/endowment funded US charity hospitals where they have a history of inventing new more effective methods of treatment. Some doctors will take less money to work in an environment focused on positive patient outcomes instead of performance metrics tied to profit.
> Canada which is just a single socialized healthcare system
I wouldn't say single. Each province runs its own system. Each province can't decide how many sub health regions it wants (SK just merged theirs, ON collapsed their community care regions into their health integration regions). GP practices are basically private for-profit companies. Hospitals operate like independent charities with wildly different processes, costs and outcomes.
That's per capital spending on pharmaceuticals. Two things to note from that:
1) The highest by far is in the US, that's absolutely true.
2) Substantial amounts are still spent in other wealthy countries.
American healthcare payers - insurance companies and their agents - also impose controls on what they will pay for drugs and for which conditions. They don't seem to be as effective in enforcing them since they haven't got the kind of monopsoninistic power as either single payer systems like Canada or constrained multi-payer insurance markets like the Netherlands.
That Americans overpaying for drugs helps to subsidise R&D that everyone benefits from seems like it make intuitive sense. I'd question whether the evidence supports a complete halt to innovation if the US adopted pharmaceutical price controls unless the price control they adopted was to restrict prices to cost of production - something that no government single payer health service does.
In the NHS, these decisions are made by the NICE which determines how many quality adjusted life years are gained from the use of a drug and then checks to see if they clear a threshold CBA value. It's worth noting that £100k+ cancer drugs that actually work are still frequently approved under this system. Recently, NICE approved Soliris at £330k/yr for treating aHUS. That's $450k/yr, treatment required for life. I suspect that many American insurance companies wouldn't fund that.
Moreover there are goods and services such as fighter jets where there is a single US government buyer and innovation still happens. Conceptually it doesn't appear that this needs to be a barrier to innovation spending.
> That's $450k/yr, treatment required for life. I suspect that many American insurance companies wouldn't fund that.
The question is, how did NICE arrive at the decision to fund it when it doesn't meet their CBA threshold?
Isn't the whole point of a CBA threshold to say: "We should defund really expensive treatments so we can pay for more cheaper treatments and improve aggregate outcomes per GBP"?
This is true, over the last decade they've made the process more complicated. Partially imo to obfuscate the fact that they are now required to fund things for political reasons that don't plausibly pass their CBA threshold.
The argument that "if the US goes socialized, you will see almost a complete halt to medical innovation over time," and therefore that private funding of research is preferred, is a bad one. It rests on the premise that the profit motive for pharma companies and the imperative to improve health care outcomes for the greatest number of people are aligned, which they are not.
Public funding of drug research is a better driver for the discovery of improved treatments than private pharma investment - under the current model, drug companies aren't incentivized to develop novel treatments (see Nexium), or to develop treatments that would improve outcomes for the greatest number of people (see Pfizer abandoning research into Alzheimer's and Parkinson's treatments).
Since the Bayh-Dole Act passed in 1980, pharma companies have profited hugely by purchasing patents held by publicly-funded researchers, and commercializing them with virtually no controls on the resulting drug prices. Even private development of drugs still relies on publicly-funded and publicly-available research. The assertion that the institution of stricter price controls would eliminate innovation seems to be untrue - I don't think that scientists are incentivized to do research solely by the promise of lucrative patents. Stricter price controls would likely mean that the government would have to participate more directly in the clinical trial phase, which would be a good thing, as there are minimal checks against manipulation of clinical trials.
As a Brit using the NHS I can only add that I trust, and expect, every government to make the NHS worse whilst they talk of how marvellous it is.
I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury. I'd like to see legislation to heavily penalise drug companies seeking 20,000% price increases and the like.
Both sides fiddle with it, trivially and constantly. They will even fiddle when they have won a second term or reorganised ministers - because what they themselves thought 4 years ago must have been stupid and should be immediately changed, or something.
Much of the waste is from badly thought through political fiddling, remnants of previous fiddling, and public-private partnerships stupidly chosen during a time of lowest borrowing in British history.
Imagine how well an NHS organised as it was in 1948 would function in today's world. Although there is no doubt that it could be better managed setting it in aspic will kill it surer than a nail in the back of the head. The NHS will face massive challenges in the next 30 years from demographic pressure on demand and staff, technology change and citizen behaviour and expectation. Radical "fiddling" is going to be needed to keep it alive. This is 100's bn pounds - it's the core of UK politics and it should be - we are a democracy.
Who's suggesting it be set in aspic? That would be idiotic.
I'd trust an independent body, with cross-party oversight, rather more to make changes, and choices, most suited to the service and populace than most politicians. There might even be some opportunity to think long term rather than just having the next election in mind.
Any time that independent body fucked up or did a bad job, they'd simply claim they didn't get enough money from the government to do the job. Whether that was the truth or not. The "cross party" oversight would then take positions according to their party priorities, if in power blame the independent body for doing a bad job, if not in power blame the government for not giving them enough money.
Unless of course that independent body had separate tax raising powers for just the NHS?
In which case I can't see how they can't be elected as they have the power of taxation.
You can't get politics out of the NHS, it spends too much money raised by taxation.
I think it's axiomatic that every human endeavour is flawed.
It's pretty clear NICE works rather well and is now accepted by both political sides and the profession. Let's start there.
In terms of funding the NHS spends a smaller proportion of GDP than most developed nations. If we can nail defence and overseas development as x% of GDP, why not also for the NHS? Perhaps consider increasing to the average EU spend?
For one example of politicians chosing to ignore NICE look at the Cancer Drugs Fund.
The CDF makes available cutting edge new technology to people dying from cancer. These meds are very expensive. They often fail the NICE appraisals. The CDF pays for the meds.
We know that these meds often don't work at all, and sometimes cause harm, and are fantastically expensive.
I suppose the TV license system is very close to an independent body with "tax" raising powers (including the ability to jail people for non-payment). No longer quite so popular.
Aneurin Bevan believed that the cost of the NHS would reduce over time as the population got healthier.
The current NHS budget is £125Bn/year. Many people think it is underfunded, but noone is willing to name a figure for fully funded. Is it £150Bn, 200, 500? No progress will be made, by either party, until someone stands up and does this.
The system interfaces with every area of life, and with capitalism. Western Capitalism says the amount spent on healthcare should grow until all available money becomes profit for the Capitalists.
Meanwhile there's always some new area of life that impacts health - spend on sport, then on encouraging sport by paying for teachers, then on improving colleges where the teachers train, ... before you know it the NHS is funding a deep mine in Siberia because it mines the metals that make the earphones used in mp3 players by students training to be teachers, to encourage them to teach more sport to children so that when those children grow up they'll need less heart bypass surgery.
Meanwhile the Siberian mine leads to contaminants in the ocean that cause excess cost to all health regimes around the world ...
Health encompasses all parts of life, it needs selfless, holistic, planet-wide approach. You could spend £150 Trillion in health and still find more areas of spending to address.
> Meanwhile there's always some new area of life that impacts health - spend on sport, then on encouraging sport by paying for teachers, then on improving colleges where the teachers train, ... before you know it the NHS is funding a deep mine in Siberia
In other words, central planning doesn't work[1]. NHS was a "special case" that tends towards the general case, as is the tendency of all untouchable mandates.
The NHS (in England) hasn't been centrally planned for some time now.
That's what CCGs are for.
Also, a bunch of stuff (drug and alcohol services, weight loss, smoking cessation, suicide prevention, sexual health, etc etc) isn't even NHS any more, and is part of Public Health which is part of local authorities.
I'd go with "you can't centrally plan health within a system of Western Capitalism".
Look at the trains in the UK - government was running one major line at a large profit, but they prop up the system as a whole with tax monies, why? It certainly seems like trains (maybe transport) could be centrally planned if you define the limits of the sector carefully.
I don't see how public health can dramatically improve until we start to have radically different conversations about diet across all levels of society. If you follow the money spent in health care it leads directly to obesity and related lifestyle diseases.
The NHS spends £11Bn/year on type-2 diabetes, 80% of which according to Diabetes UK is caused by or could be addressed by lifestyle choices. Not just diabetes of course, I don't mean to pick on one subset, I mean the NHS has to spend an awful lot of money on things that really shouldn't be things in the first place.
People who really love "our NHS" eat right, exercise, and get enough sleep... The rest are just trying to score cheap political points.
Of these three, diet has by far the most impact on t2 diabetes. The focus on casual exercise ("10k steps per day") is relatively useless compared to a low-inflammation diet. But there seem to be a lot of perverse incentives and special interests who keep the conversation muddled or focused elsewhere.
We're not just talking about diabetes though, we're talking about preventable illness, and good exercise does help prevent heart disease and stroke and some other stuff linked to high blood pressure.
There's actually quite a few illness that can and often does have origins as 'secondary gain'[0].
It's quite insane that there isn't more done to address root cause. With diabetes-2 I think NHS fails at the point when they don't address people who are at risk. Help people to change their habits by attaching pain and pleasure to their choices and making it personal. This would save NHS lot of money and most importantly help the individual.
>The current NHS budget is £125Bn/year. Many people think it is underfunded, but noone is willing to name a figure for fully funded. Is it £150Bn, 200, 500?
It's a moving target, because need continues to grow as the population ages. We're in largely uncharted territory, so it's difficult to make long-term cost forecasts. You could always find ways of spending money to improve a healthcare system, so it just doesn't make sense to pick a number ex nihilo. We do have other, better means of determining what a reasonable level of healthcare spending might be on a year-to-year basis.
The National Institute for Clinical Excellence have determined a cost-effectiveness threshold of £30,000 per additional Quality-Adjusted Life Year. This threshold is a little bit arbitrary, but it's a reasonable rule-of-thumb as to what treatments provide a net benefit to society. Based on this figure, we can start to calculate a reasonable overall NHS budget from the bottom-up - the NHS needs enough money to provide all the healthcare interventions that NICE has determined to be cost-effective.
In addition to cost-effectiveness, we also have benchmarks in terms of quality of care. It might not be clinically significant if someone has to wait three weeks for a GP appointment about their psoriasis or six months for knee surgery, but it matters to the patient. We know that wait times have been going up and patient satisfaction is going down, which is a reasonable indication that the system is underfunded. It wouldn't be reasonable to aim for instant care and 100% patient satisfaction, but we should at the least hope for stability rather than regression.
The question of affordability is perfectly fair, but the UK doesn't spend an exceptional amount on healthcare by the standards of equally-developed nations. As a proportion of GDP, our spending is roughly average for OECD nations. In absolute terms, we spend about 25% less per patient than Germany or Ireland. We can clearly afford to spend a fair bit more before we start feeling the pinch.
I think that it's perfectly reasonable to spend a few tenths of a percent of our GDP to try and take the pressure off the system and get the quality metrics back to where they were in 2015. If costs start spiralling out of control, then we need to have some difficult conversations about what kind of care we're going to ration, but I think that conversation is premature if we haven't first tried a modest increase in spending.
Incidentally, one of the provisions in the ACA over in the US specifically prohibits the use of QALY as a cost-effectiveness threshold. It's just one of many reasons it's so absurd for Americans to point to the NHS as a demonstration of how much more cost-effective healthcare would be if it were nationalised; something like the NHS with its cost-saving measures just wouldn't be politically viable there.
Yes, but that doesn't mean we should plan the NHS according to the political whims of a party who only look to the next 4 years, and a person who is usually inexperienced in the field and likely to be replaced in the next reshuffle in 12 months time.
What's the Tory's stated public position for their 30 year goals and what immediate and mid-term changes have they made in order to achieve that?
Fiddling is _not_ needed.
Planned, careful, forward looking, evidence based change (that's not focused on shifting funds towards private profit) is certainly required.)
It's just like education, every new minister (usually entirely new to the field) dicks around changing stuff because they want to justify their pay and because not changing it might seem like someone else had a good idea and that apparently is complete anathema to our current politicians.
Sure, but pretty much everyone (even current Conservative party) agrees the Lansley reforms (The Health and Social Care Act) were a fucking mess and are currently causing problems.
I'd like to see a long-term outcomes-based comparison between NHS England and the Scottish NHS, frankly.
The Scottish NHS is a fully devolved issue and has been diverging from the English system for most of a decade now, with a greater emphasis on preventative healthcare and screening programs (not to mention free prescriptions for all).
In another couple of years we may even have some hard statistical data on what practices work best!
> I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury.
They did that. The governmental bit (in England) is the Department for Health and Social Care.
NHS England is the qango that runs the NHS in England. They provide money to CCGs to commission most services. NHS England directly commissions some (so called "tier 4" services) - eg inpatient mental health services for children; medium and high secure mental health services; etc.
I genuinely have no idea what happens in Wales, Scotland, or NI. Health is devolved and they run their systems independently.
"In the UK, I showed up at 9am and was seen instantly"
I don't think that's ever happened to me. Most likely this person was the first patient of the day, so appointment times haven't slipped yet. 30 minutes in the minimum I've had to wait in general. I've also had to wait weeks to see a GP (in the countryside).
I find anecdotal articles like this pretty unhelpful in general. We all have our own anecdotes, it's more interesting to look at the data. Comparisons between UK and US healthcare are also somewhat meaningless. They've very different systems, and their are many other countries with private and public healthcare systems that you could compare.
I'm not really familiar with NHS processes, so when it took you weeks to be seen, did someone just take your info when you walked in and say they'd get back to you when they could, or was your condition evaluated first (diagnostics run, etc) and an appointment scheduled for you for a particular date a few weeks in the future?
The former. Access to the majority of non-emergency care is gatewayed via your GP (primary care physician/family doctor) - if you need to see a specialist, you can only do so by asking your GP for a referral. You'll then wait weeks or months to see a specialist, although you may be sent for tests before then. We have a chronic shortage of GPs and the system as a whole is severely underfunded, meaning that many people have to wait weeks just to be seen by a doctor. The average wait to see a GP is 13 days, but can be much worse in some areas, especially in winter.
Some GP practices have reduced the strain by offering appointments with Nurse Practitioners, who can treat common and uncomplicated conditions. This solution is far from perfect, because there's a lot that Nurse Practitioners can't treat.
Some patients are just going to a hospital emergency department because they can't get a GP appointment in a reasonable time frame. This just increases the strain on the system, because care delivered in an ED is considerably more expensive. The four hour target is actively counterproductive; When ED managers are faced with a waiting room full of people with coughs, rashes and sprained ankles, they are forced to choose between prioritising clinical need or hitting their targets.
> Some GP practices have reduced the strain by offering appointments with Nurse Practitioners, who can treat common and uncomplicated conditions. This solution is far from perfect, because there's a lot that Nurse Practitioners can't treat.
Are the NPs not permitted to treat these other conditions, or incapable? I fear there's a turf war between GPs and NPs, where GPs are worried about losing bread-and-butter work that takes little time but accounts for a large number of visits.
>Are the NPs not permitted to treat these other conditions, or incapable?
Both. They're cheaper because they've received much less training than a GP. We could allow them to treat a wider range of conditions, but there would be serious patient safety implications.
The use of nurse practitioners in primary care is relatively new and we don't have a lot of good-quality evidence on patient outcomes, so it's reasonable to act with some caution until we have better evidence. Even in their current role, they could be missing significant clinical issues that a doctor would have spotted - we just don't know at this stage. The concern isn't about the 99% of patients who have something mundane, but the 1% of patients who have something that looks mundane but is actually very serious.
There's undoubtedly some amount of territoriality on the part of doctors, but at the moment everyone is just desperately trying to cope with demand. There seems to be fairly good esprit de corps throughout the NHS, with practitioners at all levels uniting around the need to maintain good patient care against the common enemy of Jeremy Hunt.
I have never seen such a bureaucratic/inefficiently operated institution - and there are plenty to choose from in the UK. My electricity company replaced all Vs with Ks in letters to us for 7 months. The NHS is much worse (try even getting a letter to arrive within a month - to the right address - let alone receive any medical treatment).
I have not dealt with US healthcare but having experienced other countries' I'd strongly suggest not following the UK system - other European countries certainly come to mind as working substantially better. Of course, there's a huge "Save Our NHS" push due to the number of people it employs, unions, misplaced national pride etc.
Funny how your anecdotal point is just that, anecdotal. Here's another anecdotal point for you -- Pancreatic cancer (stage 2). Diagnosed on the first visit even though a private doctor had missed it previously. Surgery in less than 5 days, excellent follow-up and post-surgery care including the surgeon having a set of non-mandatory procedures approved in record time (10mins) as a preventative step towards recurrence. Two years later, cancer free with excellent reminders and follow-ups on periodic checkups.
Your experience does not dictate the system, as doesn't mine.
UK residents have the 20th highest life expectancy in the world. 21st for health-adjusted life expectancy. The Japanese take the top spot and live +2 years. The average American lives -2 years.
There's a lot more to health than the health care system, and this doesn't say much about how painful the process can be, but the stats look pretty good for the UK.
But how much of life expectancy can be attributed to the healthcare system? Maybe Brits spend more time outside, and are less stressed, etc etc. how have the rankings changed over time and what changes in the healthcare systems correlate to those trends?
I didn't claim otherwise - is there a need for that tone? What have private GPs got to do with it?
I don't doubt that the NHS would treat me reasonably quickly and probably quite well if I had stage 2 cancer. People in the UK have been trained to herald such as a result as heroics from the NHS, as if the alternative was third-world level service. I do expect - based on a lifetime of anecdotal data from myself, friends and family - that the whole process would reveal repeated mistakes, bureaucracy and time and money wasted. False dichotomy often prevails in NHS discussions.
Since we're detailing anecdata, I went on a working holiday to the US and had an accident in work. I was fully covered under my travel insurance, and doubly covered under my employer's insurance. I broke several bones in my hand and needed a costly operation to insert pins. The payment approval time from insurers took longer than the minimum wait for the operation before bones fused. I did not have the operation and have had problems in my right hand since.
I take your point about other European countries doing it better, I'm sure that's true. But the article is using the US system as a metric. I'm living in Ireland and would love to have a system as good as the NHS over here. Everything's relative but when you're comparing the NHS to clearly inferior systems there's not much point playing devil's advocate. There are enough individuals with a vested interest in the disassembly of the NHS as it is.
Only marginally. The difference is negligible and even if it weren't, there's certainly far more contributing factors than the quality of healthcare provision.
Playing devil's advocate, I guess one could speculatively argue that Ireland's private system* brings up the overall average while the public system only caters to the poor and deprived, but I don't think this would be enough to bring the averages up on its own. I'm sure it's more likely lifestyle factors.
* for those unfamiliar, Ireland has a two-tier health system with extremely poor, underresouced single-payer free healthcare coupled with privately-run hospitals for those with the means to pay.
Granted it's from wiki, but 79% of 2010 Irish health care spending was by government. And part of that 21% will be from public system co-pays and levies that have nothing to do with private-run hospital visits.
Sounds like the public system provides the majority of care.
Any "public" system still has a private-tier available to anyone that can afford a plane ticket.
Yeah, this is what I would've expected (hence the devil's advocate qualifier), which is why I think our life expectancy has other causal factors.
Although, one thing to note is the the government does invest in private hospitals as well, so that 79% figure won't be exclusively public healthcare. This is due to public-private-partnerships whereby a single site will accommodate both a public and private hospital with the entire project being funded by a combination of public and private funds, usually with an extremely favourable arrangement for the private side.
Oh come on, it's always fashionable to blame the current government. The Guardian's view (which has shifted further left and become more "us vs them" divisive in the last couple of years) of an already unpopular Conservative government is not the first source I'd used.
Personally, I've seen these reports come up from time to time, and having experienced some of the other countries listed find it very hard to believe. It sounds like a lot of the data is collected from patient surveys. My claim that citizens have a positive-skewed view of the system is relevant (I recently read a survey result where UK citizens considered the NHS a greater achievement than defeating the Nazis and the abolition of slavery).
Many Brits are in the same situation and hold the same opinion, because they've never experienced anything else. Having personally experienced the US and UK systems, I assure you that's because you simply can't conceive how bad it is in the US!
It's a myth to suggest the NHS is heavy on bureacracy. The NHS has less management than most UK business, and often those managers are dual role clinicians / managers.
> The NHS Information Centre shows that there were about 43,000 NHS managers in 2009 (about 3.7 per cent of the total workforce), although this figure does not include many clinical managers.
How does this compare to other sectors?
> According to the Office for National Statistics, the proportion of managers in the UK workforce as a whole in June 2010 was 15.4 per cent. These statistics also show that there were 77,000 hospital and health service managers across the United Kingdom, or 4.8 per cent of the NHS workforce. In other words, the NHS has a managerial workforce that is one-third the size of that across the economy as a whole.
Your letter taking a month to arrive is something that you can complain about. Did you make a complaint about it to the relevant trust?
Overall this is a great compare and constrast article, but I do have one quibble with it.
> In the US, I've always been able to see a specialist within a few days. Score one for America.
This is really, really heavily dependent on where you live and the number of doctors and specialist doctors in the area.
I live in a mid-sized city. If I need to see a typical general practice doctor for a routine problem (coughs, etc.) I can usually be seen the same day, but I'll probably have to wait a 2-4 hours depending on when I go.
But if I need to see a specialist (allergist, dermatologist, sleep doctor, etc) and it's not a life-or-death emergency, it's usually a six-week to six month wait for an opening. It literally took six months before I was able to see a dermatologist last year.
My only other option is to drive 2 hours away to the next (bigger) city that has a medical school and a large concentration of doctors. Sometimes you can get an appointment in a few days if you're willing to drive. This is actually what I've started doing when I'm referred to a specialist.
And if you live in a rural area, even routine medical care can be difficult to come by. Many towns will have a small clinic staffed by a doctor who lives in the community, but often this doctor may have rounds where he covers several communities in a geographic area. So, for instance, he may only be in the office in your nearest town Mondays and Thursdays. So if you need to see a doctor and the local nurses can't handle it, you either have to wait or drive to wherever the doctor is that day.
Where I grew up in East Tennessee, we also had a volunteer service called Remote Area Medical [0], which provided free service to very remote areas of Appalachia. I remember going to the Knoxville airport with my Dad once and seeing their DC-3 fueling up for its next trip.
By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good. By comparison to whatever the metrics of whatever government is in power at the time the NHS always looks terrible. Budgets can be set arbitrarily by the government so it’s easy to make the NHS look like it is over budget (in fact all you need to do is increase the budget by less than inflation and talk about absolute numbers to fool the public and hey presto “the NHS is terribly inefficient”).
The whole “4 hour” thing is mad - you should be seen in a reasonable time frame for the ailment you have. Severed hand? Go right ahead. Headache and photo sensitivity that’s been going for a couple of days already? We’ll be with you when we can and if things get substantially worse come back to the reception and you may be deemed more critical.
Obviously I am over simplifying the matter but the NHS is staffed by competent trained professionals who should be allowed to use their own judgment as the whether someone can wait 30 seconds, or 6 hours.
> you'll be given a stern talking to and sent home
Yes and then sometimes that person dies as the recent case in the news about the girl with asthma who was told off for being late and sent home to die.
The NHS’s matronly they-know-better is a real problem of an effective state monopoly on healthcare. You can’t complain or take your business elsewhere. If they tell you to go home that’s it and there’s no other option.
> If they tell you to go home that’s it and there’s no other option.
Not even remotely true, if you don't mind paying. You can see a GP privately, there are already lots of apps which let you book appointments. A colleague had an ear problem, couldn't get an appointment with his local GP and so used one of these app-based services and got a same-day appointment with a doctor near the office.
This is not to say that the NHS could not be better, but its problems would generally be made worse not better by introducing market or pseudo-market mechanisms. Unless universality can be guaranteed.
I don't know the story but A&E (I guess our equivalent of ER) is not appointment only. "Surgery" in the UK often refers to the office where the GP (general practitioner - ie a non-specialist doctor you'd visit first and foremost for non-emergency cases) presides.
So perhaps the story was about a patient visiting a GP but the context got lost in translation.
>By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good.
Ish. The NHS is remarkably cost-effective, but has relatively poor survival rates for cancer, stroke and myocardial infarction. International comparisons seem to damn the NHS with faint praise - it's cheap and the patients are happy, but it's not very good at keeping people alive.
Having only quickly skimmed that document, I couldn't see anything about taking into account the effects of patient age. The NHS is facing massive demand by elderly patients who presumably have lower survival rates for various ailments. They should be going into nursing care, but that has not kept up with demand.
A chunk of the poor cancer survival is down to cultural issues — British men in particular being socialized to not complain, so they don't go to their primary point of care until it's too late to do anything beyond palliative care.
This is slowly changing, but it's generational. National-level screening initiatives also help: for example the Scottish NHS's national bowel cancer screening program. But when NHS England is facing real-terms cuts in spending, new long-term preventative stuff doesn't get rolled out.
Cancer survival rates are suprisingly tricky to measure. If I'm diagnosed with an incurable cancer 5 years before it kills me Vs diagnosed 3 months before hand then scenario 1 looks better in the cancer stats but scenario 2 is better for my peace of mind and probably avoid me having to have a bunch of superfluous medical procedures over the 5 years.
Survival rates for all those things are affected by external factors that are not in the NHS' control.
Smoking, drinking and obesity are all higher in the UK than in many other Western countries, and therefore the types and severity of these issues are likely incomparable.
Compound this with the cultural differences of the NHS (you don't go for a six-month check-up unless you're elderly, you just see a doctor when you're already ill), and the fact spending has been prioritised towards other areas (particularly paediatrics), you start to see a different story.
But there's also the fact the median age of the UK is relatively high. It's so good at keeping alive in younger years they get older and then develop cancer, stroke and heart disease/attacks later in life where they might be less survivable.
We all have to die of something. The NHS can't prevent that. What it can do is stop you having a lot of those issues earlier in life as in other countries and therefore the quality of life is improved.
If you want to see an area where it's proper shit, I would not start there: go with dental work, look at obesity prevention, etc. - that's where it's really lagging behind many other countries.
As a point of anecdata, my dad, an American, lived in Wales the last ten years of his life. His arthritis got too bad for him to work, and the NHS took excellent care of him for years. Then he had cardiac issues and although his NHS doctor recommended heart surgery, they didn't schedule the procedure for several months and he died of a heart attack in the meantime (age 62).
Public healthcare took great care of him and then it killed him. Hard not to be ambivalent about that (though n.b. this is not an endorsement of the US system by any means).
>In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle.
That is so bizarre. I'd be concerned if it takes and hour. Seriously it's called emergency room because it's an emergency, not a "it can totally wait" room.
Rather depends who is there and why. Last time I went was for a small animal bite (had gone to the docs but they had no tetanus shots so sent me on), hardly life and death. Was triaged quickly, but then waited to be dealt with properly.
A lot of patients are anything but emergencies though. Since it can be near impossible to get a same-day doctors appointment in some areas. In the South of England it can be weeks.
So people just go to the hospital A&E dept instead, sometimes for quite minor ailments - although not always.
My friend had a seizure while we were on a business trip in a suburb of London. We were taken to the hospital in ambulance, I remember we had to go through a series of 6 rooms each getting progressively smaller( first one had like 200-300 ppl) and less people. Took us about 5 hrs to get to the doctor. Doctor was patient and polite.
They have vigorous triage. If you're about to die they have fully stocked ambos with paramedics providing treatment to you on the scene and then transporting you, with blue lights, to an A&E and direct into majors.
If you turn up with a broken finger you're going to have to wait for most of those 4 hours.
(I'm not defending the 4 hour limit. I think it's weird and needs to go)
Although it is an emergency room, a lot of people still turn up when it's not an emergency. It's heavily triaged. If you seriously need attention RIGHT NOW, you will get it. It's not like people are sitting in waiting rooms and dying in the meantime.
Note that the UK also has a small private system; if you're really not happy with waiting for appointments or operations you can pay to be seen. Some higher-paid jobs come with health insurance, which is really cheap because anything difficult or expensive can be shunted off to the NHS.
As I'm also an American using Britain's NHS, I was pleasantly surprised to see the article mostly matches up with my experiences using local services (though as others have called out, NHS GPs and Specialists still have regular 15-30 minute delays for pre-scheduled appointments, IME)
The only downside I would call out is that I pay slightly higher taxes in the UK than I would in the US, and I imagine that part of it goes to fund NHS programs.
That said, the small increase is a relative bargain, given the the excellent level of care provided by NHS staff and the avoidance of insurance nightmares I was used to dealing with back in the states.
Here in the US I had to take my son (he was 5 years old at the time) to the emergency room when he had slipped in the bathtub and hit his head which caused a huge gash right above his eye. We sat in the emergency room for 5 hours before any of the staff bothered to look at his open wound and then another 4 hours after that before they actually treated him.
The most infuriating part of the experience was the not-so-subtle attempt by the staff to see whether or not I had told them the truth about how he had sustained his injury by constantly asking him to recount how he had sustained his injury instead of actually treating his injury. On top of that, the staff were rude and generally dismissive when I asked how long they thought it would be before my son would receive treatment.
And then of course the billing nightmare that ensued was just extra icing on the cake. The hospital was in network for my insurance (which I verified before I went and again while I was there) but the staff neglected to tell me that they were contracted through a completely different company that turns out was not in network so I ended up having to pay almost $2000 for what amounted to a few stitches for my son.
100% f'ing right. People who think the US health care system is fantastic either (a) haven't used it much, or (b) are rich enough not to care - and in this category I'll include those with good employer-provided health care (although this number is dwindling rapidly)
Might be of interest to discuss other systems as well. I'm somewhat familiar with the system in South Korea:
- There's a National Insurance System that all citizens are signed up to at birth.
- Premiums are based on income with employers splitting the cost 50:50. Low income/unemployed people go on a slightly different but substantially similar plan with no premiums.
- Prices for procedures are nationally set and fixed.
- Hospitals and Doctors are generally private, but must accept the National Insurance.
- Patients pay a co-pay and doctors bill the National Insurance system for the full price.
- The National Insurance plan only covers a set of elective procedures. Unelective procedures are payed for out of pocket, or by private supplementary insurance (which are also quite popular). e.g. if you have cancer you can go with the prescribed National Insurance treatment and it's covered, or you can go with other treatments which the private hospitals are more than happy to provide.
- Upside: people go to the doctor early and often and as a result South Korea has some of the best medical outcomes in the world (with a few exceptions). The robust private hospital system brings in medical tourists for a wide variety of medical procedures at low prices. If you're in the Hospital and want better care than the National Insurance covers, and you have the money, your class of care options is virtually unlimited. Fewer bankruptcies than the U.S. and <7% of GDP is spent on healthcare. System is considered among the best in the world.
- Downside: The system tends to favor simpler problems that can be handled in an assembly-line fashion. Doctors need to see huge numbers of patients to make a living, so bedside chat time is very limited (but in practice it's about as much time as I see my doctor in the U.S.). Doctors over recommend procedures and tests to get the insurance money.
- Paradox: Because doctors are payed per procedure, but the procedures are limited, they tend to oversubscribe labs and imaging. This means that there are about 3x as many hospital beds and imaging machines than the U.S.
- Source: Visit South Korea semi-frequently, been sick there. Even not being insured (thus paying out of pocket) the cost was far lower than my insured care in the U.S.
I am a lot like the author (dual national, lived in both US and UK). One of my children was born in the US, the other in the UK. I agree with the author 100%. I would emphasize more the peace of mind that in the UK my family's health care is in no way tied to my job (I earn plenty of money and have never had trouble finding employment).
There are also huge societal benefits to socialized healthcare. There are far fewer desperate homeless people in the UK, because many homeless people in the US are stuck in that situation in large part because of some health issue. There's just a fundamental feeling in the UK that we're all going through this life together.
The NHS will try many things to avoid expensive options like MRIs and more expensive medications.
For Multiple Sclerosis I was given one MRI and NO medications over the course of 12 years as I went from relapsing remitting to secondary progressive. Total postcode lottery so fuck the NHS.
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[ 2.6 ms ] story [ 125 ms ] threadMore interestingly, can the US political system ever enable an evidence-based debate around it?
From the other side of the pond, it feels like debates end up being emotional rather than scientific.
(I’m a Brit and love the NHS with a passion but would not claim that it’s without flaw. Neither would I claim that we necessarily have more reasoned debates about issues here...)
I don't hold out much hope for reasoned debate to help things though - who can form a reasonable opinion about ~6% of GDP directly managed by the Department for Health? I certainly can't.
I honestly think the reason the US is slipping so much is because their political system never seems to have evidence-based debates around anything.
Worse, they have absolutely no interest what-so-ever in comparing their country and how it's actually functioning to other Developed Countries for the purposes of improvement. In fact, I genuinely don't think they care to improve anything, at all.
Americans are not all of the same opinion. They do not all use the same arguments which have the same faults. In this they are like all people everywhere. Also, their political parties do not all employ the same arguments with the same faults. Arguing that everyone has the same faults is both-siderism. It is a counsel of despair. In fact, each party will use facts and international comparisons when doing so supports their preferred policy.
The Democrats have been quite fond of international comparisons in support of their efforts to improve healthcare. I struggle to find a topic on which Republicans prefer facts to mythology but they certainly grab onto a fact when it supports what they want to do. They can recognize and employ a good argument if it presents itself.
If you hear someone making a stupid argument, regarding health care or whatever, nine times out of ten it is not because they desire a worthy thing and are too stupid to get it but because they desire an unworthy thing and are crafty enough to recognize a plausible cover story. You can recognize this happening when someone drives for a constant goal but changes arguments as suits the moment. Republican arguments for lowering taxes fit this pattern as do arguments for not doing anything about climate change.
It isn't the stupidity of politicians, or even their voters, that explain American policy. It's disharmony within the nation mixed with political institutions that expect people to work toward a common purpose.
A more fair system could be quite a bit worse for people currently in positions of influence, and that's what's going to make it hard. That's how we got Obamacare in the first place - incremental improvement for some, trying not to screw it up for the most consistent voters - and even it's coming close to voter revolt-driven rollback.
If you want meaningful change I'm convinced it's going to have to come from the Sanders-style wing. The mainstream Democratic and Republican parties are too aware of how good they've got it, and at whose expense that comes, currently.
That's kind of where it loses me. We already have a system very similar to single-payer for our veterans and it is notoriously inefficient, bloated, and unpopular. What many are clamoring for in the US is already being tried in the US and failing exactly the way opponents claim it will.
Evidence that it works well in other countries is worth considering, but it in no way proves such a system would work well here. It'd probably work well in states that are similarly culturally homogenous (like Vermont or New Hampshire), but the discussion always seems to be at the federal level.
I think what we need is more freedom for experimentation. Pick maybe a city or county and make it eligible to sidestep all of the federal and state regulations and build/create their own. Some will undoubtedly shoot for a libertarian approach while others might imitate the NHS. See how the costs and outcomes compare. Gather more evidence in a more relevant way.
London is culturally diverse. Moreso than any US city. And its NHS seems to be working ok.
A nationwide system in the US would be covering far larger and more diverse areas.
It's incorrect to say that the English NHS is a monolithic thing. It isn't.
The NHS is regional. It's split into regions by "clinical commissioning groups". There are 32 CCGs in London. These are independent from each other, and from the rest of the UK.
http://officelondonccgs.org.uk/what-is-clinical-commissionin...
> Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act (2012), replacing Primary Care Trusts on 1 April 2013. They are clinically-led statutory NHS bodies responsible for planning and commissioning health care services in their local area. There are currently 207 CCGs in England.
> The National Health Service (NHS) is the name used for each of the public health services in the United Kingdom – the National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland – as well as a term to describe them collectively.
Emphasis on that last part.
The Scottish NHS has nothing to do with London.
But even within only the English NHS, what happens in say Bristol has nothing to do with London.
My point stands: London is more diverse than anywhere in the US, and the various NHS CCGs in London are doing okay.
This is just getting boring as you argue pointlessly over semantics.
UK: Covered collectively by the NHS, which has its own branches.
England: A part of the UK that has 55 million people and its own branch of the NHS. It is racially 85% white and 7% Asian.
London: A big city in England with a population around 9 million.
The number of people in London is much smaller than the number of people in all of England, and all of the UK. Yet, England (as shown above) is quite racially homogenous (typically a good indicator for being culturally homogenous). That a single city exists in a sea that is culturally homogenous (that you feel like is "doing okay") does not mean that if all of England or the UK's population were more diverse, there would be no problems.
Nobody is arguing that the system would collapse the moment it encounters a single diverse area, so your point is irrelevant.
On both sides of the pond, we need to break the false dichotomy of UK vs US. Our systems are almost diametrically opposed, but they get vastly disproportionate mindshare and airtime. In any debate about NHS reforms, people will inevitably hold up the US as a cautionary tale and vice-versa, but hardly anyone raises Germany or Australia as a workable middle ground. This false dichotomy also dominates the debate over gun control.
Healthcare Triage did an excellent series of videos summarising the strengths and weaknesses of various international healthcare systems. I can highly recommend it to anyone on either side of the pond who is thinking about how their healthcare system could be reformed.
https://www.youtube.com/watch?v=ylsO0VVy29U&list=PLkfBg8ML-g...
https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
Here are 3 (not evidence based) reasons why medical care costs more in the US:
1) more administration (too many rules/regulations) 2) higher costs for the base goods (people get paid more, pharma, medical devices, etc) due to lack of price controls 3) people get more care, potentially even when it isnt going to help
https://www.pbs.org/newshour/nation/why-does-health-care-cos...
http://www.sciencemag.org/news/2017/03/data-check-us-governm...
Your starting assumption that price controls are incompatible with innovation is a political belief, not a fact. There's no reason why that precludes funding bounties for improvements / cost reductions (e.g. why Japan's MRIs are so much cheaper than the U.S.), using different funding models for R&D than manufacturing, etc. Individual systems could choose not to fund research but that's a choice rather than a universal truth.
This is a strong claim presented with no evidence. It is clear that the US is, by far, the global leader in this area. But to say there is no other innovation at all is going a bit far.
Indeed, it is easy to see that communist China is the world's second in this area, whether you go by papers published, clinical trials, or whatnot.
Even the libertarian Cato Institute doesn't go so far as to say that no one but the US innovates.
https://www.cato.org/publications/policy-analysis/bending-pr...
There is a lot of donor money and government grant money in medical research around the world.
Research Hospitals (off the top of my head)
- The Ottawa Hospital
- SickKids
- Sunnybrook Health Sciences Centre
- Sinai Health System
- Kingston General Hospital
Innovation
[1] http://innovativemedicines.ca/medicines/timeline/
[2] https://legionmagazine.com/en/2009/08/eight-great-canadian-m...
I wouldn't say single. Each province runs its own system. Each province can't decide how many sub health regions it wants (SK just merged theirs, ON collapsed their community care regions into their health integration regions). GP practices are basically private for-profit companies. Hospitals operate like independent charities with wildly different processes, costs and outcomes.
Thanks for parenthetically instructing us not to share anecdotes at the end of a statement which isn't even that.
https://www.statista.com/statistics/266141/pharmaceutical-sp...
That's per capital spending on pharmaceuticals. Two things to note from that: 1) The highest by far is in the US, that's absolutely true. 2) Substantial amounts are still spent in other wealthy countries.
American healthcare payers - insurance companies and their agents - also impose controls on what they will pay for drugs and for which conditions. They don't seem to be as effective in enforcing them since they haven't got the kind of monopsoninistic power as either single payer systems like Canada or constrained multi-payer insurance markets like the Netherlands.
That Americans overpaying for drugs helps to subsidise R&D that everyone benefits from seems like it make intuitive sense. I'd question whether the evidence supports a complete halt to innovation if the US adopted pharmaceutical price controls unless the price control they adopted was to restrict prices to cost of production - something that no government single payer health service does.
In the NHS, these decisions are made by the NICE which determines how many quality adjusted life years are gained from the use of a drug and then checks to see if they clear a threshold CBA value. It's worth noting that £100k+ cancer drugs that actually work are still frequently approved under this system. Recently, NICE approved Soliris at £330k/yr for treating aHUS. That's $450k/yr, treatment required for life. I suspect that many American insurance companies wouldn't fund that.
Moreover there are goods and services such as fighter jets where there is a single US government buyer and innovation still happens. Conceptually it doesn't appear that this needs to be a barrier to innovation spending.
The question is, how did NICE arrive at the decision to fund it when it doesn't meet their CBA threshold?
Isn't the whole point of a CBA threshold to say: "We should defund really expensive treatments so we can pay for more cheaper treatments and improve aggregate outcomes per GBP"?
Public funding of drug research is a better driver for the discovery of improved treatments than private pharma investment - under the current model, drug companies aren't incentivized to develop novel treatments (see Nexium), or to develop treatments that would improve outcomes for the greatest number of people (see Pfizer abandoning research into Alzheimer's and Parkinson's treatments).
Since the Bayh-Dole Act passed in 1980, pharma companies have profited hugely by purchasing patents held by publicly-funded researchers, and commercializing them with virtually no controls on the resulting drug prices. Even private development of drugs still relies on publicly-funded and publicly-available research. The assertion that the institution of stricter price controls would eliminate innovation seems to be untrue - I don't think that scientists are incentivized to do research solely by the promise of lucrative patents. Stricter price controls would likely mean that the government would have to participate more directly in the clinical trial phase, which would be a good thing, as there are minimal checks against manipulation of clinical trials.
Unfortunately, Alzheimer's and Parkinson's treatments have been a black-hole for research funding. Many have tried, most have failed.
I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury. I'd like to see legislation to heavily penalise drug companies seeking 20,000% price increases and the like.
Both sides fiddle with it, trivially and constantly. They will even fiddle when they have won a second term or reorganised ministers - because what they themselves thought 4 years ago must have been stupid and should be immediately changed, or something.
Much of the waste is from badly thought through political fiddling, remnants of previous fiddling, and public-private partnerships stupidly chosen during a time of lowest borrowing in British history.
Neither side is honest about it however.
I'd trust an independent body, with cross-party oversight, rather more to make changes, and choices, most suited to the service and populace than most politicians. There might even be some opportunity to think long term rather than just having the next election in mind.
Any time that independent body fucked up or did a bad job, they'd simply claim they didn't get enough money from the government to do the job. Whether that was the truth or not. The "cross party" oversight would then take positions according to their party priorities, if in power blame the independent body for doing a bad job, if not in power blame the government for not giving them enough money.
Unless of course that independent body had separate tax raising powers for just the NHS?
In which case I can't see how they can't be elected as they have the power of taxation.
You can't get politics out of the NHS, it spends too much money raised by taxation.
It's pretty clear NICE works rather well and is now accepted by both political sides and the profession. Let's start there.
In terms of funding the NHS spends a smaller proportion of GDP than most developed nations. If we can nail defence and overseas development as x% of GDP, why not also for the NHS? Perhaps consider increasing to the average EU spend?
The CDF makes available cutting edge new technology to people dying from cancer. These meds are very expensive. They often fail the NICE appraisals. The CDF pays for the meds.
We know that these meds often don't work at all, and sometimes cause harm, and are fantastically expensive.
https://www.theguardian.com/science/2017/apr/28/cancer-drugs...
You're right that people get a criminal conviction for non-payment of the licence fee, and that's a bit worrying when it happens to so many people.
The current NHS budget is £125Bn/year. Many people think it is underfunded, but noone is willing to name a figure for fully funded. Is it £150Bn, 200, 500? No progress will be made, by either party, until someone stands up and does this.
The system interfaces with every area of life, and with capitalism. Western Capitalism says the amount spent on healthcare should grow until all available money becomes profit for the Capitalists.
Meanwhile there's always some new area of life that impacts health - spend on sport, then on encouraging sport by paying for teachers, then on improving colleges where the teachers train, ... before you know it the NHS is funding a deep mine in Siberia because it mines the metals that make the earphones used in mp3 players by students training to be teachers, to encourage them to teach more sport to children so that when those children grow up they'll need less heart bypass surgery.
Meanwhile the Siberian mine leads to contaminants in the ocean that cause excess cost to all health regimes around the world ...
Health encompasses all parts of life, it needs selfless, holistic, planet-wide approach. You could spend £150 Trillion in health and still find more areas of spending to address.
In other words, central planning doesn't work[1]. NHS was a "special case" that tends towards the general case, as is the tendency of all untouchable mandates.
[1] https://en.wikipedia.org/wiki/Economic_calculation_problem
That's what CCGs are for.
Also, a bunch of stuff (drug and alcohol services, weight loss, smoking cessation, suicide prevention, sexual health, etc etc) isn't even NHS any more, and is part of Public Health which is part of local authorities.
Look at the trains in the UK - government was running one major line at a large profit, but they prop up the system as a whole with tax monies, why? It certainly seems like trains (maybe transport) could be centrally planned if you define the limits of the sector carefully.
People who really love "our NHS" eat right, exercise, and get enough sleep... The rest are just trying to score cheap political points.
Of these three, diet has by far the most impact on t2 diabetes. The focus on casual exercise ("10k steps per day") is relatively useless compared to a low-inflammation diet. But there seem to be a lot of perverse incentives and special interests who keep the conversation muddled or focused elsewhere.
It's quite insane that there isn't more done to address root cause. With diabetes-2 I think NHS fails at the point when they don't address people who are at risk. Help people to change their habits by attaching pain and pleasure to their choices and making it personal. This would save NHS lot of money and most importantly help the individual.
https://www.goodreads.com/book/show/144873.Healing_Back_Pain...
It's a moving target, because need continues to grow as the population ages. We're in largely uncharted territory, so it's difficult to make long-term cost forecasts. You could always find ways of spending money to improve a healthcare system, so it just doesn't make sense to pick a number ex nihilo. We do have other, better means of determining what a reasonable level of healthcare spending might be on a year-to-year basis.
The National Institute for Clinical Excellence have determined a cost-effectiveness threshold of £30,000 per additional Quality-Adjusted Life Year. This threshold is a little bit arbitrary, but it's a reasonable rule-of-thumb as to what treatments provide a net benefit to society. Based on this figure, we can start to calculate a reasonable overall NHS budget from the bottom-up - the NHS needs enough money to provide all the healthcare interventions that NICE has determined to be cost-effective.
In addition to cost-effectiveness, we also have benchmarks in terms of quality of care. It might not be clinically significant if someone has to wait three weeks for a GP appointment about their psoriasis or six months for knee surgery, but it matters to the patient. We know that wait times have been going up and patient satisfaction is going down, which is a reasonable indication that the system is underfunded. It wouldn't be reasonable to aim for instant care and 100% patient satisfaction, but we should at the least hope for stability rather than regression.
The question of affordability is perfectly fair, but the UK doesn't spend an exceptional amount on healthcare by the standards of equally-developed nations. As a proportion of GDP, our spending is roughly average for OECD nations. In absolute terms, we spend about 25% less per patient than Germany or Ireland. We can clearly afford to spend a fair bit more before we start feeling the pinch.
I think that it's perfectly reasonable to spend a few tenths of a percent of our GDP to try and take the pressure off the system and get the quality metrics back to where they were in 2015. If costs start spiralling out of control, then we need to have some difficult conversations about what kind of care we're going to ration, but I think that conversation is premature if we haven't first tried a modest increase in spending.
What's the Tory's stated public position for their 30 year goals and what immediate and mid-term changes have they made in order to achieve that?
Fiddling is _not_ needed.
Planned, careful, forward looking, evidence based change (that's not focused on shifting funds towards private profit) is certainly required.)
It's just like education, every new minister (usually entirely new to the field) dicks around changing stuff because they want to justify their pay and because not changing it might seem like someone else had a good idea and that apparently is complete anathema to our current politicians.
The Scottish NHS is a fully devolved issue and has been diverging from the English system for most of a decade now, with a greater emphasis on preventative healthcare and screening programs (not to mention free prescriptions for all).
In another couple of years we may even have some hard statistical data on what practices work best!
They did that. The governmental bit (in England) is the Department for Health and Social Care.
NHS England is the qango that runs the NHS in England. They provide money to CCGs to commission most services. NHS England directly commissions some (so called "tier 4" services) - eg inpatient mental health services for children; medium and high secure mental health services; etc.
I genuinely have no idea what happens in Wales, Scotland, or NI. Health is devolved and they run their systems independently.
I don't think that's ever happened to me. Most likely this person was the first patient of the day, so appointment times haven't slipped yet. 30 minutes in the minimum I've had to wait in general. I've also had to wait weeks to see a GP (in the countryside).
I find anecdotal articles like this pretty unhelpful in general. We all have our own anecdotes, it's more interesting to look at the data. Comparisons between UK and US healthcare are also somewhat meaningless. They've very different systems, and their are many other countries with private and public healthcare systems that you could compare.
Some GP practices have reduced the strain by offering appointments with Nurse Practitioners, who can treat common and uncomplicated conditions. This solution is far from perfect, because there's a lot that Nurse Practitioners can't treat.
Some patients are just going to a hospital emergency department because they can't get a GP appointment in a reasonable time frame. This just increases the strain on the system, because care delivered in an ED is considerably more expensive. The four hour target is actively counterproductive; When ED managers are faced with a waiting room full of people with coughs, rashes and sprained ankles, they are forced to choose between prioritising clinical need or hitting their targets.
http://www.pulsetoday.co.uk/your-practice/practice-topics/ac...
Are the NPs not permitted to treat these other conditions, or incapable? I fear there's a turf war between GPs and NPs, where GPs are worried about losing bread-and-butter work that takes little time but accounts for a large number of visits.
Both. They're cheaper because they've received much less training than a GP. We could allow them to treat a wider range of conditions, but there would be serious patient safety implications.
The use of nurse practitioners in primary care is relatively new and we don't have a lot of good-quality evidence on patient outcomes, so it's reasonable to act with some caution until we have better evidence. Even in their current role, they could be missing significant clinical issues that a doctor would have spotted - we just don't know at this stage. The concern isn't about the 99% of patients who have something mundane, but the 1% of patients who have something that looks mundane but is actually very serious.
There's undoubtedly some amount of territoriality on the part of doctors, but at the moment everyone is just desperately trying to cope with demand. There seems to be fairly good esprit de corps throughout the NHS, with practitioners at all levels uniting around the need to maintain good patient care against the common enemy of Jeremy Hunt.
I have not dealt with US healthcare but having experienced other countries' I'd strongly suggest not following the UK system - other European countries certainly come to mind as working substantially better. Of course, there's a huge "Save Our NHS" push due to the number of people it employs, unions, misplaced national pride etc.
Your experience does not dictate the system, as doesn't mine.
There's a lot more to health than the health care system, and this doesn't say much about how painful the process can be, but the stats look pretty good for the UK.
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
I don't doubt that the NHS would treat me reasonably quickly and probably quite well if I had stage 2 cancer. People in the UK have been trained to herald such as a result as heroics from the NHS, as if the alternative was third-world level service. I do expect - based on a lifetime of anecdotal data from myself, friends and family - that the whole process would reveal repeated mistakes, bureaucracy and time and money wasted. False dichotomy often prevails in NHS discussions.
Since we're detailing anecdata, I went on a working holiday to the US and had an accident in work. I was fully covered under my travel insurance, and doubly covered under my employer's insurance. I broke several bones in my hand and needed a costly operation to insert pins. The payment approval time from insurers took longer than the minimum wait for the operation before bones fused. I did not have the operation and have had problems in my right hand since.
I take your point about other European countries doing it better, I'm sure that's true. But the article is using the US system as a metric. I'm living in Ireland and would love to have a system as good as the NHS over here. Everything's relative but when you're comparing the NHS to clearly inferior systems there's not much point playing devil's advocate. There are enough individuals with a vested interest in the disassembly of the NHS as it is.
Why? Ireland has longer lifespans and better health-adjusted life expectancies than the UK.
Playing devil's advocate, I guess one could speculatively argue that Ireland's private system* brings up the overall average while the public system only caters to the poor and deprived, but I don't think this would be enough to bring the averages up on its own. I'm sure it's more likely lifestyle factors.
* for those unfamiliar, Ireland has a two-tier health system with extremely poor, underresouced single-payer free healthcare coupled with privately-run hospitals for those with the means to pay.
Sounds like the public system provides the majority of care.
Any "public" system still has a private-tier available to anyone that can afford a plane ticket.
Although, one thing to note is the the government does invest in private hospitals as well, so that 79% figure won't be exclusively public healthcare. This is due to public-private-partnerships whereby a single site will accommodate both a public and private hospital with the entire project being funded by a combination of public and private funds, usually with an extremely favourable arrangement for the private side.
If we are going by anecdotal evidence, the NHS has been absolutely brilliant for me.
https://www.theguardian.com/society/2017/jul/14/nhs-holds-on...
Personally, I've seen these reports come up from time to time, and having experienced some of the other countries listed find it very hard to believe. It sounds like a lot of the data is collected from patient surveys. My claim that citizens have a positive-skewed view of the system is relevant (I recently read a survey result where UK citizens considered the NHS a greater achievement than defeating the Nazis and the abolition of slavery).
What does that mean?
https://www.kingsfund.org.uk/projects/health-and-social-care...
> The NHS Information Centre shows that there were about 43,000 NHS managers in 2009 (about 3.7 per cent of the total workforce), although this figure does not include many clinical managers. How does this compare to other sectors?
> According to the Office for National Statistics, the proportion of managers in the UK workforce as a whole in June 2010 was 15.4 per cent. These statistics also show that there were 77,000 hospital and health service managers across the United Kingdom, or 4.8 per cent of the NHS workforce. In other words, the NHS has a managerial workforce that is one-third the size of that across the economy as a whole.
Your letter taking a month to arrive is something that you can complain about. Did you make a complaint about it to the relevant trust?
> In the US, I've always been able to see a specialist within a few days. Score one for America.
This is really, really heavily dependent on where you live and the number of doctors and specialist doctors in the area.
I live in a mid-sized city. If I need to see a typical general practice doctor for a routine problem (coughs, etc.) I can usually be seen the same day, but I'll probably have to wait a 2-4 hours depending on when I go.
But if I need to see a specialist (allergist, dermatologist, sleep doctor, etc) and it's not a life-or-death emergency, it's usually a six-week to six month wait for an opening. It literally took six months before I was able to see a dermatologist last year.
My only other option is to drive 2 hours away to the next (bigger) city that has a medical school and a large concentration of doctors. Sometimes you can get an appointment in a few days if you're willing to drive. This is actually what I've started doing when I'm referred to a specialist.
And if you live in a rural area, even routine medical care can be difficult to come by. Many towns will have a small clinic staffed by a doctor who lives in the community, but often this doctor may have rounds where he covers several communities in a geographic area. So, for instance, he may only be in the office in your nearest town Mondays and Thursdays. So if you need to see a doctor and the local nurses can't handle it, you either have to wait or drive to wherever the doctor is that day.
Where I grew up in East Tennessee, we also had a volunteer service called Remote Area Medical [0], which provided free service to very remote areas of Appalachia. I remember going to the Knoxville airport with my Dad once and seeing their DC-3 fueling up for its next trip.
[0] https://ramusa.org/
The whole “4 hour” thing is mad - you should be seen in a reasonable time frame for the ailment you have. Severed hand? Go right ahead. Headache and photo sensitivity that’s been going for a couple of days already? We’ll be with you when we can and if things get substantially worse come back to the reception and you may be deemed more critical. Obviously I am over simplifying the matter but the NHS is staffed by competent trained professionals who should be allowed to use their own judgment as the whether someone can wait 30 seconds, or 6 hours.
it's already like this, A&E is run on triage, "4 hours" is a target not an instruction
and if you go to A&E with something like a cold you'll be given a stern talking to and sent home
https://www.kingsfund.org.uk/projects/general-election-2010/...
Yes and then sometimes that person dies as the recent case in the news about the girl with asthma who was told off for being late and sent home to die.
The NHS’s matronly they-know-better is a real problem of an effective state monopoly on healthcare. You can’t complain or take your business elsewhere. If they tell you to go home that’s it and there’s no other option.
Not even remotely true, if you don't mind paying. You can see a GP privately, there are already lots of apps which let you book appointments. A colleague had an ear problem, couldn't get an appointment with his local GP and so used one of these app-based services and got a same-day appointment with a doctor near the office.
If you go private and something happens during treatment they have to put you in an ambulance and take you to an NHS A&E.
For most ordinary people if the NHS tells you to go home that’s it you have to accept it. And people die because of this!
This is not to say that the NHS could not be better, but its problems would generally be made worse not better by introducing market or pseudo-market mechanisms. Unless universality can be guaranteed.
Just like the American system, this is only useful for people who can pay for it.
https://news.sky.com/story/girl-5-died-after-doctor-turned-h...
So perhaps the story was about a patient visiting a GP but the context got lost in translation.
Ish. The NHS is remarkably cost-effective, but has relatively poor survival rates for cancer, stroke and myocardial infarction. International comparisons seem to damn the NHS with faint praise - it's cheap and the patients are happy, but it's not very good at keeping people alive.
http://www.qualitywatch.org.uk/sites/files/qualitywatch/fiel...
This is slowly changing, but it's generational. National-level screening initiatives also help: for example the Scottish NHS's national bowel cancer screening program. But when NHS England is facing real-terms cuts in spending, new long-term preventative stuff doesn't get rolled out.
Smoking, drinking and obesity are all higher in the UK than in many other Western countries, and therefore the types and severity of these issues are likely incomparable.
Compound this with the cultural differences of the NHS (you don't go for a six-month check-up unless you're elderly, you just see a doctor when you're already ill), and the fact spending has been prioritised towards other areas (particularly paediatrics), you start to see a different story.
But there's also the fact the median age of the UK is relatively high. It's so good at keeping alive in younger years they get older and then develop cancer, stroke and heart disease/attacks later in life where they might be less survivable.
We all have to die of something. The NHS can't prevent that. What it can do is stop you having a lot of those issues earlier in life as in other countries and therefore the quality of life is improved.
If you want to see an area where it's proper shit, I would not start there: go with dental work, look at obesity prevention, etc. - that's where it's really lagging behind many other countries.
The UK's was 81.1 years.
Public healthcare took great care of him and then it killed him. Hard not to be ambivalent about that (though n.b. this is not an endorsement of the US system by any means).
That is so bizarre. I'd be concerned if it takes and hour. Seriously it's called emergency room because it's an emergency, not a "it can totally wait" room.
So people just go to the hospital A&E dept instead, sometimes for quite minor ailments - although not always.
If you turn up with a broken finger you're going to have to wait for most of those 4 hours.
(I'm not defending the 4 hour limit. I think it's weird and needs to go)
The only downside I would call out is that I pay slightly higher taxes in the UK than I would in the US, and I imagine that part of it goes to fund NHS programs.
That said, the small increase is a relative bargain, given the the excellent level of care provided by NHS staff and the avoidance of insurance nightmares I was used to dealing with back in the states.
https://visual.ons.gov.uk/how-does-uk-healthcare-spending-co...
The most infuriating part of the experience was the not-so-subtle attempt by the staff to see whether or not I had told them the truth about how he had sustained his injury by constantly asking him to recount how he had sustained his injury instead of actually treating his injury. On top of that, the staff were rude and generally dismissive when I asked how long they thought it would be before my son would receive treatment.
And then of course the billing nightmare that ensued was just extra icing on the cake. The hospital was in network for my insurance (which I verified before I went and again while I was there) but the staff neglected to tell me that they were contracted through a completely different company that turns out was not in network so I ended up having to pay almost $2000 for what amounted to a few stitches for my son.
- There's a National Insurance System that all citizens are signed up to at birth.
- Premiums are based on income with employers splitting the cost 50:50. Low income/unemployed people go on a slightly different but substantially similar plan with no premiums.
- Prices for procedures are nationally set and fixed.
- Hospitals and Doctors are generally private, but must accept the National Insurance.
- Patients pay a co-pay and doctors bill the National Insurance system for the full price.
- The National Insurance plan only covers a set of elective procedures. Unelective procedures are payed for out of pocket, or by private supplementary insurance (which are also quite popular). e.g. if you have cancer you can go with the prescribed National Insurance treatment and it's covered, or you can go with other treatments which the private hospitals are more than happy to provide.
- Upside: people go to the doctor early and often and as a result South Korea has some of the best medical outcomes in the world (with a few exceptions). The robust private hospital system brings in medical tourists for a wide variety of medical procedures at low prices. If you're in the Hospital and want better care than the National Insurance covers, and you have the money, your class of care options is virtually unlimited. Fewer bankruptcies than the U.S. and <7% of GDP is spent on healthcare. System is considered among the best in the world.
- Downside: The system tends to favor simpler problems that can be handled in an assembly-line fashion. Doctors need to see huge numbers of patients to make a living, so bedside chat time is very limited (but in practice it's about as much time as I see my doctor in the U.S.). Doctors over recommend procedures and tests to get the insurance money.
- Paradox: Because doctors are payed per procedure, but the procedures are limited, they tend to oversubscribe labs and imaging. This means that there are about 3x as many hospital beds and imaging machines than the U.S.
- Source: Visit South Korea semi-frequently, been sick there. Even not being insured (thus paying out of pocket) the cost was far lower than my insured care in the U.S.
There are also huge societal benefits to socialized healthcare. There are far fewer desperate homeless people in the UK, because many homeless people in the US are stuck in that situation in large part because of some health issue. There's just a fundamental feeling in the UK that we're all going through this life together.
For Multiple Sclerosis I was given one MRI and NO medications over the course of 12 years as I went from relapsing remitting to secondary progressive. Total postcode lottery so fuck the NHS.