UKC

David Cameron must be ecstatic about this.

In reply to Root1:

Why, what's happened?

In reply to Root1:

Former coalition minister predicts NHS collapse if there is no extra funding. Exactly what Cameron would like, if can get away with it.

In reply to Root1:

It's another no news day...so we'll talk about the good old nhs again.
I wish the government would go to!
leave the nhs in peace.
I'm stepping of the soap box now.

In reply to Root1:


Do you enjoy being so cynical?

In reply to Root1:

I don't think even Cameron would be stupid enough to let the NHS collapse. To do so would surely be political suicide.

In reply to Root1:

As someone with 32 years left to work in health care, since it seems inevitable that the NHS will collapse, the sooner the better, lets just get it over and done with, then we can at least move forward.

In reply to mypyrex:


Political suicide.. ..and business bonanza.. ..money money money for your mates. Political suicide in the short term loses to longer term further sequestration of markets and wealth.

In reply to mypyrex:

Also.. ..the fatal blow has already been struck with the recent NHS bill.. ..the actual collapse will probably happen on Labour's watch, who'll then get the blame!

In reply to Coel Hellier:


http://www.theguardian.com/society/2014/jun/04/coalition-attacks-nhs-return...

In reply to Root1:

The Health and Social Care Act 2012 effectively ended the NHS as most people would understand it - Healthcare for all, aimed at everyone, which is free at the point of delivery irrespective of illness (and the cost of that illness) paid for by the taxpayer. What we have now is rather different and certainly not something I imagine Nye Bevan would recognise.

The thing is the NHS is pretty monolithic, and we aren't each ill every day, so the changes have been coming slowly and haven't really been felt yet - but they are there in the policy and the law. For example, GPs which are part of GP consortia are now directly responsible for the cost of your treatment - in a way which they were not when PCTs were responsible for funding. This is good in that it is not a board of bureaucrats with one doctor on who get to decide on treatment costs; but it is bad in that the person who you could previously rely upon to advocate for you - your GP - now has a conflict of interest. This leaves those people least able to advocate for themselves - the elderly, ill, people with learning disabilities etc., with no advocate as they are unlikely to ask for a second opinion or fight for the treatment they need.

Additionally, the lifting of the amount of private work which may be undertaken by an NHS trust means that scarce resources will not necessarily go to those vulnerable people who need them. Imagine an elderly man needs a heart bypass for 'free' (although they may well have paid for it with tax) and also a rich person willing to pay for it privately - where are the resources allocated? Who gets the op? You can't simply rustle up another cardiac surgeon(or two, four ten, etc) in the Trust. It might be nice to think the money would go on more clinical staff, but the trend has been for more management (and management pay increases prior to the pay freeze), rather than front-line clinical staff and as management does the hiring this is likely to continue.

In addition, there is the possibility of treatment provided by 'any qualified provider' (this was any willing provider but got changed in a late draft!). At first blush this makes sense, but a deeper look suggests otherwise. In old style NHS clinics is was pretty easy for clinicians to get a consult with a colleague in an allied speciality, there was no cost implication so they could just wander over and ask what they needed to know. Now, and especially in private firms outside of the NHS, that is not the case - so each consult, each test ordered, must be considered and left off if possible. Of course if you pay more you get more - and we are Back to my point about Nye Bevan above.

That said, I don't believe the NHS will collapse. I fear though that it will become something akin to the US system with good healthcare for those (few) who can afford insurance (and then only for that which they are insured for)and Medicare for those who cannot. Medicare is really not the NHS - it's quite possible to have a curable condition under Medicare which is not cured (as this would be too expensive and is unnecessary for the person to go on living) but rather is treated such that you are able to leave hospital only to return again, and again, and again until - well, until you no longer need a hospital.

The question it seems to me is who benefits from all this? I guess it's pretty clear it's people who own private healthcare companies and private insurance companies as well as the average taxpayer - but that last one is only until they get sick...

ml

In reply to Mountain Lass:

Your post is spot on. Sadly.

In reply to Mountain Lass:

I am presuming these changes were England only as health is devolved to Wales and Scotland?

In reply to Saor Alba:


Scotland has ratified its own integrated health and social care bill, which has been met with a total failure of media reporting, or associated public debate. I'm afraid that the same ideas tendering, bidding, commissioning, non-statutory providers, tariffs are common at board level, so the directionality of travel appears very similar, though I haven't read the Scottish bill to see whether it facilitates the rapid privatisation that the England bill does. There is also the indirect downward pressure on the Barnett formula that NHS reforms in England will induce in Scotland.

In reply to Mountain Lass:
"the person who you could previously rely upon to advocate for you - your GP - now has a conflict of interest"

ITYM "the person who you could rely on to block you getting to a specialist". The more I think of it, the more I prefer the German system which allows direct access to one.

A European-style social insurance scheme (mandatory insurance based on the ability to pay, not the level of risk, with the option to top-up on a commercial basis for higher levels of care e.g. private dental) would be very well worth considering.

Neil

In reply to Root1:

Well said mountain lass. The NHS is being privatised from within, and oh boy is Joe Public in for a hell of a shock. I worked in the NHS for 33 yrs and its sad to see it destroyed
Not cynical. Realistic!

In reply to Root1:


It seems to me both sides of this debate are wrong. On the one hand you have this sort of statement essentially claiming privatised health services are intrinsically bad. This is clearly not true as many countries have private or partially private health systems that work well. On the other hand you have those claiming radical changes in NHS are necessary. Given that it works pretty well currently in terms of cost and outcomes, this seems a very high risk strategy. Underlying all this are demographic changes and increasing costs of health care which probably mean some changes in terms of funding and scope of what is provided are inevitable. I don't know what's best but hysterical claims about the NHS collapsing or a need to scrap it and use different system can't be a sensible way forard.

In reply to Root1:

Just waiting to find out how my aunt is doing. She went in to A&E at one of the flagship 'centres of excellence' hospitals late last night with severe chest pains ( she had major open heart surgery last year). Her daughter (my cousin) reported that almost 3 hours later (2am) she had still not seen a doctor, and when asked when she could expect to see one was told 'within 12 hours'.

Needless to say my cousin ( who had been in a senior nursing position within the NHS for many years) was less than impressed.

In reply to MG:

It depends what you mean by private, as well. Hospitals operated as independent charitable trusts (rather than businesses) might not be such a bad idea. What would be bad would be health paid for based on need, not on ability to pay.

The schemes in Germany and other European countries seem quite successful and can be more responsive to users' needs while not shutting people out in the manner of the US.

Neil

In reply to Neil Williams:

What would be bad would be health paid for based on need, not on ability to pay.

Yes, although I suspect rather fewer services offered to all regardless of ability to pay may happen regardless due the economics.



Yes, but note they cost quite a bit more - about 11% of GDP opposed to a little over 9% for the NHS. If NHS funding were increased to 11%, would it be more responsive?

In reply to MG:
"Yes, although I suspect rather fewer services offered to all regardless of ability to pay may happen regardless due the economics."

The NHS is funded by ability to pay, through the mechanism of income tax. I didn't mean "ability to pay a lump sum on the spot". I am opposed to that, as even those on higher incomes may not be able to do it (I could probably find an extra £100 a month in tax or insurance fees, say, but I would not be able to find £10,000 for an operation without taking a hefty loan out). My point was that any insurance based scheme (i.e. removal of the NHS from general taxation) should also follow income etc.

"If NHS funding were increased to 11%, would it be more responsive?"

Quite possibly. It's a similar argument to the railways - a BR funded to the high level of today's semi-private arrangement could well have been a world leader. (I won't say "like SNCF" because the UK's local and regional rail services are absolutely wonderful compared with SNCF - people are blinded by how good the TGV is and ignore the rest).

Neil

In reply to Root1:

Neoliberalism is more akin to a religion than a programme for rational change to improve society. I think the refusal to look straight at what the USA has done for itself is typical, though the powerful are not really in the habit of behaving honestly in looking at the world or themselves, as commonly understood anyway. So the transcendent ideal is always the True reason why society is failing, because we haven't got There yet; and to learn, we have to look past 'really existing neoliberalism', the failures, at what It should be, and thereby see what we are responsible for. (And they or we don't even have to really believe it, because rewards are material as well.) Thus they - who wanted more - are never responsible because we are responsible (or we aren't, we may tell ourselves, because we were not informed by our TV service). Ultimately, the failures only affect the sinners anyway, so it all rhymes and is always justifiable, to them and sometimes us, because we are only sometimes all in it together.

http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-hea...

I think they are fokking it up: they could have done it more smoothly but they figured they could use the 'crisis' of Austerity to shock, destroy and reform. Disorientation of the public hasn't panned out that well for them and people failed to manifest Homo Consumens sufficiently, often not for the want of trying. They are going to find out that it is not simple like extracting profits from water supplies or fixed infrastructures. It is complex and it involves too much living and breathing and dying, with interpersonal contact, to be done crudely. Even if some of us pick and choose from the 'new thinking' to suit ourselves, we are soon brought to earth and have to face reality when we cannot escape our own body's deterioration. There will be a backlash, especially because they misinterpreted the 'economic growth' with their stupid (transcendent) modelling, but it will depend for its strength on the ability of those working in the NHS and those they serve, to identify naturally with each other and fight the powerful selfish ones who only identify with...

I predict that Hunt will be dropped, having outlived his usefulness and actually lost the plot, and that they will throw some cash at it; all the while regarding what the more intelligent ones, Nu Labor, had in mind and practiced, and trying to learn what that was whilst wrestling with cognitive dissonance.

Here's something:

http://www.keepournhspublic.com/index.php


"The urgent need to find ways to control spending whilst maximising the efficiency and effectiveness of health care may be greater than before; but there is still little or no evidence that market-style reforms and the use of private-sector providers can deliver either efficiency or economy. The OECD country with the most notoriously expensive, the least inclusive and the most inequitable healt-care system is the one with the greatest reliance on 'market' forces and competing providers - the USA."
John Lister "Health Policy Reform - Global Health Versus Private Profit", p. 168.

Jon

In reply to Dorq:



The OECD country with the most notoriously expensive, the least inclusive and the most inequitable healt-care system is the one with the greatest reliance on 'market' forces and competing providers - the USA."



This obsession with the failings of the US system is a straw man. The US is one alternative to the NHS model. There are others.

The commonwealth fund report is basically an opinion poll of consumers which can reflect as much about their expectations as about the service they receive. Even that report acknowledges that the medical outcomes by the NHS are mediocre. Most research focused on outcomes rather than opinions (including the commonwealth funds' own 2007 report)shows that the UK does quite badly.

In reply to Mountain Lass:

"... the person who you could previously rely upon to advocate for you - your GP - now has a conflict of interest."
This is not strictly true, if you are suggesting that GPs & their practices will benefit from the Commissioning process as Clinical Commissioning Groups are membership organisations. The funding for General Practice comes from another source, NHS England, and not from the CCGs who only have funds for Hospital and Community care.
Most of them are as frustrated as you are that a)Patients have problems getting to see them and b)Patients have problems getting referrred to a consultant.
Why do people suggest we should be like the US system which costs twice as much as is much worse than the NHS? Bizarre!

In reply to Postmanpat:

Well anything is possible by virtue of design, but the analysis of people like Allyson Pollock shows that it *is* the US model to which we are headed.

In reply to Postmanpat:


Well that's not entirely true , is it? There are a number of large US health companies attempting to gain NHS contracts. It's not unreasonable to suppose they will push and perhaps succeed in getting aspects of the (profitable for them) US system in place here.

At best the current government seems to be instigating change for changes sake with no clear vision for where the NHS is going so the concerns do seem reasonable to me.

In reply to MG:


Many already have gained contracts. Which at least has the sense that they are companies experienced in delivering healthcare. Its the contracts given to companies with no history of health service provision that is the most insane!!!

In reply to contrariousjim:


"She would say that , wouldn't she…….?"

In reply to postmanpat
The outcomes in the American system granted are fine. If you can afford it. If not then the outcomes are dire.

The NHS needs to focus on the important issues.
Accident departments at night are filled with inebriated and often violet and aggressive patients. Frankly anyone causing trouble in A&E such as threatening behaviour to staff and other patients need to be fined very heavily. If they cannot pay then send in the bailiffs. If its tolerated then it will be regarded as acceptable behaviour. (Which it currently is).
Alcohol needs to priced at least at 50p a unit and the monies used to benefit the NHS.

In reply to contrariousjim:

But that isn't the bad bit of the US model any more than the bad bit of rail privatisation being any specific companies involved in running it. Quality of service in that area is near enough always dictated by who's running it. For one example, ScotRail isn't universally hated, but First Capital Connect and First Great Western seem very unpopular - both are run by the First Group.

The bad bit of the US model is that it is not a social insurance scheme and is based on risk, not ability to pay. There is no evidence that even if the UK moved to an insurance based system (and there are strong arguments for that) that such a system would be US-style and not European-style.

A monolithic delivery organisation is only one way of delivering services, and isn't always the most efficient nor the most patient-friendly. The key to me is that the ethos (you pay a "subscription" via taxation, or if necessary via a separate insurance payment, which is based solely on your ability to pay and not the cost of your treatment or the level of risk you pose) remains in place, and I have yet to see any evidence it won't.

Neil

In reply to Root1:


Well yes. But if you think your examples are the important issues of long-term funding of health-care you're deluded. Try demographics, cost of modern health-care, the role of the state, and the economic resources of the country instead.

In reply to MG:

That doesn't necessarily follow does it? Private companies have always sold equipment to the NHS but that doesn't mean they convert the NHS o the US model. They provided a product for a price.

In reply to Root1:

I agree that this is a massive issue, and not just in the NHS. In the US they take very seriously the issue of verbal/physical abuse of Government agents and the likes - hospital staff, bus drivers, whatever. Never understood why not here.

Neil

In reply to ill_bill:
It's also false that your GP is always your advocate. My experience in getting some rather obscure health issues dealt with was to be treated as a hypochondriac. I found the GP to be a brick wall, and because of strict catchment areas around here I couldn't even choose, let alone go to the relevant specialist directly.

The GP system works if you've got something well-known and easily diagnosed, even if the treatment is more complicated. It doesn't work if you've got a load of nonspecific symptoms and want to work with someone over a period of time to find out what they are. Or not if your only option is a large city based surgery (small single-doctor rural surgeries may well work better in this regard I suppose).

Neil

In reply to Postmanpat:


Not necessarily but the concern is there, particularly given the lack of an articulated vision of this government and revelations about minsters' close links with the companies involved. The US system isn't a strawman as you claimed.

As an example, have you ever seen US TV ads? About half are pushing various sorts of medicines or insurance or similar. Most of these are clearly unnecessary and will account for part of the huge cost of the US system. . Currently this sort of ad is largely banned in the UK but concern that there will be pressure from these commercial providers to change this is not unreasonable.

In reply to MG:

But then if you want to avoid funding that, given choice you can choose generics.

The bad thing about the US system is that people who need treatment can't afford it. Provided that issue is avoided, and there is not a massive amount of waste, I care very little about the structure of how it is provided. (Note that the NHS is no angel in terms of waste).

Neil

In reply to Neil Williams:



That's perhaps the worst aspect, I agree. Although it appears to changing. But surely the fact that is cost twice as much as the NHS for worse outcomes overall is an equally poor aspect?

(Note that the NHS is no angel in terms of waste).

Well it's among the cheapest of western health systems in terms of cost so its not that bad.

In reply to MG:

"That's perhaps the worst aspect, I agree. Although it appears to changing. But surely the fact that is cost twice as much as the NHS for worse outcomes overall is an equally poor aspect?"

It's poor, but not as poor. To me cost is secondary to people who are in need of treatment getting it. But it would make no sense to move to a costlier system (again think the railways - what we have now is as a whole quite good when compared to other European countries, but it's incredibly expensive to both the taxpayer and the farepayer).

"Well it's among the cheapest of western health systems in terms of cost so its not that bad."

True, but having used the German system I think it is sufficiently better to justify the extra cost.

Neil

In reply to Postmanpat:


Do you accept that it possibly isn't a straw man, with the US companies wanting to become part of health care in the UK?

In reply to Timmd:

In what way does US contractors bidding for NHS contracts cause the system to change to be the same one?

For example, does Deutsche Bahn (as Arriva), or Nederlandse Spoorwegen (as Abellio) bidding to run rail services cause us to change to a German or Dutch style system?

Neil

In reply to MG:




I've heard a medical specialist call it 'the cheapest', but I've not found the quite and the figures.

In reply to Neil Williams:




No, but you'll note the word 'possibly' in my post. The NHS is going through changes, with an as yet unclear outcome.

In reply to Postmanpat:


Are you saying an academic isn't being academic?!

In reply to Postmanpat:


One of the single most inflationary aspects of the NHS too!

In reply to MG



Well yes. But if you think your examples are the important issues of long-term funding of health-care you're deluded. Try demographics, cost of modern health-care, the role of the state, and the economic resources of the country instead.

Hardly the most important issue but exactly that .....an example

In reply to Postmanpat:




Perhaps you are right. We should, most of us, be worried about the obsession with the successes of the US system, and decide what to do about the obessed.



Have the people spoken? I must have been distracted.


Yes, self-reporting has been shown to be problematic, most eloquently by Amartya Sen. Perhaps we should focus on bankruptcies of the sick (and or victim?). Or is there a way of parsing such a 'haircut' that would make even that sound more like healthy discipline?

Jon

In reply to Dorq:


Why would we want to do that? We should take note of both, obviously.


Which people, about what?

Why wouldn't we focus on the outcomes?

Rather bizarrely you seem to continue to be obsessing about the US system. Why?

In reply to Root1:



If it is being destroyed it's being done by its users rather than govt.

Until people realize that expecting a blank cheque treatment regime to sort out their personal lifestyle choices is going to bankrupt the NHS then nothing is going to change.
RECORD levels of obesity
RECORD levels of diabeties
Record levels of lifestyle Cancers

In reply to Indy:
Agreed

Agreed

Would be interested, from a personal point of view, to hear what constitutes a life style cancer

In reply to Indy:

Christ, give it a break. The N is NHS stands for NATIONAL, its not just for gym obsessed, muesli eating sandal wearing self righteous punters from South East England.

In reverse order: 'Record level of lifestyle cancers' Well yes, that is inevitable as we live longer - we are going to die of something.

'RECORD levels of diabeties' (sic) yes that's true, partly arising from MASSIVE changes in diet 30 - 50 years ago as affluence kicked in and lifestyles changed (one of the causes of diabetes is not what you are eating now, but the change between what you were eating as a child and what you went on to eat as an adult.)

'RECORD levels of obesity' Yes, that is tragic; strange how the govt resists attempts to control advertising and promotion of unhealthy food. Remind me just who is sponsoring the World Cup? Which clown appears regularly on children's TV? Which govt actively denigrates PE provision? What has happened to school playing fields over the last 20 years? Which govt stands by as cuts decimate provision of affordable exercise opportunities by local authorities?

Fat, diabetic cancer ridden patients are people too, and our NHS has to cope at the same time as the government has to address root causes.

In reply to mypyrex:


Smoking, poor diet, sun exposure etc etc take your pick.

In reply to Indy:

No, what TYPE of cancer would you consider to be induced by lifestyle

In reply to Rob Exile Ward:


That's pretty shocking..... your saying that people can be as irresponsible towards their health as they like because the NHS has a GOD DAMN obligation to treat them at whatever cost. Unfortunately your thinking is going to bankrupt the NHS for everybody.

The govt. has done pretty much everything they can do in a democracy unless you have Nazi style prohibitions. There needs to be consequences if you choose to be obese then you pay say the first 20% of your treatment.

In reply to mypyrex:

Poor diet for 1....

“Many people believe cancer is down to fate or ‘in the genes’ and that it is the luck of the draw whether they get it,” said Professor Max Parkin, the report’s main author and an epidemiologist at Queen Mary University of London. “Looking at all the evidence it’s clear that around 40% of all cancers are caused by things we mostly have the power to change.”

How much would a 40% drop in cancer care costs save the NHS not to mention the benefits to the economy.

In reply to Indy:

Doesn't work. If only because that means they won't be treated, and I think for them to be treated then put effort into losing weight is the way to go.

The only solution to this unless we go US-style is taxation on those foods that are likely to cause obesity, in order to cover its costs. This is the same as my view on tobacco and alcohol, FWIW.

But more to the point, what measure do you propose? Quite a lot of climbers would come in higher up the BMI scale, as would weightlifters, despite not being fat...

Neil

In reply to Indy:

'How much would a 40% drop in cancer care costs save the NHS not to mention the benefits to the economy.'

Are you interested in a sensible answer, or do you think you 'know'.

Because the answer is: feck all.

In reply to Rob Exile Ward:




how about a 40% drop in diabetes care costs?

In reply to Indy:

'Unfortunately your thinking is going to bankrupt the NHS for everybody.'

Whereas it should in fact be the preserve of the righteous and the healthy. Not sure that Nye would have gone along with that though.

In reply to Root1:

S'okay some one will be along to save it any minute now. Rolls eyes.

D

In reply to Rob Exile Ward:




From the NHS

One of the aims identified of engaging people more closely in their personal health and well-being is to increase the number of quality of life years they experience; preventing illness and prolonging life. The shift within the NHS in focus from sickness and cure to wellness and prevention reflects the fact that the management of long term medical conditions and other issues relating to old age are of increasing concern. These trends are discussed in greater detail in the Wanless reports which also outline that a more engaged public with higher levels of well-being will assist in relieving the financial pressure of such situations by remaining healthier for longer

In reply to Postmanpat:

Who could disagree with that? Not me. I'm all for engaging the public, making us all take more responsibility for our health choices (short of banning climbing or skiing, obviously, though those are the activities that have are implicated in my arthritis and a few other injuries on the way...) having a more holistic approach to health issues: starting with more investment in schools, in health education, in better meals, - even more water fountains would help! - more encouragement and facilities for sport; to legislating AGAINST the interests of industry: no advertising on cigarettes, graphic health warnings on unhealthy foods, ('this large portion will make you fat, it contains at least twice as many calories as you could possibly need, and will contribute to you dying a slow, painful and undignified death')...limits to pack sizes, ban on sponsorship of sports by inappropriate companies...

I really don't like the patronising, self righteous them vs us attitude that seems to be pervading this thread. And yes, I can see how that might be seen as ironic.

In reply to Rob Exile Ward:

Well surely that quote implies that lowering cancer rates would save money. So I I'm not sure what point you were making.

In reply to Indy:
The point I was trying to make is that not all cancers are necessarily a result of life style, whilst some admittedly are and some result from circumstances over which we have little or no control.

In reply to Rob Exile Ward:

I have no doubt that when the NHS was founded there was no need to talk about personal responsibility when it came to healthcare which is why the NHS charter only speaks of patients rights. Do you honestly think that Mr. Beven would approve of spending £100 million on gastric band surgery for people who find it too hard to resist overeating when others are being turned down for needed medication due to cost?

In reply to contrariousjim:


Heaven forbid……..

In reply to Rob Exile Ward:


Well put.

***

One of the further demands made on NHS staff, is that they act (or be?) compassionate. That they don't judge us when it is obvious that we hurt ourselves. The possibility that we are victims of our own habitual stupidity, when seen from above, is an essential shared-consideration, one that is required if we are to follow the advice that is then given. We can only empower ourselves when we respect ourselves, and being initially respected by a compassionate yet objective person is a foundation for creative change. It is important that someone in conflict with themselves is respected completely, not just when they show a correct face to society.

Once we understand responsibility by living it, we can also more easily make demands on others, especially the politically, socially, and economically powerful others who have so much influence inside and outside of our bodies, in the processes of living. No one really believes that society is dead, or that it never existed. Most people see it when they feel they belong to it and that it can be fixed in some way if everyone puts something into it. They don't necessarily want a model from above, especially if they know what is good for them/us.

Because a divided self doesn't have any energy left over to help heal society, its important that our (unifying) respect for ourselves exists first, so we can act in a way that understands and recognises human limitations and isn't hampered by hypocrisy. This knowledge of how we all make mistakes helps us be more strict in our demands of important, responsible others. (Perhaps the threat of all that is why we are encouraged to dislike ourselves so much, besides the obvious insecure-consumerist basis.) In other words, people who are internally divided are more easily divided amongst themselves.

We should probably incorporate more 'nudges', like taxes on harmful food such as refined carbohydrates; actually we may have no choice. But 'sin taxes' may only lead to a sense of entitlement and a vicious circle. Perhaps these 'bad consumption' sin taxes could go to the UN or some such international organisation, to help the less privileged abroad. We could pay for the NHS by taxes on other excesses, other more traditional 'sins', such as those recognised by the ones returning from the last World War: sins of excess that always serve in the end to divide society and by their internalisation, ourselves.

Jon

In reply to Root1:

Would this work in the UK?


I'm with BUPA for mine.

In reply to Root1:

Patients have increasingly high expectations, live longer and require more interventions in terms of medications and operations in their lifetimes. The nhs is slightly crap but very cheap compared with the alternative systems. To make it better as a country you can spend more on it proportionally,reducing defence , foreign aid etc or tax more.
To make it better as an individual you can buy insurance or self fund to see a private specialist.

What won't happen is the nhs getting better by spending the same as demand rises.
Equally nor will further pointless top down expensive reorganisations help.

I voted for these guys as they said they would ' leave the nhs to manage itself'
Followed by the largest top down reorganisation of my short 16 year medical career.


The system now has , for example, my patient seeing a private specialist in a private hospital on the nhs within 3 weeks, they would rather do that than spend £50 pound excess on their insurance policy to see the same bloke at the same hospital. Can't blame the patient! However the nhs cannot afford to provide that level of service at the current level of funding.

Examples like this underpin the concerns re collapse in 5 years. Opening up nhs contracts to private providers routes large amounts of money their way to deal with low maintainence profitable operations leaving less of the fixed budget for the old, frail, or those with mental health or other issues( who are excluded from being seen for operations in the private hospitals under nhs contracts)

'To each according to need'no longer applies, and the system of fair, slightly crap but very cheap cannot survive without it.

Surely one of the biggest problems faced by the NHS is the ridiculous salaries paid to an unnecessarily high number of non-productive administrators and managers. These in turn seem only interested in setting targets irrespective of whether or not standards of health care are maintained or even achieved. I know there has to be some sort of management system in any organisation but I do wonder if that for the NHS(and other public services) is far too top heavy.

In reply to Indy:


Is it f*ck, and in any case the causes of for example obesity are not so easily dismissed. Yes, the simple formula that consuming more than you use holds true, but people who suffer these problems tend to be of lower socio-economic class, live in areas where the cheapest most easily accessible food is of a high calorie. Psychological factors are also hugely important in the reasons why people over eat. Disaffection, poverty, joblessness are drivers to the lack of self worth that drives addictive behaviours. There is also evidence that parental behaviour is contributory to the predispositions of children to diabetes and obesity. So it is far from good enough, and societally irresponsible, to place all the responsibility at the feet of those who suffer these problems. The NHS does have an obligation to treat all these issues, and the thing that will help to correct these problems is proper education, education about these issues, laws on high street fast food outlets (not to mention gambling, loan companies that occupy the same kinds of spaces), jobs and targeted social engineering etc.

In reply to mypyrex:


The factors contributing to almost all cancers are environmental (smoking, drinking, diet - too much, too little of the good stuff, pollution, viruses and othe infective agents, UV), and genetic (family history, single genetic mutations that predispose, constellations of genetic mutations weak in their own right, but which together contribute to causing cancer).

In reply to contrariousjim:
>
Well, actually, yes it is. You can argue about the underlying causes of "lifestyle diseases" and the best way to reduce them, but at their current rate of growth they will bankrupt the NHS-at least that's what we are told from all sides.

In reply to Rob Exile Ward:


Absolutely right. The best that can be done is changing when people die, and alter the diseases that they do die of. If you successfully treat one disease, people will live slightly longer, and die of a different disease. The best that does for the economics is to bring a small hiatus in health costs imposed commensurate with increased longeavity. It doesn't reduce the costs at all, it only briefly postpones them. Worse, though is the fact that longeavity isn't producing increased productivity.. ..that is to say people living longer are not living proportionally functional lives. So the increased costs don't come with a proportional increase in tax receipts. Worse, the evidence is that there is an increasing proportion of people with chronic diseases and an increase in proportion of people with multipathology, which is expensive, and so costs actually seem to be increasing with increased longeavity that comes from succesful treatment of diseases at a younger age. In my view the best answer to that is to have accept that there will be a limit to what the health service can afford, and while we will always strive to do more, the fairest thing in society is to provide an equality of healthcare across the board with rationing of what can be afforded. It is not to say that we should allow the rich to distort the structure of the NHS to their own advantage.

In reply to contrariousjim:
I have known several people to be afflicted by Lymphoma. I would never have described the lifestyles of any of these people to have been anything other than healthy either in diet or exercise regimes. My Mrs' son was afflicted with it about thirteen years ago, never having smoked, drunk to excess worked in polluted atmospheres etc. He regularly climbed and played golf and thankfully still does.

Earlier this year I too was diagnosed with it. Similarly I would not consider myself to have led a particularly unhealthy life style. Yes, I smoked a pipe for about three years but that was thirty to forty years ago. I've always enjoyed a drink but the days when I did so to excess are a dim and distant memory.

When I was diagnosed I was told that Lymphoma is one illness, the cause of which cannot necessarily be identified with any particular lifestyle. Thankfully those sufferers I have known have made good recoveries and I am grateful, not least to the NHS professionals, that my treatment appears to be going to plan.

In reply to Postmanpat:

You can't bankrupt the NHS.. ..you can rather say that that's the pot of funds and do with it what you can. But when pre austerity we were spending only just above the european avg on our healthcare, and that on a b/g of decades of lack of capital investment (compared to our European neighbours), its a pretty specious evil argument to make that has more to do with ideology and preference for spending on other sectors, and keeping a low tax environment.

In reply to contrariousjim:

Excellent and true.

One day I think I will pick up the Daily Mail accidentally and find them blaming the high levels of inequality on the poor. Or do they do that already? Only a select few find inequality delicious and even they don't benefit, when seen objectively.

Nobody wants to f*ck up their life vehicle. I think Socrates is famous for saying that 'nobody knowingly does wrong'. Even suicide is done by a person to themselves, that is, by a person at war with themselves, or it could be argued anyway. We always think we are doing the right thing and finding out the opposite is too painful for daily awareness. Lying is a form of self-protection and we are afraid to admit how much fear is in our lives.

And there just isn't any billion-years-old reason hardwired inside us to fokk up this body from infancy on. So many things in our culture and society must be mismatched.

We could start blaming our grandparents though, as research shows that their diet/lifestyle influences our life chances. Its a shame they were so poorly nourished and protected before all the welfare state stuff started happening. Stupid fookin grandparents, without them I could have gone further.

In reply to contrariousjim:

Don't some diseases cost more than others though? Cancer treatments seems highly expensive. If instead of dying of cancers some people died in the street of, say, massive heart attacks with no health care costs, wouldn't that save money?

In reply to contrariousjim:


As you well know "bankrupt the NHS" is a common turn of phrase. In this case it means "make it unsustainably expensive"

In reply to contrariousjim:



The quote I sued above from the NHS seems to suggest that they believe that reducing the incidence of well know chronic/lifestyle) diseases would reduce financial pressure. Are they wrong? Or is the effort to do so pointless in financial terms?

(One of the aims identified of engaging people more closely in their personal health and well-being is to increase the number of quality of life years they experience; preventing illness and prolonging life. The shift within the NHS in focus from sickness and cure to wellness and prevention reflects the fact that the management of long term medical conditions and other issues relating to old age are of increasing concern. These trends are discussed in greater detail in the Wanless reports which also outline that a more engaged public with higher levels of well-being will assist in relieving the financial pressure of such situations by remaining healthier for longer)

In reply to Postmanpat:


We've been rationing for many years. The words "bankruptcy" and "unsustainability" are being deliberately and ideologically projected into an area where the solution has already been being used for decades.. ..rationing. Why is this language being use.. ..when spending has been so historically low.. ..well because there are many people ideologically opposed to the existing structure of the NHS.

In reply to Dorq:

Correct.

And can we just dismiss the idea that the private sector has anything other than a minor role to play in healthcare. If the private sector is involved in providing services, paid for by the NHS, then how does it increase profits (which legally is obliged to do)?: by cutting costs, is one way - not sexy, hard work, and usually a blunt instrument - or by increasing demand - which is sexy, fun and even better when the increased demand is paid for by the taxpayer! Increased private provision of healthcare as a solution to NHS funding is like pouring petrol on a fire to quench it.

And as for funding: what possible role can introducing insurance play? If we are all obliged to contribute to a private sector insurance scheme then that is basically another tax with the disadvantage that we have to pay an additional 10% to generate profits for the company. And there's another issue with insurance: they will always be looking at ways of maximising profit and minimising risk, again that's what they do: so what premiums are they going to offer a poor person with an unhealthy lifestyle, vs a comfortable off middle class professional with a healthy lifestyle? Not to mention pressure to introduce genetic screening.

In a mad world, a publically funded NHS is one of the few beacons of rationality. And we have to make it work better; there's no sensible alternative.

In reply to contrariousjim:


And that solution has been found to be politically unviable. As demand rises so rationing becomes more severe so service and outcomes decline relative to need and expectation.

Hence the use of the language.

In reply to Rob Exile Ward:

"And we have to make it work better; there's no sensible alternative."

Near enough every other country in the world disagrees. The social insurance schemes of Europe seem quite effective.

Neil

In reply to Postmanpat:



"Bankruptcy", "unviable", "collapse" etc all imply a cliff edge type failure of the service. "Rationing" implies a coherent reduction in what is available. These are different things.

In reply to Neil Williams:

"And we have to make it work better; there's no sensible alternative."

Historical happenstance. The Q is really: which has the most resilient way of dealing with the pinch that will come with the restriction of resources compared to health costs> The A is the NHS, because it is publically funded and already has the mechanisms to ration on and equal basis. The rich can harp all they want and go and buy their top up care from BUPA, but do not destruct the one mechanism that is capable of being future proof.

In reply to MG:


I didn't suggest they were the same thing. Nor is "unsustainable" the same as "collapse". The point is that rationing can only go so far before the decline in service becomes unacceptable, which is what had happened by 1997.

Rationing will continue to be a fact of NHS life but that is not exclusive to alternative methods of provision and reduction of demand, however much ideologues of the left might prefer that to be so.

In reply to Postmanpat:


Wasn't the problem then more that services *weren't* rationed but instead it was attempted to maintain a full range with poor results. If instead having you leg off (say) had been removed from what the NHS offered, the remaining services would have been better funder, and this would have been rationing.




Probably true but if (as you constantly hint) you would prefer a different mechanism of provision, you need to show what the benefits will be for a given level of funding.

In reply to MG:


On the contrary, given that mixed provision is a standard feature of healthcare systems which achieve relatively good medical outcomes all over the world the onus is on the refusniks to prove their point.

In reply to Postmanpat:


Well not really when the NHS, for the level of funding, produces as good if not better outcomes than the other systems. That other effective systems exist and may be more common isn't in itself a reason to change to them. If you are proposing change (to what?) the burden of proof is definitely on you to explain the benefits and also why the risk and upheaval of change is worthwhile. I've yet to see any good argument for why major change is beneficial (particularly noting your point above that rationing and costs are problem for all systems).

In reply to MG:


And also, the requirement to consider which mechanism of funding will be future proof at the same time as being capable of an equality of provision.

In reply to contrariousjim:
*An* answer is the NHS. Other answers include (and this might be fairer than the NHS postcode lottery) a national health insurance company at which you take out a policy, and that policy states what you're covered for.

Neil

In reply to Rob Exile Ward:

I would venture the view that the private sector has a massive role to play in the NHS as it is at present.

1. GP surgeries are private companies, so are dental practices. Most people know the latter, not many know the former.

2. The drug companies are all private.

3. Many non-medical services the NHS uses - parking attendants, restaurants/food, cleaning etc - are privately provided under contract. As often is non-emergency transport.

4. The NHS doesn't produce its own paper, printer ink, computers, paperclips, folders etc. That cost will be huge and will be privately fulfilled.

I'd be interested to see the figures as to what proportion it actually is.

Neil

In reply to MG:

>
Given the relatively poor outcomes and the growing financial pressures of our existing model it would surely be negligent not to explore the alternatives. This does not imply sudden wholesale change to a model of private provision. It means enabling private provision and monitoring the costs and outcomes: just what jim is objecting to.

In reply to Postmanpat:

Relative to what? The numbers I see are low costs (absolute and relative to GDP and other countries) for good or sometimes excellent outcomes in terms of child mortality, life expectancy etc.

and the growing financial pressures of our existing model

Above you noted that these are not specific to the existing model

it would surely be negligent not to explore the alternatives.

What do you mean by exploring? Looking at other models and seeing if they offer benefits seems very sensible, yes. But as I noted above, before changing there would need to be good evidence of advantages. Doing so for idealogical reasons, or simply jumping in the dark to a different system makes no sense.

In reply to MG:

There isn't necessarily a need to change lock, stock and barrel anyway. Different systems can be tried out in different areas "under" the NHS, e.g. the NHS can buy certain services in certain areas and run others themselves.

Neil

In reply to MG:

Relative to many/most other developed countries in key diseases and causes of death.



Which doesn't mean it's not a problem to which solutions need to be explored.



Despite what the refusniks pretend there is lots of work done on this and plenty of evidence of its benefits (and of its downside). There is certainly enough evidence and analysis to make it more than reasonable to try it in practice-which is of course happening-and give commissioning bodies the option rouse private provision. "Jumping into the dark" is an odd description of something which happens all over the world, has been the subject of much research and debate, and happens already in the NHS.

In reply to Postmanpat:


According to this for most key diseases etc we rank in the top 10-15 countries globally.

http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf

Given that and a health system that spends less than most other countries ranked above us, I don't see very much wrong with the current system. I've no objection to trying new things and experimenting but it needs to be done honestly. I think your enthusiasm for change is driven by an ideological zeal for private enterprise of public provision.

In reply to Neil Williams:

If it's a for profit company with shareholders, how will introducing such a company ensure an equality of provision, irrespective of means, and which is future proof? How would premiums be prevented from being tailored according to risk? If such a company was required not to tailor according to risk, how could it be profitable without simply increasing premiums across the board to address profit? Why on earth would that be better than what we have?

In reply to contrariousjim:
As an example, imagine five companies competing for the NHS leg amputation contract. The one that meets the leg-off requirements (care, experience, etc.) for the lowest cost wins the contract. This seems to work with many other types of contract pretty well. I can see the potential for it working with the NHS, just not currently the evidence for it being cheaper or more effective.

In reply to MG:

And according to e.g.. the Eurohealth report and NAO and we are mediocre at best. The former notes that "Bismarkian" models which do not discriminate between public, private for profit an private not for profit consistently do better in providing user value. Small scale "Beveridge models" do OK but large scale ones as in the UK and Italy struggle.

Studies of "excellence" in health services note that where improvements have been made (eg.in the veterans health service in the US) one of the key elements has been to devolve responsibility downwards and allow these units to develop their own solutions. No reason these cannot include non public provision.

In reply to Neil Williams:


GP surgeries are private, and its one of the problems with the NHS, with the move to smaller number of surgery owners, and increased numbers of salaried GPs, which is resulting in class of GPs with lower wages who don't see the worth in continuing in the job, and so, well don't. In any case, its not fully private given the massive structures like QOF which determines surgery pay according to performance targets.


One of the most inflationary aspects of the NHS! Good argument to bring drug companies into public ownership.. ..integrate a public drug company with the NHS.. ..integrate NHS care with presumed consent for teaching and research (and organ transplantation).


Another example being privatised hospital cleaners.. ..resulting in private company not orientated toward the clinical issues associated with hospital cleanliness. Yet hospital cleanliness *is* a clinical issue that is essential in hospital perfomance and preventing morbidities associated with hospital care. This privatisation has been associated with increases in hospital acquired infections.


Again, very costly and inflationary aspects of the NHS.

In reply to Postmanpat:



A very quick look http://en.wikipedia.org/wiki/Euro_health_consumer_index
suggests that's not really true either. England/Scotland are ranked highly on all measures except waiting times and pharmaceutical(??) . Since waiting times are going to very closely related to funding, which is low the UK, I still don't see how your data makes case for changing the system, rather than increasing funding, if we want better outcomes.

In reply to contrariousjim:
"If it's a for profit company with shareholders"

Who says it has to be? In many European countries it isn't. In Germany for example you have the statutory Allgemeine Ortskrankenkassen which do this, or you can choose private health instead in some situations.

"If such a company was required not to tailor according to risk, how could it be profitable without simply increasing premiums across the board to address profit?"

Top-ups is one way they can do it. Some people (me included) think private health insurance is a bit expensive so don't bother with it even though we have a company scheme (the tax alone is a bit much). But in countries with an insurance system it needn't be that clear cut. So you could for example have the basic legal minimum (what the NHS provides), then add top-up insurance to, for example, pay for a private room if you're going to be in hospital, or pay extra for the right to miss out the GP and go straight to a specialist, or pay extra so you'll get non-emergency treatment on a weekend, or whatever.

"Why on earth would that be better than what we have?"

Choice, mainly, and possibly the ability to get things dealt with more quickly or more conveniently to you if you wish to pay for that, without having to exit the "NHS" entirely for such treatment.

Neil

In reply to MG:

Sure, but that presumes redundancy in the system i.e. more than one provider capable of competing within a locale. We currently don't have that in the efficient stripped down NHS, and while there is plenty of space for private providers to compete (e.g. on reduced waiting times versus increased cost) there is very little relative uptake and introduction of these services. Thus the changes within the NHS bill that even up this process by allowing for any qualified provider, which apparently includes companies who have had no historical experience of healthcare provision being offered contracts on the basis of low tenders. Plus the fact its a one way process. Once an NHS provider is lost, the jobs go, the infrastructure is re-allocated or sold, and there will be no provider within the NHS capable of taking up the service again because they don't exist there any more, and the only other factor to persuade them to take up such a service again is profit. Its a one way process to privatisation, and tory govt knew it when they introduced it.

In reply to MG:

Depends on whether the companies in question spend their wages bill on getting some good sales staff and extremely good lawyers.
Its very difficult to write a contract and KPIs which cant then be gamed by the provider.

In reply to contrariousjim:
"GP surgeries are private, and its one of the problems with the NHS, with the move to smaller number of surgery owners, and increased numbers of salaried GPs, which is resulting in class of GPs with lower wages who don't see the worth in continuing in the job, and so, well don't. In any case, its not fully private given the massive structures like QOF which determines surgery pay according to performance targets."

I'd question in some ways if we even need GPs in the gatekeeper role they are in. They are clearly useful to some, but not to others. In some ways it would be far more efficient if you could go straight to the relevant specialist's clinic if you knew you needed that specialist.

If I have a problem with my teeth, I can go straight to a dentist, be that an NHS one or a private one. Why not in other areas of very clear-cut healthcare?

Neil

In reply to Neil Williams:


You're effectively describing the status quo. Not something we need to change to!

In reply to Neil Williams:


You already have that choice. You just have to pay your extra for it.

In reply to dissonance:

No, I understand that, which is why I am sceptical about the effectiveness of private provision being better. But the principle is sound and does work in many areas.

In reply to MG:



Outcomes the UK is 18th. Ultimately isn't that what counts.

According to Eurohealth survey of ten major countries England and Scotland compete for bottom place(generally with each other) at perinatal mortality, infant mortality,deaths from cancer,deaths from breast cancer,deaths from circulatory diseases,deaths from ischaemic heart disease, and five year survival rates for lung cancer,great cancer, colon cancer,and prostrate cancer.

Waiting times is one of the key areas where private provision has been demonstrated to have beneficial effect.

In reply to contrariousjim:

No, I'm not.

At present, if you go private, you go fully private and you have to have insurance (or pay yourself) to cover the full cost of treatment. Indeed, in some areas of the NHS top-up treatment is specifically banned (though dental is perhaps one example where it isn't and it works reasonably OK - you can either have the free silver filling or pay for that filling to be done white privately by the same dentist, while still having the adjacent crown on the NHS, say).

These sort of top-ups would mean you have insurance with a better level of cover - the basic insurance still costs you the basic, regulated, income-based sum, then the top-up costs you a little extra for the thing you want to top up. No need to insure ground-up for private treatment like here.

I would definitely consider a top-up that would allow for missing out the GP and for weekend appointments, for instance.

Neil

In reply to contrariousjim:

Where the extra is the full cost of the treatment outside the NHS, either via insurance or on your credit card. That's not the same at all.

Neil

In reply to Neil Williams:

Why not in other areas of very clear-cut healthcare?

One argument is that you are self-diagnosing. Going with shoulder pain to a shoulder doctor is fine if your shoulder is actually the problem. If however it is a sign of leprosy (or whatever) the shoulder doctor might miss it. The idea is the GP knows more about which direction to send you than you do, and can also filter out time wasters.

In reply to Postmanpat:


If that's correct, someone needs to sort out these statistics because those findings are at odds with OECDs findings. Making decisions on such flaky data is even more wild!

In reply to MG:

"One argument is that you are self-diagnosing."

Yes, that's exactly what I'm doing, because I'm better at knowing what I'm feeling than someone who's just getting a slightly poor verbal description of it.

(I know this having had very complicated health issues for a number of years which were caused by a combination of a silent[1] tooth abscess and gluten intolerance, all now resolved).

[1] i.e. painless but still causing problems

Neil

In reply to Neil Williams:



Yeah but most people won't be very good at it. I don't know if the argument really works but that is one justification of the GP system.

In reply to Neil Williams:


Now you're just arguing for greater funding ontop of basic. There's no reason not to do that through the efficient system of the NHS, especially given the historical capital underinvestment in the NHS compared to our European neighbours, and the fact that our investment (pre-austerity) was only just above the European or OECD avg.

In reply to contrariousjim:
No, I'm arguing for choice. So I can choose to pay extra on a commercial basis for extra services, but you don't have to.

The basic NHS - the bit that keeps you alive but not exactly in luxury circumstances, would effectively remain.

There is another railway parallel here - standard class fares are heavily regulated, but they can charge what they like for first class. But if you do want to go first class, you don't have to buy both types of ticket then throw the standard one in the bin. That's effectively how the NHS is now.

Neil

In reply to MG:

Such as the pretty common causes of diaphragmatic irritation from abdominal viscera.

In reply to Neil Williams:


Choice doesn't really exist because there isn't redundancy within our health system. To provide that redundancy is hugely inflationary, which is why so few companies actually do it. So to do so, you have to accept that you will need to increase infrastructure across the board.. ..how will those costs not be passed on to the tax payer or the consumer in great excess of the status quo?

In reply to MG:


Not really. If you look at the outcome data in the OECD report-eg.mortality from colectoral cancer, survival rates from heart attacks and strokes, they show much the same thing. The UK is well down the rankings.

In reply to Postmanpat:

With exception of the US, health outcomes from the OECD data seem very closely correlated with health expenditure. I would suggest the rather obvious conclusion is that if we want better healthcare, we need to pay more for it. The systems used to deliver it are secondary. This is of course brings us back to demographic changes and the economy.

In reply to contrariousjim:

"Choice doesn't really exist because there isn't redundancy within our health system."

There doesn't necessarily need to be. One key improvement might be to allow people to attend a GP where convenient, e.g. near work. That would mean larger surgeries in some places than others, but would also mean smaller ones in primarily residential areas.

Neil

In reply to MG:


I'm not sure the OECD survey has enough hard outcome date to demonstrate that. The Eurohelath data shows a pretty varied pattern with the exception that the UK is nearly always at the bottom although its spending per capita is not the lowest!

Either way, it doesn't seem to suggest that everything is so hunky dory we should outlaw private provision on ideological grounds.

In reply to Postmanpat:
The Eurohelath data shows a pretty varied pattern with the exception that the UK is nearly always at the bottom

We're seeing different things here - England 5th best for range of services and 5th best for prevention? 4th best for information and right?

In reply to Neil Williams:


Okay, but that freedom doesn't need any of the private provision or insurance systems you've been suggesting.. ..it just requires liberalisation of the requirements for GP registration within the existing system. There are many many such improvements that can be made, placing requirements on opening times for working people etc. But those changes don't necessitate new insurance systems or increased redundancy that comes with private provision. And indeed, one of the main ways that the NHS could be made more efficient is to reduce the extent of specialisation (with a commensurate increase in on the job training) to have more generalists that can do more without having to refer, with sub-specialisation being more unique for the more difficult clinical problems. The two main reasons for GP underperformance is a huge change in attendance patterns, the worried well have increased hugely, increased chronic care requirements, the loss of community / social contraction and attendance at GP for social reasons, as well as increased awareness of illness. GP numbers haven't increased commensurately, and the proportion of female workers who work part time has also brought new workforce issues. Another easily addressable factor is GP training which has been reduced with the MTAS/MMC changes, so it has been possible to have only 3yrs of specific GP training (vs say 9yrs for paediatrics, or 5.5yrs for pathology.. ..my discipline). It's recently been increased to 4yrs against huge traction from govt, but it should be more for a true gatekeeper service that is fit for purpose in the unprotected environment that is primary care. Again, these are things that should be happening, but haven't mostly because Tony Blair wanted to be able to say he'd produced X new GPs and X new consultants, which has only had a destructive effect despite the increased improvements in clinical care, which are mostly driven professionally from within the various disciplines. Again, this is not going to be addressed by insurance or increased redundancy to bring about private provision.

In reply to MG:



I'm looking at outcomes. Whether people survive! A lot of the other stuff, whilst obviously important, is very subjective and not much use if you die anyway.

In reply to Postmanpat:

That's not the only measure, though - quality of life is also significant.

The NHS is, generally speaking, quite good at stopping people dying. It does fail a bit on quality of life, though.

One thing it really could do with changing is its atrocious approach to sports injuries. It would be to great benefit if sports injuries were handled on the NHS, because sport is to the greater health benefit of people generally. Some people (I'm one) have no willpower and consequently never lose weight by controlling food alone. What I can generally motivate myself to do is a relatively large amount of exercise and so to do it that way. But it's no good if I get hurt and the doctor tells me things like "if you get hurt running, don't run".

Neil

In reply to Postmanpat:

Well I don't see that data on the page I linked above but it is in teh OECD report and again UK (combined here) seems pretty good - around 15th globally. Again bear in mind what we spend on health - 14th globally.

In reply to Postmanpat:

'Either way, it doesn't seem to suggest that everything is so hunky dory we should outlaw private provision on ideological grounds. '

I don't, I'm suggesting we outlaw private provision on practical and compassionate grounds.

Can you imagine the run on people's wallets if snake oil salesman - sorry, big pharma - had the right to advertise their wares and generate demand: 'Tickly cough, feeling under the weather, stressed? YOU MAY HAVE CANCER so take these pills - £1000 a pop - and you'll live for ever.' An adman's dream, making a fortune from spreading fear, uncertainty and doubt.

And BUPA are constantly doing it already with their 'screening programs', their easy solutions to early diagnosed problems etc.

In reply to MG:


I didn't get a page. I got the whole report. Which page?

In reply to Postmanpat:

http://en.wikipedia.org/wiki/Euro_health_consumer_index

In reply to MG:


Its not just what we spend, its what we have spent decades not spending compared to our EU neighbours, and which isn't reflected in the figures of per capita or as a proportion of GDP annualised spending. So what we spend has to be used to bring infrastructure up to date, or used less efficiently in the background of poorer infrastructure, for example, rather than being spent directly on care within an up to date infrastructure. So what we really need is sustained above avg investment to catch up on those performance areas at which we lag.

In reply to Neil Williams:


I kind of agree with the doc to an extent Neil, there is a balance to be struck there, and the doc is perhaps trying gently to confront it.

if someone are not relying on sport for their living, and they become repeatedly injured in recreational sport, it could be argued thatthose people have a civic duty not to heap further unncessary burdon on the NHS, as well as their employers, with constant referals and time off work.

I know at least one chap like that (known as sicknote) who fits that bill.
(Some peoples bodies are just not up to sports)

In reply to contrariousjim:

That and the infrastructure which has been built, thanks of the determination that private is best, is proving rather expensive.

In reply to dissonance:

Indeed.

In reply to Rob Exile Ward:




That's a red herring. We were discussing (well I was) the NHS contracting certain activities to private providers. They already do that with drugs so nothing changes. In any case, direct advertising can be regulated.

In reply to MG:


That is for Europe and England comes in 18th (Scotland is higher) . The UK's spending per capita is 12th in Europe. So it's not a disaster but hardly brilliant either.

In reply to Jim C:

But then by not doing sport their health deteriorates...

Neil

In reply to Postmanpat:

I don't think it is a red herring at all. One of the potential solutions for the NHS lies in not simply meeting demand, but actually reducing it; educating patients to not expect a miracle cure for every minor ailment, encouraging patients to take more responsibility for their health and activities which impact on it, making it clear when major conditions are no longer treatable, understanding the limitations of medical interventions especially in mental health, etc

Which private sector turkey ever voted for Christmas?

In reply to Postmanpat:


14th, I think, overall. And as above,if you strip out waiting times (closely related to funding) it does much better.

In reply to Rob Exile Ward:

Private health insurers certainly do give discounts for healthy lifestyle choices...they are motivated to do so because it reduces the chance of them paying out. The NHS is not motivated to do this because it gets its money anyway.

Neil

In reply to Jim C:

Apparently there are quite a few (fell) runners so 'addicted' to their single sport that they don't see how ridiculous it is to present with serious pain and ask to continue producing the conditions that signal that pain, because other sports don't satisfy them. Even a doctor who regularly runs would appear unprofessional to downplay the body's signals.

It must be hard to say the right thing to so many different people, day in day out.

Jon

In reply to Neil Williams:


There's a difference between doing exercise sufficient to improve health, and doing sport that induces injury.

In reply to Neil Williams:


Rock / ice climbing?


Again, you don't have to have a private service to do this. You can have payment by performance and inducement of specific targets, and this is already extensively used (and abused) in general practice.

In reply to MG:


As I said, many of those categories are subjective (unlike 'outcomes') and waiting times one category are demonstrably improved by private provision.

In reply to Postmanpat:

Well yes but it was you that introduced the study, not me!


and waiting times one category are demonstrably improved by private provision.

Again any evidence that, given equal funding, private care is more rapid than public? I would have thought more money>more resources>less waiting regardless of the form of provision.

In reply to contrariousjim:

"Rock / ice climbing?"

High risk of serious injury, though.

Neil

In reply to Neil Williams:


I am not sure how you make that logic add up. Since the insurers also get its money by charging more for those people making poor decisions or simply refusing cover.
The NHS, on the other hand, since it cant do either of those is actually motivated to help people make healthy lifestyle choices.
For example if we take smoking and go and look at Bupa then as far as I can tell they just point you to the NHS or a GP. They do however take into account whether you smoke when providing a quote.

In reply to MG:




Shit, can't find the thing I was quoting. Oh well….

In reply to dissonance:

"Since the insurers also get its money by charging more for those people making poor decisions"

But equally they are at a higher risk of paying out. It's like any other form of insurance - if you take young drivers as a whole, I doubt they are any more profitable than older drivers. But one who crashes 5 times a year is going to be far less profitable than one who pays over the odds but doesn't crash.

It's effectively gambling, like any other kind of insurance.

Neil

In reply to Rob Exile Ward:


Now that I completely agree with but I'd say it was the only viable solution. Smokers will argue that there filthy habit is subsidizing the NHS through tabbaco tax but the reality is that on average each case of lung cancer cost the NHS £9,076 a year according to Cancer Research UK. The Govt. has and is doing everything it can to disuade people from smoking but still people persist despite the risks. Surely the NHS shouldn't be left to pick up the tab. There's also the people that get parrelletically drunk on a Friday night end up having an accident. Should the NHS bare the cost? No doubt these are the same people that will be back in 20 years for a liver transplant after a life time of alcohol abuse.

Also I'd be fully in favor of the NHS restating its values for the 21st century which would not only talk about the NHS's responsibility to patients but patients responsibility to the NHS.

In reply to Neil Williams:


Yes and if the risk is to high then they dont bother insuring them.
Now if they didnt have a choice in insuring, for a reasonable price, then there would be a lot more effort put into education.
So getting back to your claim about the insurers being more motivated than the NHS to actually improve lifestyle it doesnt really add up.
Since they can always walk away/charge massive amounts/exclude certain conditions. Since the NHS cant it has more motivation to help people, for example, to stop smoking.

In reply to MG:


Its not just a Q of being more rapid either.. ..it is useless, for example, having a test rapidly that you never needed in the first place, as the German system is notorious for. It's that kind of system use of resources that would seem obviously less resilient to future resource restriction and ageing population where you haven't developed the targetted use of resources needed to run an efficient ship, as occurs in the NHS.

In reply to Indy:


Yeh, but with a 5yr survival of just 8%, that isn't a cost that lasts very long; the annual cost to the UK being about £2.4billion. Meanwhile, tobacco taxes bring in £9bn for the UK (2009-10 figures), which was about 2% of all tax receipts. What you also have to remember is that current emerging lung cancer deaths reflect accumulated damage usually over decades, so reflect old behaviour before health promotion and smoking bans kicked in. So if the Q is: can tax receipts from smoking keep ontop of smoking related diseases more generally. Its a hard calculation, but yes, probably they can. I wouldn't be abandoning the smokers to their fate.

In reply to contrariousjim:

Not wishing to use potentially tainted statistics from either the pro or anti smoking lobbies I've found it impossible to find independent figures for either total tabacco tax rexiepts or life expectancy of those diagnosed with a smoking related cancer. What is known is that the average smoker diagnosed with lung cancer will cost the NHS over £9k/year. If your 5 year survival is correct a smoker would need to smoke a pack a day for nearly 21 years for the NHS to break even and that would be based on today's level of tax.

Its also worth mentioning that the above figures don't include the costs of treating the estimated 11,000 people that will eventually die from passive smoking.

In reply to Indy:


The figures I used were from HMRC and from cancer research UK.

In reply to Postmanpat:


Indeed, there is nothing wrong with private providers, actually the WHO organisation praises the French system for being a patient centric mix of private/public providers. But it's definitely not any cheaper.

The reality is that we'll probably have to pay more taxes as a result of the demographic changes and that's it, all we need is some politicians to have the courage to do what needs to be done, have you seen any ? not me.

In reply to contrariousjim:


So how much does tabacco tax raise? Do you have a link? All I can find is tabacco and alcohol lumped together.

In reply to Indy:



I really can't understand this kind of view that we should let people die if we think they are responsible for their illness.
Even if we were to take a purely economic view of this, I am not sure that letting people die is economically sensible.

In reply to RomTheBear:
If you take an economic view of it, if alcohol/tobacco tax doesn't cover the costs of those vices, increase it. Simple. If it does cover the costs, the NHS should stop whining about the cost, as without it it wouldn't get the money it spends on treating those things.

Neil

In reply to RomTheBear:

There is a financial figure on a life, isn't there? Generally used in things like corporate risk assessments.

Neil

In reply to Indy:

This was what I was referring to:
http://www.hmrc.gov.uk/research/cig-consumption-uk.pdf
http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/survival...

In reply to Indy:


£9billion/year (in 2009/10 yr)

In reply to Indy:

'Also I'd be fully in favor of the NHS restating its values for the 21st century which would not only talk about the NHS's responsibility to patients but patients responsibility to the NHS.'

Yes I'd agree with that and go a step further: the NHS should be seen as a 3 way partnership between the patient, the medical professionals ... and the tax payer. Obviously these roles overlap, but each party should be mindful if his/her responsibilities to the other two.

In reply to RomTheBear:


That's a hugely naive point of view.

Do we all accept that money for the NHS is a finite resource?

If you do then then at some point your going to need to make decisions on the allocation of resourses.

Your in the position to make the call...

Patient A has a non-lifestyle cancer that's spreading to other organs. There's a drug called Avastin that will extend the patients quality of life for 2 years. Problem is it will cost £42,000 for that 2 years.

Patient B is an smoker who has repeatedly refused to give up spouting there human rights yada yada yada. They now have terminal lung cancer caused by smoking. They will need care costing £42,0000 before they die.

Who do you give the drug/care to?

In reply to Indy:

Since we are talking the NHS, to help you take the decision you spend £10,000 in consultancy fees, £3,000 in expert evidence, £2,000 in commissions, £15,000 to re-paint the cancer ward so that is ready for the patient, and then another £10,000 to re-re-paint it since you chose the wrong shade of Magnolia the first time round. Then you award a £2000 bonus to yourself for a job well done, and explain to the patients how there's nothing you can do and the hospital's budget isn't big enough to cover their treatments, but that if they have private medical insurance you have a private practice running from the same building on Wednesday evenings and they are welcome to attend following a credit check..

In reply to Indy:

Everybody and put up taxes. No-one will mind.

In reply to climbwhenready:


Just tax organic food, tofu and yoga lycras to the same level as tobacco, and once the tee-totals pay tax to the same degree as the smokers there'll be plenty of money to go round to pay for everyone's treatment with change to spare to re-re-re-paint that ward in the latest dulux shades.

In reply to Indy:
One option is that you give it to each of them for 1 year, having made it a condition of the latter receiving it that they give up smoking now. (it's a quality of life drug so you're not choosing whether to save anyone's life or not, and there's no point in providing it if it'll be made worse by more smoking).

Neil

In reply to climbwhenready:

I think a properly accounted tax increase that was very clearly linked to an increase in the NHS budget might not actually be an unpopular move at all.

Neil

In reply to Indy:







Why not spend a bit more on healthcare like many countries do and give it to both ?
Are we going to ask the NHS to decide who deserved to be treated and who doesn't ? Who is going to decide who is worthy to live or die ?

And still you are not addressing the point I made about the huge cost of letting people die.

In reply to Neil Williams:
Throwing money at it hasn't worked. Looking at NHS spending over the past 70 years shows year on year increases but extra demand has always swallowed the extra money. We aren't rich enough to KEEP throwing money at the NHS.

As I've said we need to address the demand side
... No more blank cheques!

In reply to Indy:

But that's true of health spending internationally - in some ways the NHS has done better than most in controlling health inflation

In reply to Indy:

We spend less than most comparable countries

In reply to MG:

None of that matters being the oldest in the grave yard is hardly something you want to boast about.

The NHS is becoming incresingly unaffordable. We need to have an NHS that provides what people need at a price that people are able and willing to pay.
Tough decisions need to be made.

In reply to Indy:
Excellent analysis. And the tough decisions are? And who will make them? And who will implement them?

In reply to Indy:





Private / public mix Australian style seems to work....

http://www.smh.com.au/comment/health-report-card-reveals-excellent-grades-2...

In reply to Indy:


That's a big statement, we don't spend as much as many countries in Europe.


That's going to be difficult when the biggest cause for the rise in demand is simply demographic. What will you do ? refuse treatment to people over a certain age ?

In reply to Indy:

Well, I'm willing to pay more than is currently charged in order to ensure its continuation, or at least the continuation of an insurance based scheme with a similar scope. I would however prefer to pay this on the basis of increased taxation/subscription fees rather than at the point of use, as the latter is invariably when it can least be afforded.

ITYF that there are quite a lot of people who feel the same.

Neil

In reply to stroppygob:

I knew that you were going to come along with that... the world of basic hospital + selected extras, obvious isn't it?

Cheers
LD

In reply to Lurking Dave:
We pay $159 per month. Seems worth it, though the bastards screwed me on my last hearing aids. Having said that, it was a godsend when I had my motorbike smash.

In reply to Indy:

The money hasn't gone into the ether! It's been spent on drugs, equipment, infrastructure and wages, and for a great many years at a rate where increases nevertheless kept NHS spending well below many of our European partners leading to the chronic infrastructural lag that we have had to date. Despite that, the recent inflation in NHS spending has focussed on inflating the managerial sector to create its total sector dominance, increasing the proportion of NHS spend servicing debt (now at about 10% overall), increased costs at the purchasing end, and delivering a worsening workforce crisis with a shortage of doctors almost across the board, but particularly in general practice, A+E, pathology etc

In reply to Dr.S at work:


And indeed those bits that are inflating, are not necessarily the things that improve health:
- servicing debt of PFI (up to 10% of the NHS budget now)
- inflation of management sector (which still has no professional regulation / defined professional standards as compared to healthcare professionals, despite being *the* dominant part of the workforce)
- the interaction of the service sector with the private sector - inflation of material goods required from private sector suppliers

In reply to Neil Williams:


All the main parties are far to much to the right of centre to consider this option. Labour won't reverse the NHS bill, even though Burnham let slip that he would in the immediate aftermath of its implementation. So the inexorable privatisation will occur, and precipitation introducing a patient charging switch is only 1 to 2 electoral terms away.