/ NHS top again

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Offwidth - on 14 Jul 2017
?...... and the US bottom again in the Commonwealth Fund triennial survey, combining safety, performance and affordability :

https://www.theguardian.com/society/2017/jul/14/nhs-holds-on-to-top-spot-in-healthcare-survey

......good news for the UK....at least until the money runs out.
Matt Vigg - on 14 Jul 2017
In reply to Offwidth:

OK, but:

“The UK stands out as a top performer in most categories except for healthcare outcomes, where it ranks with the US near the bottom,”

Hmm.
1
SAF - on 14 Jul 2017
In reply to Matt Vigg:

An inclusive health system like the NHS will always come out worse on healthcare outcomes, because these statistics relay on a formal diagnosis plus an outcome.

In the UK a down and out spirit drinking alcoholic has just as much right to access healthcare and be diagnosed with, lets say, cancer of the tongue, larynx, or oral cavity (all of which are strongly linked to spirit drinking), these patients due to their lifestyle are likely to present late, have comorbidities and be poorly compliant with treatment resulting in a poor outcome being added to the statistics. In the US these individuals would never get diagnosed, and would likely not even get a diagnosis after death and therefore don't contribute to the health outcome statistic, instead the US statistics for head and neck cancer will be made up of a higher proportion of affluent female smokers who present early and are very "good" patients, and therefore do much better.
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Matt Vigg - on 14 Jul 2017
In reply to SAF:

Yes but Germany is 8th on the list and all those things apply here too, so I'm confused as to how useful these measurements are. I think the fact I've been downvoted is interesting, I was merely pointing out a quote from the article, and my point was - surely health outcomes are the most important measure!
Timmd on 14 Jul 2017
In reply to Matt Vigg:

I'm wondering whether national cultural quirks can shape medical outcomes, to do with how soon people present with certain medical conditions. In the way that men often don't go to the doctor soon enough compared to women in the UK, there could be similar trends in other countries, relating to how well people do once they're in the hospital system in their country.
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Matt Vigg - on 14 Jul 2017
In reply to Timmd:

I'm certain there's truth in that, although it's always difficult to pull these things apart. Here in Germany there's a big emphasis on prevention - e.g. rewards for having an annual dental checkup and penalties if you don't. It's possible that stuff like that is more acceptable to the German mind and wouldn't work at all in the UK, dunno!

I think the fact that the NHS is such a touchy subject can only be a problem though, anything should be up for discussion as far as I'm concerned (as in anything, on any topic - not just the NHS). And before someone thinks I'm suggesting privatisation I'm not, but I am interested to compare what's good and what's not in the NHS with other systems and see what could be improved.
SAF - on 14 Jul 2017
In reply to Timmd:

> I'm wondering whether national cultural quirks can shape medical outcomes,

Also cultural quirks of how we define a positive health outcome comes in to play, is quantity of life the measure used or quality of life, or do they measure for both. How do you quantify "quality of life". The WHO use a measure called DALY (disability adjusted living years).

If you have a culture and a health system which is obsessed with keeping people alive at all costs, then the number of DALYs will be far greater and therefore outcome statistics will be poorer.

Dauphin on 14 Jul 2017
In reply to SAF:

Have you got any evidence to back up these outlandish claims? Stick with head and neck cancers.

Outcomes are normally measured and controlled across a number of different health models so we can compare merit. U.K. health outcomes were never great and have been falling dramatically since the coalition government in 2010-11.

D
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SAF - on 14 Jul 2017
In reply to Dauphin:

> Have you got any evidence to back up these outlandish claims?

What outlandish claims, questioning and critically analysing what data is used, and how it has been interrogated to get the statistics that are then used to rate a system is good academic practice. Do you take everything at face value?



Timmd on 14 Jul 2017
In reply to Matt Vigg:
> I'm certain there's truth in that, although it's always difficult to pull these things apart. Here in Germany there's a big emphasis on prevention - e.g. rewards for having an annual dental checkup and penalties if you don't. It's possible that stuff like that is more acceptable to the German mind and wouldn't work at all in the UK, dunno!

I think people might take affront in the UK, maybe bridle a little bit in seeing it as he state interfering? With things like obesity and diabetes in mind, I think the state should possibly try and do more towards improving people's health, it'd only make people healthier. I'm risking going off topic though.
Post edited at 17:51
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SAF - on 14 Jul 2017
In reply to Timmd:
> With things like obesity and diabetes in mind, I think the state should possibly try and do more towards improving people's health, it'd only make people healthier. I'm risking going off topic though.

Why is that off topic? Peoples lifestyle choices, and the culture behind those lifestyle choices, directly impact on the health outcomes of the nation. for example, binge drinking as a social activity in the UK will effect the NHS statistics on liver disease.
Post edited at 17:55
Matt Vigg - on 14 Jul 2017
In reply to Timmd:

Well it's 50% or more of the problem/solution I guess, in that you need to see what works elsewhere then work out if it's relevant or possible in the UK. I often think this when you hear people talking about the success of legalising drugs in Portugal, just because it's working there doesn't mean it would in the UK because the starting point could be a million miles apart.
SAF - on 14 Jul 2017
In reply to Matt Vigg:

I agree we do have to look elsewhere. I think some of the successes of the NHS may also be it's downfall.

It is not uncommon to come across patients in the UK whose attitude to their health is that it is their doctors/ the NHS responsibility to make them better, and they take no or minimal responsibility for their own health. For example type 2 diabetic patients with raised sugars, continuing to drink fizzy pop and eat cake, whose attitude was "the doctor should have given me better medication"!
Also the NHS is great because it offers care to all, but on occasion this means throwing good money after bad, patients with COPD being treated on HDU/ ITU with high tech Ventilators (NIV and CPAP) on multiple occasions, only to go home and continue smoking inbetween.

I don't know enough about insurance based health systems to know how they would deal with patients and situations like that, but I imagine it would be somewhat harsher.
1
Dauphin on 14 Jul 2017
In reply to SAF:

> What outlandish claims, questioning and critically analysing what data is used, and how it has been interrogated to get the statistics that are then used to rate a system is good academic practice. Do you take everything at face value?

Okay, so that's a no then. Shooting from the hip doesn't constitute critical analysis. Where's your data obtained from?

Best Wishes.

D
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summo on 14 Jul 2017
In reply to Matt Vigg:

> I think the fact that the NHS is such a touchy subject can only be a problem though, anything should be up for discussion

But the nhs is a national treasure, any discussion involving it must be 100% positive otherwise you'll be guilty of treason.

This survey seems to say the nhs does very well considering what it has, but if everyone paid more into it, then it would outcomes to match.

summo on 14 Jul 2017
In reply to SAF:

> for example, binge drinking as a social activity in the UK will effect the NHS statistics on liver disease.

Plus a proportion of 999 calls on Fri & sat, and a&e visits.
alx - on 14 Jul 2017
In reply to SAF:

Judging by your knowledge are you a health economist? NICE tech assessment group member? Health insurance?
2
Dauphin on 14 Jul 2017
In reply to summo:
It's says it's great apart from the most important measure - outcomes, where it ranks close to the u.s. Shockingly shite in other words, unless like Jeremy Hunt you inhale from a glue bag.

D
Post edited at 20:03
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no_more_scotch_eggs - on 14 Jul 2017
In reply to Dauphin:

nice line in hyperbole there
no_more_scotch_eggs - on 14 Jul 2017
In reply to summo:

> But the nhs is a national treasure, any discussion involving it must be 100% positive otherwise you'll be guilty of treason.

> This survey seems to say the nhs does very well considering what it has, but if everyone paid more into it, then it would outcomes to match.

that would be my analysis too.
SAF - on 14 Jul 2017
In reply to Dauphin:
> Okay, so that's a no then. Shooting from the hip doesn't constitute critical analysis. Where's your data obtained from?

> Best Wishes.

> D

I didn't state any data just my view on the topic. So what you're basically saying is that unless I have done a phd or similar and collected "data", I am not allowed to formulate my own opinions based on 18 years experience working in both acute and non-acute settings within several NHS trusts. Unless those opinions meet with your approval of course!

Best Wishes
Post edited at 20:23
Dauphin on 14 Jul 2017
In reply to no_more_scotch_eggs:

Not really. It's absurd for the Guardian to get this headline from a study that gives equal footing for eleven or twelve measures and then squeezes in the fact that outcomes are a poorer than others and we were doing well in reducing preventable deaths until the Tories took control of the NHS again.

Also treats the NHS as a single entity which it isn't. Devolved in Scotland and Wales, no?

D
Matt Vigg - on 14 Jul 2017
In reply to SAF:

I've been insured privately and publicly here and all the private companies have a long complicated set of choices for you to consider when comparing policies, many of which will reward good behavior and punish bad. Eg the dental treatment percentage goes up if you have annual checkups and down if you don't (in terms of the percentage they'll pay). They also often have an excess amount which no doubt deters people from going to the doc for small things and some policies will reward you with 1 or 2 months rebate if you don't claim anything in a calendar year. Compare this with getting everything for free no questions asked and obviously people will use the free system more, treat it with less respect (across a population at least) and there'll be more waste.

I'm still not arguing for privatisation here but it's very clear that having everything free vs having to consider your own resources changes people's behaviours so it needs careful thought how best to make use of that.

Of course simply making people pay a small fee would be too simple because it would stop some people getting treatment at all (until they can't ignore things any more) that's why I like the prevention idea that operates here. The private system particularly is very agonist/antagonist designed to push you into the right direction, dissuading you from using the system too much but pushing you into doing the essentials.
no_more_scotch_eggs - on 14 Jul 2017
In reply to Dauphin:
Well, indeed.

But 'shockingly shite'..?

On around 8% of GDP- a whole lot less than meaningful comparator nations- I think that's pretty good.

As Summo says, spend some more and see if we can get outcomes that match our accessibility ratings.

Edit- interesting that the GDP figures are different than they ones I recognise from Kings fund reports- but they are all higher, and the point about the NHS's comparative position remains
Post edited at 20:57
Dauphin on 14 Jul 2017
In reply to SAF:



No Ph.D. or novel research necessary, just evidence.

I didn't state any data just my view on the topic. So what you're basically saying is that unless I have done a phd or similar and collected "data", I am not allowed to formulate my own opinions based on 18 years experience working in both acute and non-acute settings within several NHS trusts.


Okay Anecdotes. Cool.

Best Wishes.

D

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Matt Vigg - on 14 Jul 2017
In reply to Dauphin:

You're not coming across very well here... Maybe you should list your credentials in the interest of balance!
summo on 14 Jul 2017
In reply to Dauphin:

> It's says it's great apart from the most important measure - outcomes, where it ranks close to the u.s. Shockingly shite in other words,

Would agree, everyone the nhs treats dies eventually. It's a terrible failing, they must try harder.

Timmd on 14 Jul 2017
In reply to SAF:

> Why is that off topic? Peoples lifestyle choices, and the culture behind those lifestyle choices, directly impact on the health outcomes of the nation. for example, binge drinking as a social activity in the UK will effect the NHS statistics on liver disease.

It depends on how much you make a distinction between treatment and prevention., which is why I thought I might potentially be going off topic.
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Offwidth - on 15 Jul 2017
In reply to Offwidth:

The host report...... took a bit of finding until I abandoned the host web contents route and tried Twitter.

http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/#utm_source=mirror-mirror&u... Health

The main comments on the UK:

"The U.K. stands out as a top performer in most categories except for health care outcomes, where it ranks with the U.S. near the bottom. In contrast to the U.S., over the past decade the U.K. saw a larger decline in mortality amenable to health care (i.e., a greater improvement in the measure) than the other countries studied. (The U.S. has had the smallest decline, or lowest level of improvement.) In the early 2000s, the U.K. made a major investment in its National Health Service, reforming primary care and cancer care in addition to increasing health care spending from 6.2 percent of GDP in 2000 to 9.9 percent of GDP in 2014 (Exhibit 1). 7 The reforms and increased spending may have contributed to the rapid decline in mortality amenable to health care in the U.K."

I'd have agreed with Dauphin if he had just said that the Guardian have been a bit naughty (not his style I guess). People seem to need league tables that combine dissimilar statistics in such a way that the overall comparison becomes less meaningful.
Dr.S at work - on 15 Jul 2017
In reply to Timmd:

> I'm wondering whether national cultural quirks can shape medical outcomes, to do with how soon people present with certain medical conditions. In the way that men often don't go to the doctor soon enough compared to women in the UK, there could be similar trends in other countries, relating to how well people do once they're in the hospital system in their country.

I'm sure this is true - the Netherlands tend to do very well - and I think that relates to their forthright approach to problems
Fuchs on 15 Jul 2017
In reply to Offwidth:
I have no idea why people are happy about this survey's result - the UK is 10th out of 11 for healthcare outcome (i.e. treatment success). That is literally the ONE most important thing a healthcare system is supposed to deliver.

I also find the headline somewhat odd. It suggests the NHS is frequently ranked top, when in fact the 2014 Euro Health Consumer Index ranked the UK 14/37, or a 2017 LSHTM study found the UK to rank 30th in the world.
Post edited at 17:29
Ciro - on 15 Jul 2017
In reply to Matt Vigg:

> They also often have an excess amount which no doubt deters people from going to the doc for small things and some policies will reward you with 1 or 2 months rebate if you don't claim anything in a calendar year. Compare this with getting everything for free no questions asked and obviously people will use the free system more, treat it with less respect (across a population at least) and there'll be more waste.

It seems obvious but I'm not sure it's true. I used to have private health insurance through work (in the UK) and I think seeing the (subsidised) premium coming off your pay packet every month gives you a sense of entitlement that paying for your healthcare through general taxation doesn't, and a feeling that you want to "get your money's worth", especially once you've made that first claim for the year - might as well go on and see what else you can get out of it.

In my case, it meant I was able to receive extensive physiotherapy treatment for chronic back problems, ultimately getting me back into all my sports again. With the NHS, that treatment would have stopped once I was back to day to day activities and reasonably pain free. I would have had to pay for my own sports physiotherapy.

no_more_scotch_eggs - on 15 Jul 2017
In reply to Fuchs:
Different studies measure different things.

I disagree that outcomes are the one important thing. The best outcomes in the world are great if you can access them, and meaningless if you can't. World beating outcomes for all would of course be the ideal, but no system has achieved that so far. Being able to get access to good outcomes, in a system that is safe and responsive to you is not a bad deal to my mind, and given the commonwealth fund report we're discussing includes service user feedback, this seems to be a fairly widely held view.

Also- outcomes in this report isn't for every single condition the service deals with- they took a limited number of important conditions and based the report on that. But that's why you have too look at the report as a whole- a system that has excellent cancer survival rates, but poor outcomes on hospital acquired infections and high rates of avoidable deaths from venous thromboembolism isn't necessarily doing as well as its 'outcome' score would suggest at first glance- because performance in the latter will be captured in safety ratings, no outcomes. That's why the NHS's top ranking in system safety is important- as avoidable deaths due to the healthcare system itself are a big deal.

The report strikes me as likely to be correct in relation to the strengths and weaknesses of the NHS. Access and system safety are real achievements and ones that matter to people. Outcomes in the areas measured are important too, and these need to be better. But as per my previous post- we get this performance from a relatively modest investment in comparison with other similar nations. Imagine what our outcomes could be like if we spent what the French or Germans do...
Post edited at 23:28
Matt Vigg - on 16 Jul 2017
In reply to Ciro:

I know what you're getting at but I'd say a few things about it, I've done the same when it comes to physio, I've made use of it. In my policy there was a limit but you could argue physio is generally preventative anyway, better to spend a few hundred euros/pounds now than have another dislocated shoulder or torn ACL requiring surgery later. Also at the end of the day private insurance only works if money in is greater than money out so either premiums go up (yours or someone else's, depending on the regulations) and/or it's designed to influence behaviour to get the cheapest outcome for the insurer. I'm not an expert on the regs but I know that there's a cap on how much premiums can be raised in Germany which inevitably means companies have to find other ways to make the numbers work, regulations are definitely a critical part of the setup though even in the private system.

Another thing is that it seems (yes this is anecdotal) that climbers are part of a small subset of people that use all the physio they can get their hands on. I've been told many times by physios that it's a real struggle getting people to do the exercises or turn up at all and not doing your exercises long after the physio sessions end is often what puts us back in their practices so an extra few sessions is much more likely to get people preventing the next injury.

Actually I may publish my anecdotes as research, I've seen a ton of physios in four different countries over about 20 years!
Ciro - on 16 Jul 2017
In reply to Matt Vigg:

Indeed, thinking long term more comprehensive physio makes sense. Unfortunately, I imagine with the fragmentation of the NHS and everyone trying to justify their expenditure and hit targets, in the short term it makes more sense to achieve an early "satisfactory" outcome.

I'm not just thinking about myself and climbers though, friends in the office would talk about persuading their doctor to get scans and tests done because they wanted to get their money's worth out of the insurance. Again, long term this may be no bad thing if the excess testing sometimes picks up something early when it's more easily treated, so I'm not saying it's a problem - just that people may not in fact use the free at the point of use system more liberally.
Offwidth - on 16 Jul 2017
In reply to Matt Vigg:

Why not ask UKC for space for an article. I'm a (critical) friend of the NHS, my main critique is the UK population use it innapropriately too often and don't properly support the funding for it... there should be much better behaviour in prevention and utility and a clamour to get GDP equivalent NHS funding up to at least the GDP weighted EU average. However, despite my support for the NHS my advice to climbers is to always know where a good climbing physio is your area, before you get injured. The NHS cover for such injuries is too slow and patchy and correct quick action aids fast recovery.
climbwhenready - on 16 Jul 2017
In reply to Dauphin:

> U.K. health outcomes ..... have been falling dramatically since the coalition government in 2010-11.

[citation needed]
Matt Vigg - on 16 Jul 2017
In reply to Offwidth:

Well I was kidding, I doubt my random injuries alone would do the topic justice. I would find it interesting to see any info on whether increasing spending on prevention decreases spending overall, I'm sure I vaguely remember hearing about research into that over the years. I don't doubt it would improve outcomes long term but as Ciro says above extra money for prevention is probably seen as too luxurious in the current climate.

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