Nhs Cuts Start In Earnest

[Si1]

Whether it pays for the full costs, or not, is irrelevant - it's certainly not an accounting trick. What is important is that the productive assets (operating theatres, medical equipment) are appropriately and efficiently utilised. In practice, their competitors are the private health providers, which are far more expensive - so, they end up charging market rates, which comfortably covers all the external costs.

At present, facilities and staffing are based upon a 5-6 day working week. This means that the facilities have spare capacity, and staff is the limiting factor. One way to improve utilisation would be to employ 30% more staff, so that the weekends and evenings could be fully staffed. Another way is to sell void time.

NHS trusts are not permitted to accept private cases where they could compromise the operation of NHS work. So, time for facilities is only sold in idle time, where it can't compromise NHS work. Similarly, the staff will be operating as independent contractors working outside of their NHS time.

In practice, many trusts which take on large amounts of private work, end up building entire private wings. This way, they clearly demarcate all the costs of their non NHS work.

Your other point was that we spend too much on healthcare - and that is probably true, although in comparison to many other countries, it isn't that bad. What really is needed is a rethink on just what the NHS should cover, and what it shouldn't. mdman said things better than I could.

I really enjoy these kind of posts and it goes to highlight how poor many are on both sides of the debate

financial expoitation of facilities' downtime appears to be a superb efficiency drive, and surely a good reason for a market in healthcare providers so this kind of thing can be maximised, why shouldn't heathcare be a UK export? I wonder what the odds are on treatment facilities being used 24/7, time being divied out on a commercial and even export basis, all for the betterment of return on capital, much of which is originally from the taxpayer?

[Si1]

Give the people the facts and let them decide.

'Analysis' tho I believe your motivation is candid, which is fair play on any discussion baord, firstly I have not seen a single quoted 'fact' from you that beards any kind of analysis, and secondly I have seen no 'analysis' either from you that is worthy of the name, which is one of those little ironies on discussion boards when someone's moniker seems to bear no resemblance to their behaviour.

[Analysis]

If the NHS is entirely privatised and the tax used to fund it returned to taxpayers, that will mean tax cuts.

Those taxpayers will then have to pay for the cost of their healthcare. Whether or not they pay more or less will depend on how sick they are, and how efficient the private healthcare market is.

I believe an OECD study was quoted that indicate how poor the UK healthcare system is. There are other studies that refute that. One was published by the Commonwealth Fund

This ranked the UK 2nd out of 11 developed World healthcare systems overall, 4th for speed of access to doctor/ nurse, 2nd for access to OOH care, top for confidence is getting treated if sick, and 6th for waiting to see a specialist.

The UK is the only system that is free at the point of access. As the price is zero, this increases demand.

Given this performance, I have to query the evidence base for marketisation improving quality and outcomes here, particularly the sort of market structure implied by the White Paper (with conflicts of interest, poor evidence for commissioning emulating free market-driven innovation, complexity, and the malign influence of the business lobby on cronyism).

The areas where the NHS has been open up to competition include:

- OOH care, where costs doubled once GPs dumped it while patient complaints soared

- ISTCs for routine operations - cost more than NHS trusts despite taking on simpler patients, not following up complications and despite all that having high complication rates when adjusted for the patient clinical risk profile

- private WICs - where a consultation with a nurse costs nearly double a GP appointment

- private GP contracts (called APMS) - where the PCTs try to cover up the details of the contract, but what evidence exists points to much much higher payments per patient coupled to high staff turnover

Other areas where private companies have got their hooks in include

- PFI, that even a banker involved described as a licence to print money - PFI contracts are paying lenders a far higher cost of capital than they are entitled to given the risk. The maintenance contracts are also extremely expensive for the taxpayer

- the national IT program - a big White Elephant

- the liberal use of management consultants by PCTs, strategic health authorities and the department of health - a culture that absolutely corrodes any notion of public service and provides a jobs merry-go-round for senior civil servants and managers. The incentives of these consultancies are not aligned with the interests of taxpayers; usually they are in complete conflict

My suggestion for improving costs immediately includes:

- abandon the IT program

- abandon PFI. Look for legal means to renege on contracts, even if that means passing legislation to create a new class of bankrupt trusts

- stop using management consultants

- give up on the idea of commissioning being fit for purpose for driving market reforms. A bunch of GPs in a room deciding how to commission hospital services does not a free market make.

- stop treating foreigners/ those not entitled to NHS treatment

- close down WICs and other free points of entry that simply stoke demand and increase cost without improving quality. Put the burden back on GPs

DOI - GP board member of one of the new clinical commissioning groups

Bang on the money. You obviously know a bit more about what's really going down.

[Analysis]

I really enjoy these kind of posts and it goes to highlight how poor many are on both sides of the debate

financial expoitation of facilities' downtime appears to be a superb efficiency drive, and surely a good reason for a market in healthcare providers so this kind of thing can be maximised, why shouldn't heathcare be a UK export? I wonder what the odds are on treatment facilities being used 24/7, time being divied out on a commercial and even export basis, all for the betterment of return on capital, much of which is originally from the taxpayer?

Already open 8-8 in many departments at my Trust - which is a significant change on 10 years ago. Private patient numbers up (we're having a drive at the Trust to get £1M per annum of business in at the expense of smaller private institutions locally). Sounds as though this is happening in NHS Trusts elsewhere looking at other posters. We do some quite cool stuff with training - we have an OR with 15 cameras, weblinks, robotic surgery etc and are teaching all around the world now. In my own speciality we do some work abroad and could readily expand this should profit be the name of the game. No reason not to compete globally on actual healthcare provision in a bigger way either.

Except that there will be less time available (and motivation) for us to treat non-paying patients and to carry out non proft making activities. I have no problem with all of this, as long as people are given the facts and can make an informed decision, rather than be told that there will be no NHS cuts and by the way you have to pay the banks all that money.

Goodnight...

[mdman]

I really enjoy these kind of posts and it goes to highlight how poor many are on both sides of the debate

financial expoitation of facilities' downtime appears to be a superb efficiency drive, and surely a good reason for a market in healthcare providers so this kind of thing can be maximised, why shouldn't heathcare be a UK export? I wonder what the odds are on treatment facilities being used 24/7, time being divied out on a commercial and even export basis, all for the betterment of return on capital, much of which is originally from the taxpayer?

There are troubles with this analysis

A series of confidential enquiries into post-operative deaths indicated death and complication rates are far higher out of business hours.

Surgical practice in the UK has altered as a result of this

The major cost of the NHS is staff, not operating theatres or equipment costs. Employing healthcare workers at night or weekends, whether private or public, will be more expensive.

There are good reasons to presume that wards should not be crammed full of patients, nor that the turnover time between patients occupying the same bed be too short. Many hospital doctors believe this 'efficient' practice has led to the high rates of MRSA and other HAIs in this country. Government policy was to blame doctors and other clinical staff for not being 'bare below the elbow', a charge for which there is not a single shred of evidence. A doctor recently challenged a camera crew doing a news piece on Cameron and Clegg for not being 'bare below the elbows' while on the ward. The point he was making was that managers bullied clinical staff to comply with this evidence-free directive, but not politicians or media people. In fact, he had previously had a letter published in the papers denouncing 'bare below the elbows' and linking MRSA to ward over occupancy. He has since been suspended from his job

Politicians have for decades desired to treat healthcare systems like factories. They're not. The NHS is the most efficient healthcare system in the developed World. If you try to generate these sort of utilisation efficiencies from this position, I can guarantee that quality will dive, market or no market.

[libspero]

Politicians have for decades desired to treat healthcare systems like factories. They're not. The NHS is the most efficient healthcare system in the developed World. If you try to generate these sort of utilisation efficiencies from this position, I can guarantee that quality will dive, market or no market.

In 2000 we spent £70bn on the NHS. By 2010 we were spending £140bn.

Why has spending doubled in the space of 10 years? I don't remember the NHS being in crisis in 2000..

Edited July 31, 2011 by libspero

[Si1]

There are troubles with this analysis

A series of confidential enquiries into post-operative deaths indicated death and complication rates are far higher out of business hours.

Surgical practice in the UK has altered as a result of this

The major cost of the NHS is staff, not operating theatres or equipment costs. Employing healthcare workers at night or weekends, whether private or public, will be more expensive.

There are good reasons to presume that wards should not be crammed full of patients, nor that the turnover time between patients occupying the same bed be too short. Many hospital doctors believe this 'efficient' practice has led to the high rates of MRSA and other HAIs in this country. Government policy was to blame doctors and other clinical staff for not being 'bare below the elbow', a charge for which there is not a single shred of evidence. A doctor recently challenged a camera crew doing a news piece on Cameron and Clegg for not being 'bare below the elbows' while on the ward. The point he was making was that managers bullied clinical staff to comply with this evidence-free directive, but not politicians or media people. In fact, he had previously had a letter published in the papers denouncing 'bare below the elbows' and linking MRSA to ward over occupancy. He has since been suspended from his job

Politicians have for decades desired to treat healthcare systems like factories. They're not. The NHS is the most efficient healthcare system in the developed World. If you try to generate these sort of utilisation efficiencies from this position, I can guarantee that quality will dive, market or no market.

that's an interesting take, I am grateful for it, your assertion that the NHS is the most efficient system in the western world is rather loaded, and even the previously quoted study does not support it very well, with rather opaque stats; i would rather see something from the formal research literature presumably in medical economics or management journals??

and as to the specifics of space-sharing, your point about staff costs is rather inspecific, the NHS would appear [from previous online debates etc] to spend more on staff than they need to, the pay scales, as have been argued quite a bit, have been rather generous in international terms, and besides, in any organisation, some of the staff costs are fixed and infrastructure related so don't linearly rise with increased resource utilisation, some will, of course; but although I do not know the specifics, I do feel that it is unlikely to be as simple as saying the biggest costs are staff therefore you should not expand resource utilisation - if it works, an internal market is all about this; in some cases you migght expect it to work, in some cases not, and it is down to the abilities of the staff body (minus, hopefully, bloated management) to promote it where it helps

finally, tho I am no admirer of top down behemothian organisations, you still go on to say how efficient the NHS is despite previously criticising the amount of management - surely you can't have it both ways?

[mdman]

In 2000 we spent £70bn on the NHS. By 2010 we were spending £140bn.

Why has spending doubled in the space of 10 years? I don't remember the NHS being in crisis in 2000..

It was in crisis actually.

People were dying while on waiting lists for CABG and angiography

Cancer detection and treatment was much slower - the 2 week referral pathway has transformed that part of cancer care

Fixing this required spending more money. Well if you get captured by all the productivity rhetoric, that extra spend does not translate into productivity gains. It delivered quality gains.

But there are also really poor spending decisions - like the IT system, the expansion of PFI contracts etc

And quality isn't simply down to spending more. There has been a collapse in hospital nursing standards here with nurses encouraged to become managers or nurse practitioners, leaving the core tasks of nursing to healthcare assistants. This is partly about money (managing the ward with fewer nurses), but also a change in the culture, with nursing becoming a degree course more than a caring vocation. This blight affects all of healthcare - GPs with 'special interests' act up as consultants, NPs act up as doctors, paramedics act up as casualty officers (in terms of who to take to A&E) - it is driven by a belief that the best way to be more efficient is to get cheaper staff to do the work.

Right now, GPs are being exhorted to employ more nurses to manage 'rules-base' medicine so that GPs can concentrate on the more complicated stuff. Well I'm a GP and a profit-seeking business owner. If I believed that changing the staff mix this way was good for business, I would do it. I won't - it invites disaster.

In Australia, there has been a huge push to try to reduce mortality from melanoma. It has effectively involved a massive increase in the dermatology service so that people can self-refer. That delivers higher quality care but at the cost of productivity. The NHS is currently embarking on a program where it wants to deliver higher quality, higher productivity, better access and cheaper cost all at the same time. This isn't possible. Allocating resources involves trade-offs.

[mdman]

that's an interesting take, I am grateful for it, your assertion that the NHS is the most efficient system in the western world is rather loaded, and even the previously quoted study does not support it very well, with rather opaque stats; i would rather see something from the formal research literature presumably in medical economics or management journals??

and as to the specifics of space-sharing, your point about staff costs is rather inspecific, the NHS would appear [from previous online debates etc] to spend more on staff than they need to, the pay scales, as have been argued quite a bit, have been rather generous in international terms, and besides, in any organisation, some of the staff costs are fixed and infrastructure related so don't linearly rise with increased resource utilisation, some will, of course; but although I do not know the specifics, I do feel that it is unlikely to be as simple as saying the biggest costs are staff therefore you should not expand resource utilisation - if it works, an internal market is all about this; in some cases you migght expect it to work, in some cases not, and it is down to the abilities of the staff body (minus, hopefully, bloated management) to promote it where it helps

finally, tho I am no admirer of top down behemothian organisations, you still go on to say how efficient the NHS is despite previously criticising the amount of management - surely you can't have it both ways?

So on productivity, I tend to look at the UK spend per capita, and also the number of doctors/ nurses per 100k of population. Given our system is free at the point of access, we score very high on productivity compared to countries like France, Germany, USA, Canada, Japan etc. If salaries are higher here than elsewhere, the evidence indicates we are more productive for the money than our peers.

As for the internal market, it bears no relationship to the sort of free market Adam Smith describes whatsoever, so I very much doubt it will deliver the utilitarian benefits that free markets can deliver. If someone can structure the UK healthcare market as a free market that does deliver these benefits, I would support it.

[Si1]

So on productivity, I tend to look at the UK spend per capita, and also the number of doctors/ nurses per 100k of population. Given our system is free at the point of access, we score very high on productivity compared to countries like France, Germany, USA, Canada, Japan etc. If salaries are higher here than elsewhere, the evidence indicates we are more productive for the money than our peers.

there are other opinions and indicators that suggest the opposite (not compared to the USA tho!) , as you fairly said earlier in the thread, I am sure the stats are a minefield. [edit - the liberal-to-right-wing press, even the serious stuff that cites its sources, appears to strongly disgree with your position here, particuarly with respect to how the current system will handle future demands]

As for the internal market, it bears no relationship to the sort of free market Adam Smith describes whatsoever, so I very much doubt it will deliver the utilitarian benefits that free markets can deliver. If someone can structure the UK healthcare market as a free market that does deliver these benefits, I would support it.

yes, much of what I see, as an outsider, suggests that we end up with a fudge; nevertheless, decentralisation does seem to be occurring and in the long run this strikes as an improvement

Edited August 1, 2011 by Si1

[Guest eight]

Politicians have for decades desired to treat healthcare systems like factories. They're not. The NHS is the most efficient healthcare system in the developed World. If you try to generate these sort of utilisation efficiencies from this position, I can guarantee that quality will dive, market or no market.

I don't know how it was intended, but that last bit sounds about 10% prediction and 90% threat.

[Bloo Loo]

So why not privatise healthcare and education to make profits? You still haven't explained that?

why dont you just get on with making the cuts needed, and we can all continue to benefit from the Jewel in our Crown....the NHS.

[mirage]

there are other opinions and indicators that suggest the opposite (not compared to the USA tho!) , as you fairly said earlier in the thread, I am sure the stats are a minefield.

yes, much of what I see, as an outsider, suggests that we end up with a fudge; nevertheless, decentralisation does seem to be occurring and in the long run this strikes as an improvement

Decentralisation and marketisation are only an improvement in some areas. The obvious benefit of the a market is competition. The obvious down sides are fragmentation, lack of coordination, duplication of effort and supply failure or cartel formation where there are high barriers to entry or poor visibility.

In general, the organisational (as opposed to technical) changes in healcare that deliver the largest benefit are an increase in scale of integrated systems.

For example, cancer networks have been organised that integrate care, particularly exchange of information, between GPs and across multiple secondary and tertiary centres and multiple specialities. This has positively transformed cancer care.

Another thing that has transformed cancer outcomes are national screening programmes, which are centralised national programmes. Within these, for example cervical cytology screening, the evidence is that larger specialist centres deliver better output, and the move is towards further centralisation there.

Similarly in cardiac care, results have been greatly improved by integrating emergency cardiac catheterisation centres with ambulance services accross entire regions.

There is no reason or evidence to suggest that introducing markets at this level of the organisation will deliver efficiencies. Sure, private providers may compete and drive up standards for small discrete proceedures that can be easily commoditised. It is perfectly good for providing glasses or perhaps cateract operations. These things don't require massive coordination to deliver the best results.

This is analogous to massive private sector organisations. Google delivers its service by means of a single integrated global infrastructure. So does DHL.

You can compete with Google or DHL but you will only do so with investment of massive resources producing a parallel system, where you will compete side by side. A similar argument could be made concerning some of the more efficient large private healthcare systems in the USA, such as the Keiser-Permanente, which is similar in scale to the NHS.

You will not increase internet search efficiency by forcibly breaking up Google into a hundred "competing" companies and imposing some competitive bidding system for services that parts of the company do for each other.

Whilst I don't deny that market mechanisms are fantastic in many contexts, free market puritans often seem to miss the very mechanisms delivering efficiency for some of their private sector champions.

Sometimes it seems to me that people advocating privatisation of aspects of the NHS are analogous to shareholders of a major company advocating break-up and competition between different bits of the company. Well sometimes that is the right thing to do, but when a break-up cuts across large-scale well integrated systems requiring lots of information transfer, it can be a disaster.

[PopGun]

why dont you just get on with making the cuts needed, and we can all continue to benefit from the Jewel in our Crown....the NHS.

Why not answer the question?

[Bloo Loo]

Why not answer the question?

They can privatise all they like, for all I care...as long as the privateers build their own hospitals, provide their own ambulances, train their own staff etc etc.

[mirage]

One good way the NHS could be privatised is simply regard it as a single competing health insurer.

Allow private organisations to offer universal coverage with universal acceptance criteria on the same basis as the NHS and see if any can do it cheaper or better. Anyone who opts out of the NHS gets (1/UK population) of the NHS tax burden as a tax rebate.

I'm sure there will be companies queing round the block to offer the service the NHS provides.

If you are just talking about private companies cherry-picking the easy stuff and leaving the NHS with the loss-making complexities then you aren't comparing apples with apples.

[PopGun]

No I don't work for the same private sector employer your other half works for. I work for a small private sector company that offers a good value service.

Good for you

Perhaps there should be a poll.

Yes there should, it would stop people declaring their own pov as widespread 'fact'.

The amount I would pay for private health care would be a lot cheaper that the amount I current pay into the NHS via NI. I pay around £750 NI every month, I know not all of it goes to the NHS but a large percentage does. I would definately vote to opt out!

A sensible choice when you're young and healthy. Get a complicated illness mind, and I very much doubt it would still be cheaper. Get a long term condition and you’re seriously screwed.

Health Insurance could be the answer; however this would get incredibly more expensive as you age. Besides we all know how finance can frag markets.

Edited August 1, 2011 by PopGun

[Injin]

Pro tip - when talking about healthcare spending it's helpful to realise that there is no magic box that contains just the choices to buy healthcare products and services.

While the NHS may well be the best healthcare service in the world, what people might have actually wanted to do with their money is go for a picnic, or maybe buy a conservatory or something. Until the NHS is funded by some other mechanism than theft, we have no idea what people really want to spend their cash on.

[Injin]

A sensible choice when you're young and healthy. Get a complicated illness mind, and I very much doubt it would still be cheaper. Get a long term condition and you’re seriously screwed.

Health Insurance could be the answer; however this would get incredibly more expensive as you age. Besides we all know how finance can frag markets.

Not a problem - the solution to high prices is high prices.

[PopGun]

They can privatise all they like, for all I care...as long as the privateers build their own hospitals, provide their own ambulances, train their own staff etc etc.

Agreed, but we both know that won't happen.

[PopGun]

Not a problem - the solution to high prices is high prices.

What like with Houses?!

I know where you're coming from btw, I'm just too cynical to think it would work out that way.

[mirage]

Excellent - how much comes into the Exchequer? Must virtually pay for the entire health service, the buildings, everything.

Oh no - wait a moment is this where 'private' doctors make use of the public facilities at below the real total cost?

In many cases NHS doctors do private work for NHS trusts for no additional remuneration, as trust employees in other words.

[mirage]

The last company I worked for offered a private health care scheme, the cost to the employer was about £75 per month for a family cover plan. I paid nothing.

Yes of course it would be cheaper for healthy people to opt out of a universal insurance system.

It would be cheaper whilst you are healthy, that is.

You will have to persuade the a majority of the voting population out of universal insurance funded from progressive general taxation. That battle doesn't have much to do with how efficient or otherwise the NHS is as a healthcare system.

[Bloo Loo]

Yes of course it would be cheaper for healthy people to opt out of a universal insurance system.

It would be cheaper whilst you are healthy, that is.

You will have to persuade the a majority of the voting population out of universal insurance funded from progressive general taxation. That battle doesn't have much to do with how efficient or otherwise the NHS is as a healthcare system.

the problem with insurance funded cover is that no-one gives a frack about the price.

About 1982, I had a couple of dogs...it was no issue to wham them up the vet for jabs, illness whatever...costs were reasonable.

Now we have pet insurance, you cant afford NOT to have insurance....prices have shot up..to the benefit of vets, insurance firms and drug companies.

[PopGun]

the problem with insurance funded cover is that no-one gives a frack about the price.

About 1982, I had a couple of dogs...it was no issue to wham them up the vet for jabs, illness whatever...costs were reasonable.

Now we have pet insurance, you cant afford NOT to have insurance....prices have shot up..to the benefit of vets, insurance firms and drug companies.

+1 Indeed, look at house prices ffs.

You don't have to be an expert to work out what the logical conclusion of all this will be.

More finance or insurance vehicles just isn’t the answer.

Edited August 1, 2011 by PopGun