Doctors Strike

[ChumpusRex]

I think you are right regarding NHS QALY being only around £20,000.

Incidentally, IIRC, Netherlands' QALY is around twice that, with only some 20% or 30% bigger budget/person than the NHS.

The NHS don't publish a cost-effectiveness-threshold figure. However, in 2005 it was estimated at between £20k and 30k/QALY. NICE doesn't usually approve drugs where the drug cost is over £30k/QALY (but does on occasion, e.g. Herceptin for breast cancer).

I suspect that the target has risen a bit since the last estimate - not least because of substantial wage rises at all levels.

[mirage]

The remaining question is when the data was collected.

Those salaries are in dollars. If you convert into pounds at the 2006 rate you will see that there is something very wrong with it.

This is a thinking error a bit like not being able to see the symmetry between public and private sector revenue.

How would converting any set of salaries quoted in a single currency into any other currency at any exchange rate change the relative positions of those salaries?

Further, since I presume you are really trying to get at relative purchasing power changes since then, the pound was stronger then than now, so in real terms GPs should have got relatively cheaper than then, all other things being equal.

[mirage]

No, the Govt thinks you are only worth £18k, which it had to take by force from people in the private sector.

The 7k in you give back in tax, is just PR to make you think you have actually made some kind of net contribution. You haven't.

In a grossly simplified form it works like this:-

The Govt takes £18k from someone in the private sector, it then tells you that it has paid you £25K, but kept £7k back as tax. You never had that additional £7k did you? Neither did the Govt.

Of course in reality, the Govt did take the full £25k off someone in the private sector, if you account for the processing costs and waste of the transfer process.

Brilliant logic. It's true that you can just net out the tax paid back by public sector employees. And as I pointed out earlier it is true in the same sense that Coke doesn't pay an employee the gross salary, it just pays net and then pays the government some tax. so no one really gets paid what they get paid.

"But Coke isn't funded directly by the government"

So what? It's still true by the same (pointless) logic.

What you forgot is that if the state employee doesn't really earn the gross salary, then what they "really" earn is the net 18k PLUS THE BENEFIT OF NOT HAVING TO PAY INCOME TAX. Which, er, adds up to their gross salary.

So your point about the gross figure being merely a psychological sop is pretty wrong, isn't it?

Do you just mean that you think they are overpaid by the state? Well so do I.

All transactions in the economy net to zero so by this schoolboy error of an argument no one "really" gets paid anything since they just got it off someone else. Divide any closed economy into private and public sectors and each by definition entirely fund the other.

Oh but only the private sector generates wealth? Not true in fact or principle, since you can make an entire economy public and generate at least some wealth. The crown estate generates lots of wealth. So again, you are only complaining about efficiency and value.

You are annoyed at the waste of the state. Why not just focus on that?

[Tired of Waiting]

This is a thinking error a bit like not being able to see the symmetry between public and private sector revenue.

What do you mean by "symmetry" in this context?

How would converting any set of salaries quoted in a single currency into any other currency at any exchange rate change the relative positions of those salaries?

Just do the maths, and you will see. That chart says that UK docs. salaries were around USD120k in 2006. Do the maths using 2006 exchange rate, and see if it tallies with GPs salaries here back in 2006.

Further, since I presume you are really trying to get at relative purchasing power changes since then, the pound was stronger then than now, so in real terms GPs should have got relatively cheaper than then, all other things being equal.

Exactly!

Think a bit more.

[Dr Renter]

Interesting that you pick probably the most overpaid employees in the country as a comparison.

Also, "except consultants and GPs" means junior doctors, typically under the age of what? 35? Are you really saying that they should all be on £60,000+?

Where did you get £60,000 plus from? Tube drivers, at the moment are still under £50,000 I believe. And "except consultants and GP's" doesn't just mean junior sectors, you're forgetting the group in the middle, the registrars, the doctors who essentially run hospitals, particularly out of hours and do the same jobs as a GP, without actually being paid like a GP.

[LuckyOne]

I disagree. Most healthcare provision is either a simple entity like a hip replacement, epidural or colonoscopy, or can be split into simple components such a GP appointment, outpatient referral or antibiotic prescription. The only area where it is almost impossible is acute hospital admissions which are too variable. I honestly feel that this country needs a short dose of private healthcare, just to give the public an indication of how expensive healthcare would be in a free market.

The "expensiveness" of private healthcare (like many other services which could be provided privately) is a function of the tax paid by the user.

State provided services are very expensive for those who pay a lot of tax as they are paying for the services consumed by many more than their own families. State provided services are very cheap for those who pay little or no tax as others are paying for the services that they and their families consume.

If we could get to a system which showed the taxes that we pay versus the state provided services that we consume over our lifetimes, I suspect that high tax payers would be quite unhappy and low tax payers would be a little less unhappy.

[mirage]

I think you are right regarding NHS QALY being only around £20,000. But I'm not sure you know what QALY actually means. It's in effect the maximum the NHS will pay to save your life - assuming you are fit and healthy that is. Otherwise your life ("Quality Adjusted") is worth less, and accordingly they won't spend as much.

Incidentally, IIRC, Netherlands' QALY is around twice that, with only some 20% or 30% bigger budget/person than the NHS.

That is one of the reasons i want our NHS to keep its current budget, but use it better.

QALY

It is an attempted quantification of life in units of a year of life in perfect health. Where health is less than perfect a scale is used to reduce the QALY per year of life.

An life saved in perfect health is not therefore one QALY, unless the patient only lives a year afterwards.

Nor is a QALY the maximum the NHS will pay. The QALY is the year. The maximum the NHS will pay per QALY added is a separate matter.

So I presume you are saying that the Netherlands will pay up to twice the NHS per QALY, on only a 20-30% greater budget per capita. I don't know if this is true, or how comparable the data are.

The interesting thing here is that paying more per QALY could represent either greater efficiency in a health service, or less efficiency.

You would obviously have to know how many QALY's were actually bought, wouldn't you, along with differences in patient populations.

[mirage]

The "expensiveness" of private healthcare (like many other services which could be provided privately) is a function of the tax paid by the user.

State provided services are very expensive for those who pay a lot of tax as they are paying for the services consumed by many more than their own families. State provided services are very cheap for those who pay little or no tax as others are paying for the services that they and their families consume.

If we could get to a system which showed the taxes that we pay versus the state provided services that we consume over our lifetimes, I suspect that high tax payers would be quite unhappy and low tax payers would be a little less unhappy.

Not necessarily. Care is extortionate in the US, regardless of taxes paid for Medicade etc.

It is expensive there because it is a constrained and poorly functioning joke of a market.

It is expensive here because demand is from the richer patients who want a premium service and supply is constrained by the state.

I don't really know how expensive it might be if we went full free market here. Would be interesting to see. There would be inefficiencies relative to the current model and also efficiencies. You could loosen up medical school numbers and add some supply there, but most of the wage bills are from non-doctors and recruiting them hasn't always been easy despite no such BMA imposed training limits.

[Tired of Waiting]

QALY

It is an attempted quantification of life in units of a year of life in perfect health. Where health is less than perfect a scale is used to reduce the QALY per year of life.

An life saved in perfect health is not therefore one QALY, unless the patient only lives a year afterwards.

Nor is a QALY the maximum the NHS will pay. The QALY is the year. The maximum the NHS will pay per QALY added is a separate matter.

So I presume you are saying that the Netherlands will pay up to twice the NHS per QALY, on only a 20-30% greater budget per capita. I don't know if this is true, or how comparable the data are.

The interesting thing here is that paying more per QALY could represent either greater efficiency in a health service, or less efficiency.

You would obviously have to know how many QALY's were actually bought, wouldn't you, along with differences in patient populations.

Of course QALY is per year! It's the acronym for Quality Adjusted Life Year = QALY.

I know that.

Yes, the Netherlands' QALY threshold is much higher than ours. Google it.

In effect, a Dutchman's life is worth around double ours.

And every pound wasted in high salaries reduces the NHS QALY = it kils people.

That is why I do not want a reduction of the NHS' budget. Just a better use of it.

[mirage]

The private sector borrows its money into existence from private banks (physical cash excepted.) This is the source of all commercial bank money - what we use as our medium of exchange.

The UK state (government, public sector ...) does not borrow money into existence. The money it takes and spends, either through borrowing (gilts) or through taxation, is pre-existent commercial bank money already in circulation.

The state also issues some (debt-free) money into existence, both physical cash and electronic central bank money. The latter circulates only within the banking system as the medium of inter-bank settlement - we have no direct access to it.

These three types of money, and in particular their sources and origination, are well-explained in the book Where Does Money Come From?

http://www.positivem...come-from-book/

All of which is irrelevant to the question of revenues. Credit creation is not a revenue. Interest payments are.

It makes no difference to my point. All you are pissed off about really is control of money supply and profit skimming by the financial sector. Fair enough, but not the point here.

[Si1]

It is expensive there because it is a constrained and poorly functioning joke of a market.

...

I don't really know how expensive it might be if we went full free market here. Would be interesting to see.

so on the one hand the US doesn't have a "full free market" but on the other hand it does

my word

[Dorkins]

Yes, the Netherlands' QALY threshold is much higher than ours. Google it.

In effect, a Dutchman's life is worth around double ours.

Alternatively, the Dutch healthcare system is much less efficient than the NHS, so it costs more money to achieve the same improvement in health.

To make a true comparison, you would have to look at equivalent interventions e.g. the total cost to treat a broken arm in both countries.

[Tired of Waiting]

Alternatively, the Dutch healthcare system is much less efficient than the NHS, so it costs more money to achieve the same improvement in health.

To make a true comparison, you would have to look at equivalent interventions e.g. the total cost to treat a broken arm in both countries.

No because their health budget/person is only 20-30% higher than ours, IIRC.

[mirage]

Fundamentally wrong on many counts.

The State is most definitely not just another organization, as it also regulates and issues and controls the means of exchange of all the other organizations.

So what? It is a transacting organisation in the economy. Any special features you choose to pick out have to have some relevance to the accounting argument you are trying to make. This has no relevance. "Controls the means of exchange" indeed!

Coke merely acts as the State's tax collector for the money it pays it's employees. It isn't keeping the tax it collects.

So what?

It also, of course, has to pay corporation tax itself -as well as an additional employers NI contribution.

So what?

The accounting distinction is 100% real, in that Private sector employees make a net Tax contribution and Public sector ones don't.( I class private sector companies that live on Govt contracts as de facto Public Sector)

Really? And what about other companies that rely in turn on them? Where do you draw the line? You don't know.

Net out tax consistently over the economy or don't bother. If you net out tax for doctors but not for Coke employees, then at least account for the benefit of not paying any tax for the doctors.

Now, if, as you claim, the NHS is actually making a net contribution then I'm sure you'll be able to tell me how much profit it made last year ?

I didn't claim anything of the sort. Reading comprehension.

Edited June 21, 2012 by mirage

[mirage]

No because their health budget/person is only 20-30% higher than ours, IIRC.

No you have made a mistake. The Dutch system could be more OR less efficient with those numbers. Dorkin is right.

[mirage]

so on the one hand the US doesn't have a "full free market" but on the other hand it does

my word

The US system is conventionally refereed to as a free market but is in fact a corrupt cartel, ie a poorly functioning market.

[mirage]

Of course QALY is per year! It's the acronym for Quality Adjusted Life Year = QALY.

I know that.

And yet you refered to it as a monetary value that represented the maximum paid per life saved. So you understood but just expressed yourself poorly, I'll assume.

Yes, the Netherlands' QALY threshold is much higher than ours. Google it.

In effect, a Dutchman's life is worth around double ours.

And every pound wasted in high salaries reduces the NHS QALY = it kils people.

That is why I do not want a reduction of the NHS' budget. Just a better use of it.

You are thinking about it too simplistically. Your conclusion about Holland may be true, but it doesn't follow from those numbers.

Edited June 21, 2012 by mirage

[Tired of Waiting]

No you have made a mistake. The Dutch system could be more OR less efficient with those numbers. Dorkin is right.

Did I? Really? Care to explain?

[mirage]

Did I? Really? Care to explain?

OK

Paying more for a QALY could either represent having more free resources because of efficiencies elsewhere or...

Needing to spend more per life year because you are inefficient, whilst delivering fewer of those life years to the population.

Like Dorkins said, you need to compare cost and QALY effectiveness of specific interventions and look at how many QALYs are actually being produced.

[Tired of Waiting]

And yet you refered to it as a monetary value that represented the maximum paid per life saved. So you understood but just expressed yourself poorly, I'll assume.

It as a "monetary value that represented the maximum paid per life saved", and yes, it is per year, but since we were talking about QALY(ear) I didn't realise I had to say "year" again. I thought you knew that. My mistake then.

You are thinking about it too simplistically. Your conclusion about Holland may be true, but it doesn't follow from those numbers.

Again, care to explain?

[Goat]

Not necessarily. Care is extortionate in the US, regardless of taxes paid for Medicade etc.

It is expensive there because it is a constrained and poorly functioning joke of a market.

It is expensive here because demand is from the richer patients who want a premium service and supply is constrained by the state.

I suspect the legal system has a major influence on the cost and efficency of healthcare in the US.

The "sue anyone for anything" culture means that doctors practice in a way to minimise their exposure to a medical malpractice suit, which means lots of additional tests that non-US doctors wouldn't worry about on the off-chance that the patient has a rare condition that if not diagnosed could land them with a multi-million pound bill.

[mirage]

so on the one hand the US doesn't have a "full free market" but on the other hand it does

my word

Anyway, what do you mean here? I didn't imply that the US was "full free market" in that post, did I?

[mirage]

I suspect the legal system has a major influence on the cost and efficency of healthcare in the US.

The "sue anyone for anything" culture means that doctors practice in a way to minimise their exposure to a medical malpractice suit, which means lots of additional tests that non-US doctors wouldn't worry about on the off-chance that the patient has a rare condition that if not diagnosed could land them with a multi-million pound bill.

Yep. And regulations that don't allow import of cheaper drugs from abroad. And the way Medicare and Medicaid are structured and lots of other things, not least the barriers to entry.

Then you have other fundamental problems with private provision of health care, such as information asymmetry and the agent problem - in other words the doctor is economically motivated to get you to pay a lot, not to benefit your health.

Edited June 21, 2012 by mirage

[Tired of Waiting]

OK

Paying more for a QALY could either represent having more free resources because of efficiencies elsewhere or...

Needing to spend more per life year because you are inefficient, whilst delivering fewer of those life years to the population.

No! QALY is not how much you spend on average to save a life (or to save a Quality Adjusted Life Year)!

QALY is a threshold, and for all patients in a system!

Like Dorkins said, you need to compare cost and QALY effectiveness of specific interventions and look at how many QALYs are actually being produced.

[mirage]

No! QALY is not how much you spend on average to save a life (or to save a Quality Adjusted Life Year)!

QALY is a threshold, and for all patients in a system!

No it isn't. It is a quality adjusted life year. It is not how much you may or may not spend to achieve a QALY. It is not a pyament threshold. It is a measure of years of life, like your age, but adjusted for health.

So you are wrong again.

Don't give up though.

Edited June 21, 2012 by mirage