[ExI] Yet another health care debate

[Tom Nowell]

Now, to rip into my own country's health care system following Fred's suggestions:

Fred Moulton asked: 

For each health care system under consideration please do the following:

1. Determine what are they component parts and how they are connected;
such as emergency care, pharmacy, etc.  Are there parallel systems?
 Component parts - Primary health care trusts provide you with a General Practitioner (family physician) and community based care. They are also responsible for purchasing hospital treatment. Each hospital is usually a separate entity, although some are gathered together. There is some dental provision, but this has become so patchy most people see private dentists. Although everything belongs to the "National Health Service", an element of competition was brought in under Margaret Thatcher's government, and has been rearranged under the successive governments.

2. Determine how it is controlled, financed and regulated at the macro
level.  And then how these macro level factors influence micro level
decisions.  And the reverse.
 The top-level control is by the Ministry of Health, centred in London. They issue targets - some are from central policy, some from knee-jerk reactions to the political issues of the day. It is paid for by taxation. The main things people pay for themselves are prescription drugs (but the charges on these are capped), and social care. Oh, and dentistry is mostly out of your own pocket. 

3. To the extent that some or all of a health care system is controlled
by an identifiable entity does that entity have a goal or goals?  Are
these goals internally consistent and do they conflict with the goals of
other groups?  How are these conflicts resolved?
 The macro level control is from the Ministry of Health setting targets. The way treatments are paid for is set centrally. The Primary Care Trusts are responsible for getting people treated, but they may choose which hospital trusts to purchase from. The hospital trusts have to try and claim as much as they are entitled to from the government, while keeping costs down.
 This creates a conflict, as hospital trusts are frequently obliged to offer expensive services which they are inadequately compensated for, while management tries to up the amount of more profitable treatments done. Also, some hospitals have tried to outsource everything possible, leading to lower standards of cleanliness (from using cheapest bidder cleaners) which conflicts with the clinical need to avoid hospital-acquired infections, less flexible meals for patients (cheapest bidder caterers) which can conflict with individual patient needs, slower laboratory test results (sending lab tests offsite to a cheaper lab across town rather than having a lab onsite).

3. Do individuals and groups have alternative options which they can
pursue without penalties? 
 NO. This is currently a serious political issue, as cancer support groups are complaining about this. In the NHS, you either have to be totally public funded, or totally private funded. Many trusts won't fund the newest biotech anti-cancer treatments, as they cost thousands to give a cancer patient a few per cent higher survival rate or to give a terminal case a few more months of health. People with cancer have offered to pay for the cost of the drugs, only to be told that they will then have to fund the rest of the treatment costs as well if they do - so they would have to pay the hospital costs, pay for the doctor to administer the drugs, and the rest, all massively increasing the cost. 
 This has annoyed a lot of people.
4. Are the caps or limits or rationing on various types of care?  Are
all illnesses and diseased covered and to what extent?
 Yes, new drugs have to be evaluated by NICE (the National Institute for Clinical Excellence). Many expensive treatments are rationed, as is cosmetic surgery. This has led to claims of a "postcode lottery" into what is covered where. *Theoretically* all diseases are covered, just not all treatments, so you can be referred to what treatment is nationally recommended. This can be as simple as prescription of the cheapest generic drugs, or it can be along the lines of "I have a disfiguring condition, and only surgery can stop me looking hideous!"."Yes, but the plastic surgeons have a long waiting list. Here, have a referral to the self-esteem counsellor in the meantime so you don't feel so bad about it."

5. What are the demographic and other inputs into the system?  This
includes factors such as age, work history, obesity, smoking, substance
abuse just to name a few.
 Demographics - entire UK population, including the obese, the smokers, the junkies. There is occasional rationing along such lines eg some surgical units refusing to operate until the obese lose some weight, or vascular surgeons not operating on smokers, alcoholics being denied liver transplants. This is usually based on clinical experience - they don't bother wasting treatment on those who are likely to have a worse outcome and can do something about it.

6. How are outcomes identified and measured?  Age of death, amount of
suffering, time on waiting lists for diagnostics, time on waiting lists
for surgery, percentage of persons receiving preventative care, etc.
 Very badly. Although there is excellent demographic data to show ages of death and infant mortality, and many government targets are recorded, there is a huge problem in UK healthcare. Most outcomes aren't reported properly. You have no idea how good your surgeon is, there is little measurement of how good individual hospital units are, and systems for picking up incompetent/malicious doctors have well-publicised failures. There is a real need to improve reporting and recording of outcomes.

Criticism aside, the NHS does a decent job - trauma care is good; public health care is good, except where media frenzies over vaccine side-effects have persuaded parents not to immunise their children; after throwing a lot of money at the problem, hospital waiting lists have finally dropped; cancer treatments are delivered quicker than ever. However, there's some inefficiency and wastage in the system, and I'm aware that UK cancer survival rates are lower than most of the EU - I'm not sure how much is down to lifestyle and how much to difference in treatment though.

Tom (still proud of the NHS, wouldn't live in a country without socialised health care unless he had a job offering excellent healthcare, etc.)