What would help the NHS?

[Floppit]

Politically and culturally what can we do to keep the NHS healthy, or return it to health depending on your point of view?

I don't have the knowledge base to answer the question re politics but culturally I think we need a slap upside the head. I'm appalled by some of the pettiness I see on patient comment boards, one which stands out was the quality of waiting room seats (normal conference sort of seats)! The jingoistic 'post code lottery' may be a real problem and one keenly felt by those the wrong end of it but in contrast to the vast inequalities seen elsewhere it needs some perspective. As much as criticism is needed to keep things thriving and growing, so is realisation of where and how it works and that seems to me often lacking.

I'm really proud of the NHS, to me it is such a damn good thing and perhaps even more so than our mostly democratic governance it is one of very few things that inspires a degree of national pride in me.

[Tony Williams]

I have no inside knowledge about the NHS either, but it seems obvious that it can't go on as it is. There are two factors pushing it into the financial mire: the ageing population, which will need ever more care over the next few decades (especially since medical science is allowing people to live longer), and the steadily increasing complexity and cost of the treatments which are available. Together, these will just keep on pushing up the financial demands to what will very probably be unsustainable levels.

I can't see the NHS being given any more money, not after the huge increase of the early 2000s (which sadly, like the increase in education spending, does not seem to have been converted into a comparably large improvement in services).

What to do about it? I don't know, but there will probably have to be some sort of rationing. Recent moves to make it easier to mix and match between NHS and private health care might help to take some of the pressure off, but face the objections that they will establish a two-tier system. But what else can be done? Not everyone can drive a Rolls-Royce.

[Floppit]

I doubt that denying healthcare is cost effective as it just pushes the bill from the NHS to Social Care. Even if the Social Care was rationed or removed it would still entail cost as family pull off work to plug the gaps and in doing so become more reliant on state welfare, if that was removed my guess is the crime an punishment bill would go up. If people of working age wind up debilitated, especially if they have dependants the knock on effects are considerable.

I also struggle with the reality of there being a lack of funds. I may well be alone in doing so and I wouldn't deny that the NHS is short of cash but we're one of the World's wealthiest nations so it seem to me more about how we are choosing to spend our money than an absolute lack of it. I'd like to see Sony go bust before the NHS, I'd like to see health matter more than a new TV.

Technology and cost of treatment does push up bills in one way but doesn't it also cut them in another? If something is cured then long term costs are saved, if treatment is more effective it perhaps can be shortened. I'd like to know more about how this balances out, through the media I get the cost increase bit with brass knobs on but less so the gains and surely they are just as real.

[Tony Williams]

I also struggle with the reality of there being a lack of funds. I may well be alone in doing so and I wouldn't deny that the NHS is short of cash but we're one of the World's wealthiest nations so it seem to me more about how we are choosing to spend our money than an absolute lack of it.

Hmm. Although I worked in the public sector throughout my career, I am aware that there if our national economy is to prosper, we need to encourage the private entrepreneurial sector to generate income. I don't mean to imply that public sector spending is simply a "cost"; obviously it is not, since it pays for eduction as well as health care plus a lot of infrastructure. But not everyone can work in the public sector, or who would pay for it all? So there is a limit to the proportion of employment and spending which can go to the public sector, otherwise the economy suffers and there'll be less tax income to spend anyway.

The health service not only received a huge boost to funding over the past decade (something like a 30% increase in real terms IIRC), it's being given "protected status" by both major parties while most other aspects of public spending are going to have to be cut back severely to try to pay back the massive government loans following the economic recession. So I think that's the best the health service can hope for over the next decade - not to have its budget cut. Since demands can be expected to increase steadily for the foreseeable future, that will mean decreasing resources to share around.

Technology and cost of treatment does push up bills in one way but doesn't it also cut them in another? If something is cured then long term costs are saved, if treatment is more effective it perhaps can be shortened. I'd like to know more about how this balances out, through the media I get the cost increase bit with brass knobs on but less so the gains and surely they are just as real.

I think this is a very difficult one to answer. By and large, additional treatments (including new drugs) tend to cost more. Whether they lead to any savings depends on the circumstances. After all, some treatments will have the effect of prolonging life, possibly requiring continuing medical support thereafter, whereas before the treatment was available the people afflicted might simply have died.

I think that NICE tries to do these sums when it comes to the costs and benefits of new drugs, but of course they can be subjected to intense and emotional public (and sometimes political) pressure to approve an expensive new treatment which just prolongs lives for a brief period.

Lots of tough questions, no easy answers.

[Pebble]

Politically and culturally what can we do to keep the NHS healthy, or return it to health depending on your point of view?

I don't have the knowledge base to answer the question re politics but culturally I think we need a slap upside the head. I'm appalled by some of the pettiness I see on patient comment boards, one which stands out was the quality of waiting room seats (normal conference sort of seats)! The jingoistic 'post code lottery' may be a real problem and one keenly felt by those the wrong end of it but in contrast to the vast inequalities seen elsewhere it needs some perspective. As much as criticism is needed to keep things thriving and growing, so is realisation of where and how it works and that seems to me often lacking.

I'm really proud of the NHS, to me it is such a damn good thing and perhaps even more so than our mostly democratic governance it is one of very few things that inspires a degree of national pride in me.

The way I tend to look at patient complaints is that if the flower arrangements, seating and decor are their main concerns, then it is likely they are satisfied with the basics. When they complain of negligence, incompetence and rudeness then you really have problems.

People always want more, only by getting to a position where every whim can be catered for can you seriously reduce complaint numbers, up to that point one only chages the focus of the complaints.

Such complaits are however useful, they tell you what you need to change to satisfy the largest number - and lets face it comfortable seating in plesant surroundings should be provided where this is possible - by comparison with the cost of care this is peanuts.

The forthcoming real terms reduction in income is a big challange. When you invest, you get less and less return per unit investment. When you cut costs you often lose more than expected due to the impact on the psychology of the workforce. The Hospitals have been focused on efficiency for the past couple of years, because of the drive to move services to the community. So failure to pay for the shift in service will result in continued contraction in the hospital services coupled with a failure to expand the community services adequately. This is likely to result in huge gaps in service provision, with probable excellence in high end acute care, but poor access to that care.

I cannot see the political will for the rational alternative - rationing! This would require that many treatments are simply accepted as too expensive - renal dialysis for example is not truly cost-effective.

The private sector will not solve the problem, they increase costs for simple services unless you accept a noticable reduction in quality - if you are prepared to accept that why not just do it in a managed fashion (compeditive NHS tendering plus agreed minimal standards of quality) without the need to generate associated profits? The only advantage I can see in increasing private involvement is to ensure that those who can pay get the opportunity to do so and maintain service quality for themselves, and therefore do not become disgruntled enough to punish at the ballot box.

[barefoot]

I became more interested in the NHS after my Dad and then later myself had bad NHS experiences with regard to lost physical files - happened no less than three times!, and appointments with specialists delayed over and over. But I'm definitely no expert, just read bits and pieces online, spoke to friends in medicine, and thought about things a little. I hope some people on the inside of the system who know all the real problems reply to this thread!!

I disagree with Pebble that the private sector cannot help the problem. I read a white paper by a think tank several months ago that didn't seem biased. One of the conclusions as to why the French system is one of the (and actually ranked by the WHO as the) best in the world was the mixture of public and private interests - most GPs in France operate private practices but the majority of their income comes from public insurance funds. Another one of the best healthcare systems in the world is the one in Singapore, they have universal healthcare supported again by a private sector. They have a system of healthcare accounts that you can top up and transfer between family members to pay for day to day health care, along with insurance covering the more unlikely events.

Singapore spends 6% GDP and comes 6th in the WHO ranking, France spends 11% and comes first, the UK spends 8.4% and comes 18th. We should learn from the mistakes and successes of other countries and just copy them where appropriate! My opinion is that people are very polarised in their assumptions about healthcare. In the UK people generally think private health care companies are a terrible thing, and in the US they go ape shit about any mention of socialising health care - Obama is having mixed successes with his reform right now :S. In reality, I think if a balance could be found between private and public we could all be better off - not that I'm saying its an easy thing to do, but I don't think it should be dismissed as an option as the vast majority of people in the UK would instantly do. If it works in other countries, it could work here.

I find it difficult to talk to people about the NHS, they are not prepared to be critical about it. There is some sort of national pride and sense that it is really fantastic and before discussing any of the problems in the NHS with people outside of the medical profession, I have to get passed this ridiculous assertion. It's not that I'm not grateful for the NHS, but to me, if we're 18th in the world despite being the 6th largest economy we're doing something wrong that we can improve upon.

And as for politics - I think my last two paragraphs make it a political nightmare, and very difficult to change (or at least campaign on changing), even David Cameron keeps banging on about his ring-fence for the NHS so that it doesn't get cut. Not that I think the NHS should be cut, but I'm fed up of him saying it now and its still months away from the election!

One thing I was thinking about this xmas - does anybody know about NICE? From what I understand, they decide what drugs are affordable and therefore choose what drugs/treatments people get. To me, this seems counter to how capitalism works. For example, in about 2001, a relative (the only wealthy one in the family!) bought a 40" flat screen TV, it cost several thousand pounds, but that company invested that capital into more research and eight years later, I bought my first flat screen tv for a few hundred pounds. I'm curious if NICE works like this or not, i.e. only getting a small number of the most recent expensive drugs in order to give pharmaceutical companies the capital they need to do more research. I realise there is there a moral issue where you have to guarantee all patients the same health care. But I'm sure you could argue against that by saying that certain drugs are on a trial basis or something though, and that type of purchasing drugs would be more compatible with capitalism.

Anyway, I've waffled on for ages now!

[Floppit]

I cannot see the political will for the rational alternative - rationing! This would require that many treatments are simply accepted as too expensive - renal dialysis for example is not truly cost-effective.

The private sector will not solve the problem, they increase costs for simple services unless you accept a noticable reduction in quality - if you are prepared to accept that why not just do it in a managed fashion (compeditive NHS tendering plus agreed minimal standards of quality) without the need to generate associated profits? The only advantage I can see in increasing private involvement is to ensure that those who can pay get the opportunity to do so and maintain service quality for themselves, and therefore do not become disgruntled enough to punish at the ballot box.

I think the whole issue of rationing healthcare would make an interesting topic in it's own right. I'll admit that it's the way it sounds that puts me off, I think of WWII rationing with each person holding so many tokens and when they're gone they're gone. But, as people are not born equal or with equal chances, personally I'd want to see the likes of Sony go broke before that happened and I'd never vote for it. On the other hand I accept it would be insane to blow a whole department's budget to add a month to one person's life so I also accept that some extent of rationing must exist.

I wonder whether some of the problem is that for those outside the medical profession (and at a guess some within!) struggle to understand how rationing would be done and what it would mean in real terms. Surely it can't just be about medical cost versus medical gain? If a breadwinner is lost from a family that would have otherwise continued to support their family, or a single parent lost where the child has no relative to step in, these things invoke new costs that when looking for what relieves the burden on the state need to be taken into account. And yet, on the other hand to have a world where a parent is treated just because they have offspring and a childless person is left to die is also abhorrent.

I think it would make for a brain stretching topic, here or in it's own thread.

[Pebble]

The last WHO healthcare ranking was produced in 2000. Indeed after years of underinvestment at that time the UK ranked 18th, the US with 15% of GDP expended on healthcare came 37th, with very poor longevity, maternity services, infant mortality etc. There has been no update by them or anyone else, even the most die hard 'everything is worse under labour' person must realise that the NHS has improved enormously - though I agree could have done more for the investment.

Think tanks do not produce white papers unless they are biased. Why would you put the effort into a such a piece of work unless you or those who are paying you to undertake a huge amount of work have a clear objective.

Think of what you are complaining about - lost files! Where has the govt directed the expenditure in information management in the NHS - yes a failed computer systems. Who says things are perfect?

The French system has the advantage of getting you very quick access to specialists. The down sides is that being a fee-for- prescription service, the French recognise they are being plied with too many chemicals. The central services are run by a command and control module, which is excellent for research, but actually more extreme than the NHS in terms of being 'socialist'.

So a part private system can work, never said it can't - it simply has perverse incentives and therefore costs that do not serve the primary aim. Where people need motivation this helps alot, but remember you get what is sold not what you ask for.

[Tony Williams]

So a part private system can work, never said it can't - it simply has perverse incentives and therefore costs that do not serve the primary aim. Where people need motivation this helps alot, but remember you get what is sold not what you ask for.

So the logical approach to healthcare is to ask: "what kind of behaviour - by doctors and patients - do we want to encourage? And how do we organise the service to encourage that behaviour?"

Oh but of course - some what say that smacks of social engineering! Yes it does - and what's wrong with that?

[Floppit]

Oh but of course - some what say that smacks of social engineering! Yes it does - and what's wrong with that?

Well, for a start do you want a health system to tackle what ails the human body or what ails society? If you get the latter would you be prepared for it to remain a means to control society should a government you utterly oppose gain power?

[Tony Williams]

Well, for a start do you want a health system to tackle what ails the human body or what ails society? If you get the latter would you be prepared for it to remain a means to control society should a government you utterly oppose gain power?

All governments get involved in social engineering and use taxation policy to achieve their aims - the current primary target is to find ways of getting banks to stop paying obscene bonuses. Of course, any sort of redistributive taxation (e.g. from rich to poor) is a form of social engineering. There is nothing wrong with that.

However, such policies can only influence people's behaviour, they don't determine it. That's a heck of a long way from "controlling society".

[Floppit]

I sense that your answer doesn't really address my point. You asked what was wrong with having social engineering as an aim in determining healthcare structure and I think I gave a relevant answer. You didn't ask whether social engineering takes place or the extent to which it's effective, just what was wrong with it as an aim for healthcare.

Looking at how Bush and the RC church have tried to manipulate contraception/sexual healthcare to meet their own social ends I think my point still stands.

[DrS]

does anybody know about NICE? From what I understand, they decide what drugs are affordable and therefore choose what drugs/treatments people get. To me, this seems counter to how capitalism works.

I don't know any detail, but it seems to me that NICE decides on treatment availability from a primarily economic viewpoint, with the result that many drugs or procedures are restricted. One in the news over the last few days was a rheumatoid arthritis treatment which is apparently available very widely in Europe, and now in Scotland, but is not to made available to sufferers in England and Wales on economic grounds. That doesn't sound like counter-capitalism to me, quite the reverse, and in a socialist-rooted welfare state, quite counter to the original principles.

[Tony Williams]

I sense that your answer doesn't really address my point. You asked what was wrong with having social engineering as an aim in determining healthcare structure and I think I gave a relevant answer. You didn't ask whether social engineering takes place or the extent to which it's effective, just what was wrong with it as an aim for healthcare.

I actually meant "what's wrong with social engineering" in a general principle sense (prompted by the current political debate about tax changes to reward marriage).

However, as far as healthcare is concerned: an example of how not to do it is the attempt a few years ago to rationalise GPs' contracts and responsibilities and encourage them to arrange systematic evening cover, which inadvertently led to them getting massive pay rises for doing less work, with most of them opting out of evening cover. Another example is the balancing act over prescription charges: there used to be no charges, but since they were brought in there's been an attempt to keep them low enough not to penalise the poor (although I understand those on various benefits still get them free) but high enough to discourage unnecessary prescribing.

[Floppit]

I actually meant "what's wrong with social engineering" in a general principle sense (prompted by the current political debate about tax changes to reward marriage).

Sorry I thought the comment about social engineering was in reference to the OP, I had taken it to be your aside re the previous suggestion for what you felt would help the NHS. If you were referring to social engineering in any aspect at all obviously my retort wouldn't make much sense.