Three more reasons the NHS has to change

Last week I wrote in the Mail Online about Lionel and Ellen who have been together for 82 years! That this couple are alive is a testament to the success of modern medicine and their channel of communication is a witness to how technology has transformed our lives. In the year they were born, 1911, life expectancy for women was 54 years and for men 50 years; today it is 82.2 and 76.7 years respectively. In 1911 there were no fridges, few cars and the radio was still eight years off.

We have been hugely successful at increasing our longevity and the NHS has been central to delivering this achievement. Easy access to medicine has had a huge impact on our society and we are rightly proud of every life saved, injury healed and body restored.

Yet it is precisely because of our success at medicine and innovation that demands on the NHS as it is currently run have become a ticking time-bomb. The rising demand falls into three categories.

Firstly our wonderful but ageing population means that there are fewer people to pay tax to fund the NHS, just when demand for medical care is rising. At present there are more than five people working for every person over the age of 70 years; in under 18 years time there will be 3.7 people working to support everyone over the age of 70, because with people living longer, the population of 70 year olds will have increased by over 50% (6.2million in 2010 to 9.6 million in 2030). If we continue to rely on taxes as the sole source of funding for the NHS, the burden on the working population will be crippling.

Secondly we British are super-innovators. Our technological advances mean that we can do much more to keep people alive and improve their quality of life. I am not aware that anyone has stopped to cost what some of the advances that are beginning to emerge from the pipeline, such as stem-cell therapies, bio-sensing implants, pre-implantation genetic diagnosis etc. But I am sure that to expect the tax payer to fund them all is economic suicide.

And thirdly we refuse to grasp the nettle of broader treatment coverage – or “diagnostic drift”. The NHS was brought in so that everyone could have access to necessary medical and emergency care. People now expect it to sort out every part of their body with which they are dissatisfied. We cannot afford the NHS to continue to be expected to be in charge of happiness, and we need a frank, open debate about this to manage the public’s expectations.

I have heard no opponent to the Health Bill address just how they would transform the NHS to be fit for purpose in the 21st century. Last week I also wrote about the economic reality of a rising public sector burden on the economy – no one came up with any realistic alternative solution. We urgently need to tackle funding; we must face up to unsustainable demands, and next time I’ll address the third time-bomb of dependence.

The Health and Social Care Bill: Final Stages in Parliament

With opposition to the Health and Social Care Bill having reached new heights, we must look behind the rhetoric and remember basic principles. The most important point to remember is that the NHS exists to provide the best possible, affordable treatment to patients. People are living longer, largely because of medical successes. Health is poorer in old age. The cost of providing even treatment of today’s standard to everyone is therefore going to grow inexorably in real terms. Rising healthcare expenditure is further fuelled by genuine medical progress, which often involves ever more sophisticated and costly treatment. No country can truly provide the best healthcare to all its citizens. Every Government would like to be able to do so and every opposition party tries to make political capital out of the impossibility of complete success.

The UK has certain highly creditable ideals about which all major British political parties agree: that healthcare on the NHS should generally be free, that all NHS patients should be treated as equally as possible and that all illnesses should be covered. Even these principles are already subject to exceptions. Charges can be payable to dentists and opticians and for prescription drugs. A person who lives in a remote rural area cannot expect to receive an ambulance as quickly as someone who lives close to an ambulance station. Illnesses may not be effectively treated if NICE has deemed necessary drugs too expensive.

In the light of the need to control NHS expenditure it is vitally important that the NHS should run as efficiently as possible. An organisation as large as the NHS, which is on some measures the largest employer inEurope, cannot help but be burdened by some inappropriate bureaucracy and inefficiencies. The fact that the NHS is in the Public sector intensifies the risk.

All political parties accept that the NHS needs to become more efficient. However, they have differing views about how to achieve the goal. Conservatives believe in the adaptation of free market principles to encourage the NHS to provide what patients and medical professionals want. The Labour Party strives to control the NHS through a management structure designed to serve the public interest. Liberal Democrats place emphasis on statutory safeguards designed to ensure fairness, the availability of services and accountability. The approaches of the three main parties are ideologically different and will never be fully compatible, even though the desired end results are largely the same.

The Health and Social Care Bill began as a carefully drafted drive to modernise the NHS by the adoption of specific principles. Other political parties have lacked the parliamentary votes to alter the thrust of the Bill. They have instead negotiated Government support for an ever growing raft of amendments that typically enshrine in legislation points that the Government believes would have arisen naturally as a result of the implementation of the Bill. These amendments do not alter the essence of the Bill but they make it harder to understand and implement. Some are to be welcomed but many dilute the message of the Bill and confuse the clarity of the intentions behind it.

My reasons for supporting the Bill have remained unchanged since it was first introduced to Parliament. The features that I most like are:

• Reducing layers and numbers of “middle managers”. Action of this type generally increases the efficiency of large organisations.
• Getting decisions taken at the lowest sensible level so that they are made by the people with the most relevant understanding and experience.
• Aligning the interest of Government, patients, medical professionals and managers as far as possible, by having real clinical targets and concentrating power in the hands of medical professionals.
• Judging the performance of the NHS in terms of outcomes for patients.
• Arranging rewards, whether financial (e.g. profits, pay, money for investment) or personal (e.g. promotion), to reflect success in providing the best affordable treatment. For example, a private company will only be able to make a profit from the NHS if no other provider (including non-profit organisations and charities) can supply a better service at the same price.
• Independence from day-to-day political interference.

The NHS is too important for decisions to be ruled by emotion. Yet public debate has been at a disappointingly low level, hindered by bias. The Labour Party is stoking concern over conspiracy theories and encouraging inaccurate media coverage. Liberal Democrats, particularly in the House of Lords, are still seeking to amend the Bill without opposing it. The Conservative Party is failing to get its message across to medical professionals and the Public.

The Government will not be deflected by opposition because they believe, rightly in my opinion, that they are fighting a just cause. They take comfort that medical professionals have been wrong in their attitude to healthcare management on many occasions in the history of the NHS. For example, the BMA opposed the creation of the NHS shortly after World War II and likened Nye Bevan to Hitler.

A number of misconceptions are being put forward by opponents of the Bill:

• A claim that profit will be put before patients. This allegation is the opposite of what the Bill says. The overriding duty of the NHS is to serve patients. It will be illegal to award contracts in a way that is expected to further profit at the expense of patients.
• A suggestion that private companies will benefit inappropriately. In fact, they will only gain when they can contribute to a better outcome for patients.
• Comment implying that the Government wants 49% of hospital beds and theatre time to go to private patients. This interpretation of the Bill is scaremongering. If all private hospitals closed and all their business was undertaken by NHS hospitals, private patients would only represent 11% of NHS hospital work. The 49% cap is a safeguard applying to individual hospitals and is unlikely to restrict non-NHS income frequently, if ever. No NHS hospital currently comes anywhere near the 49% cap. Owing to other provisions in the Bill none ever will unless NHS patients are expected to benefit in the circumstances applying at the hospitals in question.
• Statements that private companies will cream off profitable work leaving difficult cases to the NHS.   The Law will be broken if contracts to private companies are lucrative enough for patients as a whole not to benefit.
• Some Labour supporters and media commentators seem to think that the Bill does not mean what it says. This view is strange since the Law on the NHS can be enforced in the Courts just as in any other field.
• Some commentators are suggesting that the Government is being unreasonable in excluding particular groups such as the BMA from certain talks about the implementation of the Bill once passed. In fact, the excluded groups have said that they firmly oppose the Bill and have appeared not to wish to help it forward constructively. The subject matter to be discussed in the talks is therefore in a category where the excluded parties are unlikely to make a contribution.

Parliamentary debate has occurred and is nearing an end. The reality is that the Bill is going to become Law. If the NHS suffers because medical professionals will not cooperate with the Government, the blame cannot all be laid at Andrew Lansley’s door. A few months can be a very long time in politics. Was Nye Bevin right or wrong when he called the BMA a “small body of politically poisoned people” who had decided “to fight the Health Act itself and to stir up as much emotion as they can in the profession.”?

US Voters reaction to Obamacare

By Tom Packer

Obamacare represents for good or ill probably the most important change in domestic policy of President Obama’s administration.

The two acts that compose ‘Obamacare’ represented a compromise with congressional sentiment rather than Obama’s ideal blueprint. Obamacare passed very narrowly in April 2010. Not a single Republican in the Senate or the House of Representatives voted in favour of the main bill. Large Democratic majorities allowed it to pass, in spite of 34 House Democrats voting against.

As I have already shown, the US healthcare system was already a distinctly mixed system in terms of government involvement.  Nonetheless if Obamacare sticks and comes fully into effect it will be the most radical reform of US healthcare since at least the 1960s. How popular or unpopular has this proven to be with voters?

Since the law was passed in March 2010 most polls have shown the US public opposing it by margins ranging from ten to twenty points. Notably, most of these polls have been by Rasmussen Reports, often considered one of the more Republican-leaning pollsters. But the decision of Democrats to decline to publish polls on the health reform with a straight up and down question itself speaks volumes.

A rare exception to this general finding  has been the Kaiser Tracking poll which has been taken monthly since April 2010 which has found much less opposition . In April 2010 this even found a plurality of Americans supportive of the law. However most even of Kaiser’s subsequent polling has found the reverse

Perhaps the most important test of public opinion so far is the 2010 US Elections. They  are a particularly important test as they allow the measuring of intensity. Obamacare may appear to be unpopular with a (slim) majority of the public but who cares more and actually votes on it?

In November 2010 the Republicans made almost unprecedented gains in the midterm elections (Congressional elections, midway through a presidents’ term)  elections which include the entire US House of Representatives and around a third of the Senate and matter  a great deal for how the United States is governed

The party that holds the presidency almost always loses seats in midterm elections (1998 and 2002 being the two exceptions over the last seventy eight years).  However 2010 was an extreme example of this, with Republicans gaining sixty three House seats from the Democrats – the most gains since 1938. They gained seven Senate seats despite having many more seats they held up for re-election than the Democrats.

This landslide is often ascribed to the economy but in fact the link between the economy and midterm election results is very tenuous there is simply no strong or clear link between the economy in a given year and midterm election results (Presidential elections are a very different story)   For example in 1982 during a bad recession the President’s party actuallymade gains. Moreover, the polls found that only around a quarter of Americans blamed Obama for the bad economy fewer than blamed Bush.

Voting for Obamacare was correlated with defeat for Democrats. A greater proportion of Democrats in the House of Representatives who voted for the law won re-election.But overall they fought much safer seats than the Democrats who voted against, many of whose districts were in states that had voted for John McCain in 2008, not Barack Obama.

Congressman Bobby Bright of Alabama’s second district  is an example of this. He voted against the law and then lost his seat. But he lost it by only 2%, while Barack Obama had lost it by 20% two years earlier in a much more favourable year for his party. Bright actually ran about fourteen points ahead of the typical Democrat result that year. This result therefore suggests voting against Obamacare helped rather than hurt Democrats.

For a given level of Democratic support in a district opponents of Obamacare did much better in the 2010 election. Democrats in districts reasonably competitive between the two parties were roughly twice as likely to lose re-election if they’d voted for Obamacare.

Interestingly, this was not true of other signature policies of the current US administration. For example the  fiscal  ‘stimulus’ (much bigger than in the UK) lacked the same correlation with a poor performance in November 2010.

In the two years since it was passed, Obamacare has not become popular. Kaiser’s tracking survey shows consistent levels of public support and opposition, with a little fluctuation in both directions. The first poll of April 2010 showed 44% approval to 41% disapproval. By this January approval was at 37% and disapproval at 44%. Rasmussen’s surveys also suggest that if there is a trend, it is of increasing unpopularity.

The Republicans are almost unanimously committed to repealing Obamacare given the opportunity, and will be hoping to benefit electorally. However, introducing a law and repealing one once it has been passed are different considerations. The same Kaiser poll in January also found that more voters wish to keep or expand the law than to repeal it. ‘Expand’ almost certainly means different things to different voters, but that people would give such an answer nonetheless speaks volumes.

Polling has showed considerable support for individual elements of the law taken by themselves. The ban on denying coverage for pre-existing conditions was in the Kaiser poll in December backed by 67% of Americans.

However what has sometimes received less attention is how much other aspects of the law are unpopular. Perhaps most notable of these is fining adults who neglect to buy health insurance. Kaiser’s January poll found opposition stood at 67% to 30% – much higher than opposition to Obamacare as a whole. So the complexity of Obamacare is reflected in the politics of the legislation. Some measures are decidedly popular, others decidedly not. In terms of the electoral politics as well as the policy Obamacare is more a collection of measures some popular some decidedly not.

The NHS has to heed our credit rating warnings

The announcement from Moody’s this morning on the UK’s credit rating is another warning that spending cannot stay as it is on public services, and this of course includes health, the biggest burden. As I wrote for the Daily Mail yesterday:

The fundamental reason for change (i.e. what should be made clear but isn’t with the Health Bill) is that we cannot afford the NHS to carry on as it is! We need to plan and improve it so we can look after the sick and elderly in the future without the NHS being a massive tax-burden.

So the first time-bomb we need to diffuse is the economic one. The credit rating agency Standard and Poor have given us warnings. Firstly we have at least 20 hospitals that are in such a financially bad way that they will need massive subsidies of tax-payers money to keep them viable. Secondly, they have also warned that rising health costs with no policy change will mean that within the next 3 years, some G20 countries will have their healthcare-related credit downgraded. We could be one of them, especially if the economy doesn’t grow and our health spending does. If we are downgraded, the cost of borrowing rises and spending on health and social care would have to be slashed.

Therefore we need to welcome more private investment in the NHS, from providers, research and from individuals. To do this the Bill enables hospitals to raise their private income cap. This will mean that they can increase income from private patients, take part in more research and clinical trials, offer office or laboratory space to e.g. small biotechnology companies. All with NHS services being protected by law.

The Bill also encourages more services to be delivered by independent companies (who pay their own overheads, staff pensions and development costs), thus saving the NHS money.

One of the big mistakes over the past months has been for the coalition to allow there to be both perceived public-private fight and real anti-business sentiments. The NHS already spends 28% of its budget in the independent sector, depending on it for everything from IT support to drugs to physio. It is an example of a fantastic partnership. Yet investor confidence is rock bottom. Those who risked setting up new businesses in the past to support the NHS have had precious little political support or appreciation. Those that want to supply services are still being stymied by banks delaying their lending decisions – what use to take 3 months now takes 12 – by which time circumstances have often changed.

I am no fan of businesses who give themselves big bonuses or make excessive profits. But the NHS has to welcome both ethical business support and more private patients. I’d like to know from where else opponents think they are going to raise the money without jeopardising our entire economy.

Andrew Lansley must spell out the importance of private enterprise to the NHS

Julia Manning for Daily Mail 08th February

The Health Bill bashing descended into an Andrew Lansley lashing session yesterday.

Despite vocal support from GPs themselves, opposition politicians and unions have been joined by journalists who are all venting their ire on the man and his manouveres to change the NHS into a front-line led service.

Some of the formal objections published by professional bodies have read like New Year wish-lists for their own particular speciality rather than anything strategic or realistic for healthcare overall. The Bill has become the whipping boy for every disappointment, regret and unrealised expectation that anyone has ever had about the NHS.

 

Amidst all the Tarentino-esque cries of ‘Kill the Bill!’ people are clearer as to what they are objecting to: the lack of narrative, the messy process, their interests not being served, the watering down or rising complexity. 2020health sketched out the complex of new structures last year (see above), although that was before another layer of 50 National Commissioning Board outposts were added.

But what is not clear is the NHS’s solution to the well defined problem – we knew in the last parliament that £20bn savings had to be made. But history also shows that the NHS never misses an opportunity to miss an opportunity – most NHS staff are far too content on their guaranteed taxpayers salaries to set in motion the radical changes that are required to ensure rising demands can be met. So without a political kick up the backside we’d continue with too many hospitals requiring public money bailouts, excessive waste, shocking neglect of the elderly and a clinical workforce divorced from the reality of the cost of care.

As a letter to the Times today points out, there are significant benefits to the NHS from expanding the opportunity to treat private patients. Overall there is still an untold story of partnership between the NHS and private sector which is not only being lost, but which is being damaged by the public sector utopians (see diagram below). The top story on the news today was the danger of anti-business rhetoric in the UK at present. This has been fuelled by stories of greed – but let’s be honest – where there are humans there is greed, no matter whether they are employed in the private or public sectors. It is a separate issue.

 

A significant problem for the economy is that confidence for investors in healthcare in the UK is being massively damaged both by the short-sighted, protectionist opposition to competition that is being driven by the health unions, and the lack of long-sighted political leadership that has a secure narrative detailing the massive contribution of the private sector to growth. George Osborne’s speech last night to the Federation of Small Businesses was not before time, and it has to be built on. Noble Lords must today take a historical perspective. The NHS has a track record of making flawed policy work, and it wouldn’t be where it is today without competition and private investment.

Did you brave the ice and snow this weekend?

Adapted from Baby it’s cold outside but don’t slip on the ice until Monday

Julia Manning for Daily Mail 3^rd Feb

With the weather men and women rightly promising us snow last weekend, the advice from the NHS should have been be not to go outside until Monday. Not because it’s too cold, but because the chances are that if we have an accident, we will get a third-world level of treatment if we need to visit our local hospital. Last year a study from Dr Foster showed that patients admitted at weekends have a higher death rate. On Friday a large study by University College London agrees, showing a 16% higher death rate if you are admitted on a Sunday and an 11% higher death rate if you are admitted on a Saturday. And don’t think it’s just the elderly who have a poorer prognosis. A teacher at my daughter’s junior school fell over on the ice one December weekend. She died of undetected internal injuries – aged 32.

For those with more minor injuries, chances are you will be left languishing until the skeleton staff is bolstered on Monday. However a GP friend of mine saw his son’s fractured leg neglected from the Saturday of his accident to the following Wednesday when this GP finally got a hospital doctor to take some action and get his son treated and discharged.

Secretary of State Andrew Lansley has ordered a ‘fundamental rethink’ of how hospitals are run at the weekend. However as I said last November, we know there are too many hospitals with resources spread to thinly. Wouldn’t you prefer a longer ambulance journey with the confidence of immediate, high quality treatment than the uncertainty of a short journey that ends in a hospital ghost-town and prospects of inferior treatment?

The real scandal is that this isn’t news. We’ve known it for decades. Why haven’t hospital chief executives done something about this?

The Cost of Abiraterone

Guest blog by Beverley-Ann Perera-Anderson

In October 2011, 2020health hosted a roundtable on ‘Commissioning for Cancer Care.’ Ensuring people who are sick obtain the medicines they need, is an ongoing topic of interest for 2020health and is one of the reasons why we picked up on the media coverage of the draft guidance on abiraterone.

Prostate cancer is the most widespread cancer that affects men in the United Kingdom.  Each year 37,000 men are affected and over 10,000 men die each year from this illness. Abiraterone is being assessed by National Institute for Health and Clinical Excellence (NICE) as a late-stage treatment for men affected with advanced prostate cancer.  It’s of particular interest as it was developed in the UK, initially by the UK Institute of Cancer Research. Abiraterone has been shown to extend the life of men affected with this cancer for more than three months.  The Chief Executive of NICE, Sir Andrew Dillon recognised that one of the main benefits for this drug was that patients can take it orally and in the comfort of their own home, one of the ‘value’ measures to which NICE is supposed to give particular regard.

The cost of Abiraterone for one months supply is £3,000, and it has been made available via the Cancer Drugs Fund at an undisclosed discount price while undergoing its NICE assessment. But yesterday the England and Wales health watchdog stated that the benefits of the drug are not cost-effective for the NHS. Cancer charities are infuriated by the decision and think that NICE have overestimated the volume of abiraterone that would be prescribed, thus over-estimating the cost to the NHS. The final decision is expected in May. Whilst there are fewer life-extending drugs coming through the system, they are often some of the most expensive. Rationing is never easy.