NHS III - this time it's another post about the NHS

Why do we need to modernise? According to the Prime Minister, the NHS is "second best". The Government's white paper states that they aim to 'once again make the NHS the envy of the world' and 'success will be measured, not through bureaucratic process targets, but against results that really matter to patients ' It is very difficult to find recent data, but given that the last World Health Organisation (WHO) report comparing data was 2007, well into the New Labour government it seems reasonable to use it. I have also used data from Organisation for Economic Co-operation and Development reports (OECD), which also only provide data up to 2007. So, given these provisos, how second rate is the NHS? 

In 2007, WHO* ranked the UK as having the 18th best health care in the world. Top was France, and second was Italy. Also above the UK were a number of small countries such as Andorra, Malta, Singapore and Oman, which don't really bear much comparison. 18th place was achieved at a cost of 8.2% of Britain's GDP. This was the 41st highest amount and compared to France's 11.2% and Italy's 8.9%. All of the developed countries that were higher in the league spent a far larger percentage on health than the UK, with the exception of Japan and Spain, who spent the same as the UK. Notably, the UK performed much better than many developed countries with much higher spending. Switzerland's 11.4% got it 20th place, Germany's 10.7% brought in at 25th place and most  damning of all, The USA's 15.2% got it placed 37th, just behind Costa Rica and Dominica. 

If we look at the expenditure on health per head of the population the NHS again comes out of the stats very well. Britain, spent $2990, the 18th highest amount, on health per person. Top placed France spent $3593, 20% more,  German (25th) $3619, 21% more, Switzerland (20th) spent $4469, 95% more and the USA (37th) spent $7285, an astonishing 144% more. Once again Spain (7th) out performed the NHS with expenditure of $2658 per person, 12% lower and Italy $2701 (2nd) also had a 10% lower. However, if we take into account the cost of living in each country, according to the OECD stats, it would make Spain the same as the NHS and Italy more expensive. All of the other countries would remain relatively more expensive than the NHS for a worse ranking. 

So what about outcomes? Once again it is difficult to get good data. The last OECD report  on what are known as 'preventable deaths' was 2004. In the developed world, these are the sort of thing that are often associated with risk-taking such as smoking, drug abuse and daring to cross a road. I suppose there is a strong cultural quality to this indicator but I would argue it demonstrates how well the broader aspects of health care, such as education, are working. In 2004 we were in 12th place. Once again the USA was lagging behind and so was Austria, who the Prime Minister has been held up as a shining example of good practice recently. We also beat the WHO's top ranked country, France. No country, spending less per head, when cost of living is taken into account, had a better ranking. 

The Coalition have said that there will be 'a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates.' In 2009 some alarming statistics from an OECD report were widely reported in the British press. 'The sick man of Europe' - said The Telegraph, who stated that, 'heart and cancer survival rates were amongst the worst in the developed word.' A WHO bulletin, published soon afterwards, argued that these results were an example of 'non-transparent framing' which was explained as data provided as a 'deliberate tactic to manipulate or persuade people.' 

These are the same stats that the Coalition have been throwing around to prove that the NHS is 'second best'. It certainly sheds a new light upon the white paper when it says, 'Patients will have access to the information they want, to make choices about their care'. In the bulletin, Gerd Gigerenzer. an expert in 'risk literacy' from the Max Planck Institute in Berlin examined the apparent chasm between UK (35%) and US (60%) survival rates of 5 years after being diagnosed with colon cancer. In fact as, Gigerenzer demonstrates, the mortality rate is 'roughly' the same. The difference in so called 'survival rates' is actually largely explained by the widespread screening in the US which leads to massive over diagnosis of non-progressive cancers. For those categories reported by the press, the UK was placed 12th overall, once again ahead of the curve in relation to our relative funding.

The Coalition continue to stress that Britain is not getting the appropriate results in return for the increased spending over the last thirteen years. After years of under-investment there has been a massive increase in spending, from 6.6% to 8.8% of GDP, which the government has repeatedly told us is in line with the EC average. That might be the case, but if we compare spending with the older, more developed EC members or those from Scandinavia, from my reading of the information, Britain still spends less (%) than all the other countries. According to the OECD, even Spain overtook us in 2008. 

Is the NHS 'second best'? Well, it probably is. But, I hope, that this post has demonstrated that it is more to do with continued under-funding rather than with the structures or productivity of the staff. Even with the limitations of the data it seems safe to conclude that we are getting excellent value for money from the NHS. The dedicated staff punches above its weight across a range of indicators. These are staff who  regularly put in that little bit more because they feel valued by their employers and the community and recognise that health is more than a job. These are the staff who will shortly be sold down the river in exchange for higher share dividends. 

Philosopher George Santayana defined fanaticism as "redoubling your effort when you have forgotten your goal." It seems apt, in these circumstances because if there is one firm conclusion I can draw from my reading; it is that the involvement of the private sector does not guarantee any great leaps in productivity or quality of outcomes. As we have seen over the last couple of years, the private sector is not even that good at making money. Outcomes are obviously important but the NHS is important for other reasons. It is a glue that binds our society and can't be measured in perecentage points. Sadly, the Tories are too blind to see that these rather intangible qualities mean that the NHS is still the envy of the world. 

So how to modernise? Well, if we want to knock France off the top of that league - we'll have to spend a lot more money, but I suspect, not as much as France. 

*WHO’s assessment system was based on five indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system’s financial burden within the population (who pays the costs).

NHS Reform II - the 'disordering' of society

A few weeks ago, a GP friend told me he had been contacted by an undergraduate with 'Executive Function Disorder'. The condition had been diagnosed by educational psychologists after he failed his exams. The 'disorder' presents the sufferer with difficulties in: 'organising, prioritising and activating work'. In my day that would have applied to virtually every student I knew. The student, having been given short shrift by his current GP, had contacted the practice to see if they would treat the condition. I was reminded of this story when I was reading the Government's 'white paper.'

According to the proposals, the Coalition's ambition is to 'liberate' the NHS. From what it is being liberated, they don't make clear:  

'First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care. Second, there will be a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates. Third, we will empower health professionals. Doctors and nurses must to be able to use their professional judgement about what is right for patients. We will support this by giving front- line staff more control. Health care will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients.'  

As anyone who has ever stayed in a Disneyland resort will tell you, even the most 'magical' places can treat visitors like cattle. Massive institutions are essentially dehumanising because they have to process such large numbers and individuals can often get lost in over all outcomes. There is no doubt that requiring treatment within the NHS can sometimes leave you feeling slightly soiled. I'm sure you have had good and bad experiences. I'm not entirely sure what putting 'patients at the heart of everything' actually means, but, if it were to insist that everyone is always treated with appropriate dignity then that is a worthy aim. 

By calling them 'second rate', paying them less and removing decent working conditions, I don't think the staff are being treated with much dignity. Anyone who has worked in health care will know that the system has always worked through the 'good will' of many practitioners filling the gaps between their jobs and the work actually required. This is the 'vocational' aspect of the job. Turning the work into a contractual agreement has always missed this point. One of the shocks for the Labour Government, following the now infamous GP contract, was that they ended up paying for things that GPs had largely always done because they were good practice, not because they were paid. Despite what you may think, health professionals are still working over and above what their contracts state. Let's see the private sector bring that attitude to the table. 

Unfortunately, what the government means is 'no decision about me, without me.' The Coalition are selling us a wonderful vision: choice about what treatment, carried out by which top professional, where and when? All of this, of course, will be based upon freely available information with which to make a fully informed judgement. It sounds amazing, but, as 'JPD' commented on the blog yesterday, 

"I don't want a choice about where I have my kidney stones out! I just want decent treatment locally. I have enough stuff to worry about without trying to work out whether the decreased relative risk of dying is worth the higher cab fare."

We will all be affected one way or another. What about the families of the one in five of us who, it is now projected, will reach 100. Will they want anything but effective local services for the aging relatives? Anyone who has spent time researching a new TV purchase on the internet will immediately shy away from the thought of making like for like judgements on something as vague as medical outcomes. As one orthopaedic surgeon I know has pointed out: in a free market, driven by profit and with patients making judgements based on historical outcomes, no one will take on the difficult cases anymore. Why would hospitals or individual practitioners risk having their averages damaged? 

According to the Government 'patients will be in charge of making decisions about their care.' My friend, the surgeon, spent six years in medical school in London, another 14 years getting all his surgical examinations and also has a number of years experience on top of that as a consultant...and the patient is in charge? Perhaps they are big fans of casualty? As patients, we are already 'in-charge', as much as we can be. We say 'yes' or 'no', but there is a big gap between that and most patients being able to make truly informed decisions about treatment. The proposals insist that 'Doctors and nurses must to be able to use their professional judgement about what is right for patients' but one of the great myths that recent politicians have peddled and, I think is rife within society these days, is that everyone's opinion is equally valid. Everyone has a right to express their opinion, yes, but that is not the same thing at all. I don't want a hospital consultation that takes the form of a Radio 5 phone-in. Let's regulate the health professions in a thorough and credible way and then back their clinical decision-making. 

The response to the student was to tell him that 'Executive Function Disorder' is not an illness. They have drawn a line and said, "sorry, there may be something wrong with you but it is not a health issue." Perhaps we should back health professionals to do that more often. The 'disorder-ing' of our lives has reached epidemic proportions.  Forty years ago Woody Allen joked that, " I don't want to become immortal through my work, I want to become immortal by not dying." Unfortunately, I think many people no longer see this as an unrealistic expectation. Too often the punchline on Woman's Hour - don't tell the lads please - is 'if you are not sure, speak to your doctor.' It's as if the GP has become the secular world's  father / confessor. Is there any wonder the NHS is feeling the pressure.

Anyway, I must stop, the Mrs wants to have a chat about my 'Cricket on TV lethargy syndrome'. Amen.

Is this the end of the NHS?

The NHS came into existence on 5th July 1948. It had three founding principles: that it meet the needs of everyone, that it be free at the point of delivery and that it be based on clinical need, not ability to pay. The Coalition's health reforms essentially represent the end of this NHS. It seems that the main aim of the Health Secretary, Mr Lansley, is to hand over the provision of NHS care to private companies. This policy is called “ patient choice. ” Although, the result will be less choice. The new GP Commissioning Consortia will control 80% of the commissioning budget but they will immediately need to cut one fifth of the NHS budget (£20 billion). It also looks as if the GPCCs will take on the debts of the Primary Care Trusts (PCTs), which are being abolished. The inevitable removal of services, because of the cuts, will therefore be blamed on the GPs and not the government.

In effect, GPs have been given no choice but to form consortia (GPCC) which will have the job of commissioning NHS care under the control of a National Commissioning Board (NCB ). The lack of business expertise and commissioning experience means that GPs, inevitably are turning to private health organisations, our local consortia already has close links to one of these companies. As I pointed out in a post last week there is serious and possibly damaging conflict of interests when GPs become both the service providers and service purchasers. This situation will be exacerbated by the need for cuts but also the demands of the new market regulations and the instruction to reduce the level of GP referrals to hospital.


The NHS will no longer be the 'preferred provider' of services. All services will be open to 'market' competition. This sounds like a sensible practice until you realise that that will mean the closure of local hospitals and services. Local hospitals will have to 'make' money or else go out of business. As in all developed areas of private enterprise, the market will create larger, more powerful corporations not more choice for the consumer or patient as some people still insist on calling them. Decisions will be profit rather clinically driven.

The winners will be the shareholders of the powerful private firms standing by to take a share of the budget. Patients and NHS employees will lose out to pay shareholder dividends. Like a new supermarket selling 'loss-leaders' these firms are powerful enough to drive NHS providers out of business in order to dominate the market. The losers will be the patients who will have to travel further for treatment and, almost inevitably will see the 'free' services rationed. As one GP commented to the BBC, "That’s a chilling prospect for the elderly, those with chronic illness and people with mental illness and long-term needs, who are often of no commercial interest to the corporate providers because of their high health care costs."


The other losers, of course are  the NHS staff. They will see thousands of jobs cut and many will be forcibly transferred to the employment to private companies with removal of national terms and conditions and NHS pensions. Why should you care about the 'second rate' health care professionals, to use Cameron's words? All I would say is: did hospitals get cleaner or dirtier when the cleaning contracts were transferred to the private sector? Will paying people less improve the quality of care? Will it encourage the next generation of bright and talented young people to work in health care?


The proposals have even brought criticism from within the Conservative Party. Notably, Stephen Dorrell, the former Tory health secretary and chair of the all-party Commons health select committee, gave a damning response. In the committee's report he stated, that the reforms would create 'significant institutional upheaval' and although 'We share the government's objectives. We also say that this is in several respects not the most effective way to deliver them." Like the rest of us the committee was very surprised that none of these proposals were mentioned during the election campaign. The plans were denounced on Monday by six health service unions - including the British Medical Association and the Royal College of Nursing - as "potentially disastrous".


The point is that for many people, wealthy enough and educated enough, these reforms may not have much of an impact. As usual, it will be the poorer sections of our society who will be most disadvantaged. Is that progress? (Cue Elgar - this is the Oscar winning scene) Perhaps it is sentimental on my part, but those founding principles, the interpretation of which may be at the heart of the NHS's problems, have always struck me as something that was truly inspiring and thoroughly democratic at the heart of our culture. I really think that it sets us apart. The NHS is imperfect, so reform, yes, but, let's not throw those aspirations away.

Shall I be mother?

The current rules about parental leave "patronise women and marginalise men". That is the view of, father of three, Nick Clegg, who has announced proposals to allow couples to share paternity leave. Fathers will be able to take up any remaining unpaid leave if their partners return to work without using their full entitlement. Clegg has criticised the rules as 'Edwardian' and has confirmed that the Coalition intend to consult on a complete reform of  parental leave by 2015. 

According to the BBC, the proposals will also allow parents use the leave entitlement together and to take leave in separate periods rather than as one continuous period. The reforms were first announced by Labour last January and their proposals seem to have found support with right-wing think-tank Demos. Their report concluded that: 'Rather than pay, the keys to maintaining parents' confidence in their ability to bring up children were flexible hours and the ability to be creative at work.' 

The Coalition want to create a more flexible system that will make the leave work for families' individual needs. The report entitled The Home Front, concludes that being in employment is good for parenting but can have a negative impact when the job is characterised by inflexibility in terms of hours and the culture of the workplace. The report also highlights that fathers work longer hours than childless colleagues, with a third putting in more than 48 hours a week. In 2010 the Department of Work and Pensions reported that 76% of mothers return to work within 12 to 18 months of having a child. It suggests that parents either don't enjoy childcare that much or that money, contrary to the Demos report, is a major consideration in deciding on childcare priorities. 

Jill Kirby, a director of the Centre for Policy Studies and author of 'The Price of Parenthood' says that:

"around 50,000 stay-at-home mums have been forced back to work over the past year. Faced with high mortgages and rising household costs, the number of stay-at-home mothers has dropped to just 2.07 million, the lowest level since records began in 1994. The overwhelming reason for mothers to return to work is sheer financial pressure, often much earlier than they would like. Many women do feel really trapped by their own situations."

A recent study by uSwitch.com found that average family income drops 34% during maternity leave, one in four mums end in debt, with an average of £1329 and 50% of mothers returning to work, with children under three, said the reason was financial presure. A YouGov Poll in 2009 found that a third of working mothers would not work at all if they had a choice. 

In the same year a report, 'What women want and how to get it' produced by the Centre for Policy Studies written by journalist Cristina Odone argued that 'notions of women's progress over the past decade have been measured by the 'wrong' things, such as more women in top jobs, a shrinking earnings gap and better state-funded childcare...There also needs to be a cultural shift where women are valued "not just for what they produce at the end of a working day.'

The slack in childcare has been taken up by day-nurseries. There are now 15,000 nurseries in the UK and around 277,000 children under three are enrolled in day nurseries, and 21% of children aged under two spend some time in day nurseries. After grandparents, day nurseries are the most popular form of childcare for working parents who have children under three. 

As Cristona Odone concluded, what parents really want is the choice. Her report recommended that rather than simply offering childcare vouchers; families should be able to get national insurance credits for carers, allow working partners to take up the unused tax allowance of the other parent and make it easier for firms to employ part-time workers.

Meanwhile, in Brussels back in October, the 'family friendly' Coalition MEPs voted against draft legislation that would entitle mothers to 20 weeks maternity leave on full pay. The current entitlement in Britain is six weeks. The Coalition is strongly opposed to the legislation because of the possible effect on British business and is lobbying the Council of Ministers who will have the final say. What I think is truly patronising is the belief that a cheap 'family friendly' makeover will hide where the Coalition's true priorities really are.

Now, where did I leave the children?