This week’s New England Journal of Medicine reports on the relationship between coffee drinking and mortality in a cohort study of Americans. The study followed

229,119 men and 173,141 women in the National Institutes of Health–AARP Diet and Health Study who were 50 to 71 years of age at baseline

and this paper reports on their coffee drinking habits. Its main finding (my emphasis):

During 5,148,760 person-years of follow-up between 1995 and 2008, a total of 33,731 men and 18,784 women died. In age-adjusted models, the risk of death was increased among coffee drinkers. However, coffee drinkers were also more likely to smoke, and, after adjustment for tobacco-smoking status and other potential confounders, there was a significant inverse association between coffee consumption and mortality.

This is why we do confounder adjustment … so I can slurp down another black coffee in complete peace of mind. And check the details:

Adjusted hazard ratios for death among men who drank coffee as compared with those who did not were as follows: 0.99 (95% confidence interval [CI], 0.95 to 1.04) for drinking less than 1 cup per day, 0.94 (95% CI, 0.90 to 0.99) for 1 cup, 0.90 (95% CI, 0.86 to 0.93) for 2 or 3 cups, 0.88 (95% CI, 0.84 to 0.93) for 4 or 5 cups, and 0.90 (95% CI, 0.85 to 0.96) for 6 or more cups of coffee per day (P<0.001 for trend); the respective hazard ratios among women were 1.01 (95% CI, 0.96 to 1.07), 0.95 (95% CI, 0.90 to 1.01), 0.87 (95% CI, 0.83 to 0.92), 0.84 (95% CI, 0.79 to 0.90), and 0.85 (95% CI, 0.78 to 0.93) (P<0.001 for trend).

If we’re going on an American coffee standard, I’d say I’m drinking 6 or more cups of coffee per day, so I have a 10% reduced risk of mortality over 15 years (the rough period of the study). Sadly, though, I’m not protected against cancer:

Inverse associations were observed for deaths due to heart disease, respiratory disease, stroke, injuries and accidents, diabetes, and infections, but not for deaths due to cancer.

The effect was also observed in non-smokers (that’s me!)

So, the word is in from the world’s top medical journal: the more coffee you drink, the longer you live!

In my previous post on Obamacare commenter Paul has suggested I’m putting too much faith in government intervention to reduce inequality or contain costs. I’m about to go away for the weekend so don’t have much time to attend to my blog (nor may I next week, when classes start) but here’s a pair of questions that I think are related to that question, and to the (apparently still unsettled!) government vs. private debate. These two questions possibly also show how much we don’t know about health systems.

Did the NHS reduce health inequality?

One of the big claims of the NHS is that it reduced entrenched health inequality by giving poor people access to healthcare they were previously denied. I’ve implied before that I’m not confident the NHS has achieved that much in this regard, and pointed to the existing health inequalities in the UK as evidence of this. I’m loathe to say that it achieved nothing, but this fascinating and excellent paper from the British Medical Journal, published in the year 2000, suggests that despite the estabishment of the NHS, health inequality in Britain has persisted for 100 years. So is it the case that the huge intervention in the market that is the NHS achieved nothing in reducing inequality?

Does the US health system need political, not system reform?

It’s true that there’s very little evidence that private health markets reduce inequality or contain costs, but there are only two developed nations that have actually conducted this experiment (the US and Switzerland), and although the experiment is ongoing in many developing nations they don’t provide a good health policy laboratory (due to all the development issues and tropical diseases they are dealing with simultaneously). Switzerland, obviously, is a bit special, so there is really only one major economy that is actually trialling an even close-to-privatized system, and there’s a big problem with the experiment going on there: the USA is a plutocracy, not a democracy, and its capitalist system is pretty busted (see, e.g. “Too Big to Fail”), in the sense that it is heavily captured by special interests and the political system in which it is embedded is corrupt, unrepresentative and basically not democratic. Furthermore, the USA has a significant race problem that doesn’t exist in other places, is historically very specific to the USA, and creates a whole set of social problems that a place like Switzerland or Australia doesn’t have to cope with. So is it possible that a root-and-branch political reform, based on breaking the sectional interests in the US economy and the power of the super-rich to influence politics, would enable a purely private health system to function? If so, it’s unlikely that any attempts to salvage the market-based system that are based on regulation or minimal government intervention are going to work, because of the power of those sectional interests. Should proponents of market systems for health care be looking to developing nations for their examples?

I’m off to take an extended bath in the country! So comments won’t get much attention until next week …

My weekly TOC from the New England Journal of Medicine (NEJM) contains some interesting articles about cost containment in health care, including some discussion about what Obamacare might or might not do to contain costs, based on lessons from Massachusetts (RomneyCare?). Apparently the Affordable Care Act contains some quite innovative and also potentially punitive measures to force hospitals to reduce rates of readmission after discharge, but has missed some other opportunities in the mix. The NEJM has clearly moved on from debate about whether Obamacare is a good or bad thing, and debate about whether it’s going to be constitutionally viable, to discussion about how it will change the health industry. I wonder if this is going to make the NEJM (the world’s top medical journal) look stupid in about 6 months’ time…?

The first article in the NEJM contains a discussion of the problems facing the health system in Massachusetts, which famously introduced a version of Obamacare a few years ago. This system essentially forces people to take up a health insurance plan, penalizing those who don’t, on the assumption that such a model will improve equity and reduce costs through expanding the risk pool. Unfortunately, it appears that the plan hasn’t led to any serious levels of cost containment – according to the NEJM article, costs have risen significantly since 2006. The basic cost for a “bronze” package is $275 per month, which I’m pretty sure is significantly higher than my “silver” care package in Japan, and is $100 higher than it was just a year or two ago. The article claims that this is because of problems in the payment system in the Massachusetts system: it’s not the insurance plan per se, but the way in which hospitals are paid for providing services. Hospitals have been paid under a fee-for-service plan, and this encourages providers to charge for extra services and make extra money. Massachusetts is solving this problem in two ways: by moving to “global health payments” and by forcing people into “accountable care organizations” (ACOs). The former is a system of payment based on the expected total cost of a person’s illness, rather than the services provided within it, designed to penalize providers (i.e. hospitals) who fail to deliver the required care within the expected cost framework associated with any given disease. The latter are large organizations charged with taking responsibility for the care of a group of patients (similar, I think, to the NHS’s clinical care commissioning), and composed of large numbers of amalgamated insurance purchasers. Essentially, “global payments” are an attempt to exit from the fee-for-service system towards a payment system that discourages over-servicing, and ACOs are an attempt to merge small healthcare providers together to give them more negotiating power (as an example, all public employees are going to be combined in one ACO). These two reforms in tandem look suspiciously like an attempt to force the Massachusetts system towards something that looks like the NHS. There’s a hint here as to a basic fact – on the commissioner (health insurance) side, cost containment is best achieved by consolidating commissioners in order to achieve greater bargaining power with providers, and the maximal example of this is the government-run single-payer system. It appears that Obamacare is likely to have a lot in common with this system.

The next article describes Medicare’s attempts to reduce costs through reducing readmissions, and describes some initiatives in Obamacare to reduce readmissions in order to contain costs. Reducing readmissions is something of a holy grail in healthcare cost containment, because readmissions are a theoretically avoidable source of significant healthcare costs – you got your operation, left hospital but had to come back for some kind of medical complication, so you represent a hospital admission that can be prevented through hospital-focused quality control (rather than lifestyle change). Reducing these leads to reductions in overall costs, and better patient experience (no one wants to go to hospital). The article includes a fascinating discussion of what Obamacare aims to do to reduce readmissions – penalizing the worst offenders – but also discusses why for many hospitals reducing readmissions is not a viable financial goal:

Unless they are at maximum capacity, hospitals face two major economic disincentives to reducing readmissions for the specified diagnoses: the direct costs of the program itself and decreased revenues resulting from successful interventions. Interventions to create and sustain reductions in readmissions typically average $100 to $200 per discharge and often have spillover effects, decreasing hospitalizations for nontargeted diagnoses and reducing readmissions from any cause even outside the 30-day window and across payers. Although these effects are desirable outcomes for patients and payers, they detrimentally affect hospitals’ finances.

This is an interesting and often-overlooked aspect of the private healthcare market: it’s not in the interests of hospitals to reduce rates of illness, since they get paid by insurers to treat sick people. And for hospitals that don’t have outrageously high rates of treatment failure, a little bit of treatment failure is (financially) a good thing[1]. This kind of concept just does not apply in the publicly-run systems of the UK and Australia. The article goes on to introduce the concept of a “warranty” rather than a penalty, under which hospitals have to provide care for a condition at a given price and as part of that care have to offer a warranty – so readmission to hospital gains them no financial benefits, since they have to correct any post-surgical complications without extra payment. This forces hospitals to get it right the first time.

Unfortunately it’s not that simple. A third article in the NEJM challenges the idea that reducing readmissions is a worthy goal. It points out that, although numbers of readmissions may vary substantially, rates may not (and rates are what it’s all about in this business). Furthermore, there is evidence that readmissions, although apparently preventable, are often outside hospital control:

The growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital’s patient population and the resources of the community in which it is located — factors that are difficult for hospitals to change.

There is also evidence that readmission rates may increase when service improves, or that patients may be happier when readmission rates improve, because good quality continuity of care may identify additional health care needs:

whereas some studies have shown that sustained efforts can reduce readmission rates somewhat, others have shown that interventions aimed at improving care coordination and access to follow-up care actually increased the rate of readmissions, presumably because of improved access to needed care, with commensurate improvement in patient satisfaction

The authors of this article also point out that in focussing on readmissions the system privileges cost containment over quality of patient experience (i.e. productivity), which is a kind of cost containment in itself, though perhaps less quantifiable in a fee for service system:

over the past decade, we have seen very little improvement in patient safety, and although mortality rates have declined for a few conditions, they remain high for most others. Many of these deaths are preventable. Yet we are focusing tremendous resources on preventing rehospitalizations for three conditions that account for approximately 10% of all hospital admissions in the Medicare population.

They suggest that we should focus on patient safety, and if we’re going to focus on avoidable readmissions we should focus on very narrow time frames (3 or 7 days), the conclusion being that hospital readmissions are not where we are going to find our savings. I think this is another example of how “efficiency gains” never materialize in health – regardless of the health care system you are experiencing, when you hear politicians talk about “efficiency gains” you should think “oh! a wanker speaketh!” Especially if they talk about sacking back office staff (but a statistician would say that).

The thing I think is most fascinating about these three articles is what they imply about the state of knowledge of health care systems today. Despite 100 or so years of development in health insurance and health systems, modern health care theory is incapable of working out exactly what we want from healthcare. Even worse, modern healthcare markets are constructed without any real understanding of what kind of product we’re buying when we participate in them – we know we want “health” but we don’t know whether being readmitted to hospital is a good or bad thing, and people buying health care (insurance companies) and selling it (hospitals) not only can’t agree on a mechanism for setting prices, but the hospitals are profiting from selling (in some cases) a product no one wants to buy, but are forced to buy the hospitals’ own mistakes (hospital readmissions). What kind of private market works under these conditions? It’s not an information asymmetry, it’s an information fuck up. Also noteworthy is the gradual movement of the Massachusetts system towards a form of NHS-lite, in order to reduce costs. Is that telling us something?

The NEJM is holding a fascinating debate on health system performance and planning, within the (admittedly limited) context of the US system. As this debate plays out it gives the rest of the world a fascinating insight into how weak the theory underlying privatized markets for health care really is. It’s not that market systems are fundamentally right or wrong – it’s more that we haven’t worked out how to price health care, so price signals just don’t work. Can such a thing be done? And if so, would an entirely private market in health care work? All my posts to date claim that an entirely private market is a disaster and an impossibility – but is the problem not the notion of a private market per se, but that we don’t yet have a sophisticated enough understanding of health (and, conversely, of markets) to be able to construct such a thing in the first place?

fn1: obviously a lot of treatment failure gets you shut down and your managers charged with negligent homicide, so it’s a bad thing[2]

fn2: no one, however, is suggesting that hospital administration are maintaining such a balancing act. What they *are* doing is prioritizing what they consider to be more important issues, like quality of patient care (see article three).

Continuing my series of ideas to reform the NHS, for this post I will consider a minimalist reform that aims to increase private investment and spending in the health sector without significantly disrupting the current form of the NHS. Mindful of the problems of central planning for resource allocation in health, this reform idea will introduce some mechanisms to allow increased flexibility in the public sector. It’s worth noting though that the last two governments (Labour and Conservative) have attempted to introduce flexibility into the public system through fictional markets, competitive budgets and the like, but these methods haven’t worked. Part of the reason for this is simple institutional inertia – the NHS is huge and has a 60 year history and its own culture, that won’t change quickly – but part of it is also due to the political sensitivity of the health sector, and the inability of the NHS to separate simple, practical decisions on how best to run the system from the political sensitivities of its political masters.

The reform plan I’m describing here doesn’t necessarily depend on a shift to fee-for-service payments, but it is considerably easier to manage if this does happen, so I’m going to wave my magic bloggers wand and assume that this happened. I’m also going to leave out all discussion of minimal privatization within the public system (of things like pathology services) because they’re irrelevant to the central model, but they could certainly be included. We also won’t look at the primary care sector, which is a desperate pit of trouble that deserves its own post, though in this one we’ll set up some institutions that might serve as competition to the current moribund GP model.

Introduction

This minimal reform model aims to achieve three key goals:

  • Increase private funding of the hospital sector without damaging the ability of the public sector to provide free, accessible care for all
  • Widen the range of service providers in the hospital sector (both public and private) to enable the sector as a whole to respond to health problems more flexibly than it does now
  • Make the public sector less vulnerable to political interference and more flexible

We will do this through allowing the establishment of private hospitals that provide care on a fee-for-service basis, having the government and private providers set up new, flexible specialist surgical centres and turning all hospitals into “Foundation Trusts” partially independent of the government, funded on a fixed and legislated basis (so free of political interference) and capable of responding flexibly to changes in the overall health market. The easiest way to do this is to introduce a fee-for-service funding system, but a system of contractual funding agreements wouldn’t necessarily hinder these reforms.

Increasing public hospital flexibility

One of Labour’s better ideas in this regard, transforming better performing hospitals into “Foundation Trusts” that were partially independent of the NHS with more financial flexibility, was a good one, though probably of limited effectiveness. I think now the Tories are extending this to all hospitals, so that on paper at least the hospitals are semi-independent of government and have more flexibility over their decisions. This model is supposed to enable the hospitals to make financial and governance decisions independently of political interference, potentially including contracting out some services to the private sector and reorganizing clinical services to be more efficient. I think they can be re-nationalized by the government if they fail to meet certain financial and healthcare standards, primarily to prevent market failure. The unfortunate side-effect of this re-nationalizability  is that the government can intervene where hospital decisions are politically inconvenient, but obviously this intervention is a significant political decision and carries its own political risks, so should reduce the inclination of governments to interfere in all but the very largest of decisions. The Tories have already introduced a system to Foundation Trusts to set up private wings, aimed initially at health tourism, as a way of making more money – a policy I said previously won’t work in isolation to solve the NHS’s problems. But if these hospitals are given this flexibility in conjunction with some additional government investment in new types of facilities, and the entrance of fully competitive private hospitals in a fee-for-service competition with public hospitals for extra money, then significant additional investment and structural reform can begin to take place.

Allowing hospitals to be flexible means allowing them to be able to close some services and expand others. Consider two hospitals, A and B, located relatively close to each other in a city like Manchester. Hospital A has a large hand surgery specialty clinic, incorporating a large number of surgeons, grand rounds, a research facility, extensive links with academia and a teaching role; Hospital B has a small orthopaedic clinic that occasionally attends to hand surgery in amongst its other functions. Almost certainly, Hospital A will have better surgical outcomes (less cock-ups) and much lower rates of readmission and corrective surgery; it’s also likely to have much better rehabilitation services and post-surgical management. It likely also provides each surgical service at a lower cost than Hospital B, due to economies of scale and efficiencies from its more experienced staff. So the logical decision is for Hospital B to close its hand surgery operations altogether, and simply send them all to Hospital A. If both hospitals are being paid the same fee for every surgical service, it’s likely that B is making a loss on these services while A is making a profit – potentially a large enough profit to pay the transport fees to the patients and/or a finder’s fee to Hospital B. In this case it’s rational to close them, unless there is some strong reason why patients can’t make it to A if they live near B (unlikely in the modern world, and especially unlikely if the local hospitals have the flexibility to arrange patient transport networks). Currently these kinds of closures and rationalizations are hard to achieve, because as soon as the local newspaper gets wind of the closure of a clinic (let alone a whole struggling hospital or wing!) they run a vocal campaign against the local member, and often get their way. But by converting all hospitals into robustly independent Foundation Trusts these decisions are removed from government interference to at least some extent.

Government investment in new types of facility

One type of simple reform that was introduced to me by a hospital performance director in the UK was of shared specialty rooms. The performance director told me that his hospital and a few neighbouring hospitals were all facing a problem getting in a certain type of specialist (cardiology, I think). For these specialists to be employed by a hospital, they typically need to have a mixture of surgical and consulting work – so they want to have a full-time work load structured around a mixture of non-surgical and surgical work. But my interlocutor’s hospital didn’t have sufficient demand to justify such a clinic full time, so their specialist was under-worked and overpaid – or they had to make a decision not to employ one. The neighbouring hospitals had the same problem, and they had a vision of setting up a shared specialist facility, funded by all the hospitals but set up either in one of them or central to all of them, in a new building. Unfortunately they didn’t have any ability to do this – as public hospitals they couldn’t invest in such a facility, and with no private entrants in the market they couldn’t do it. Thus they had to either go without a specialist, or waste money on a specialist, in this one discipline. Foundation Trusts with suitable powers would be able to get around this problem by consolidation, closure and mergers; there’s no reason why they couldn’t cooperate with each other for maximum benefit, since they aren’t actually competing per se. But another option for these trusts is to invest in a new facility, or to petition the government to fund the establishment of such a facility.

So, another part of the solution to the NHS’s current problems is the establishment of new types of facility, specialist centres serving multiple hospitals on specific disciplines. Another type of facility the NHS has been trialling is a type of private provider that takes up excess demand in high volume, low-risk surgery like cataract surgery. The government could fund the establishment of such centres to serve the needs of busy and overburdened Foundation Trusts, who could then close their own wards and theatres devoted to these specialties and focus on their core service areas. These smaller, clinical facilities would be somewhere between an outpatient centre, an inpatient facility, and a GP clinic, and would be quite easy to target at areas of need. For example in areas with a high burden of diabetes-related illness the government could set up a diabetes specialist clinic that provided GP services trained in diabetes specialties; minor surgical procedures related to diabetes; community nursing aimed at improving testing and dietary changes; and surgical facilities for handling common complaints related to diabetes (such as eye problems and possibly even some kinds of serious internal surgery). Then nearby hospitals would be free to give up some of these procedures, or handle only the most serious ones as part of their specialist services, referring all the minor stuff directly to the local facility.

In essence this means the government spending more money on the NHS, but doing so through investment in new facilities specifically aimed at enabling existing facilities to rationalize and become more efficient – this is a combination of capacity expansion and efficiency gains in a fairly easily identifiable package. Governments often talk about “efficiency gains” in the NHS as a magical cure for all the problems facing it, but these efficiency gains almost never materialize because they’re built around making existing staff work harder. In a system as resource-constrained as the NHS, putting your finger on a bulge in one part will just produce a lump somewhere else. A better idea is to invest in new facilities that will enable existing hospitals to cast off the things they don’t do well and focus on what they do do well.

These facilities could, however, be even more flexible – as could the Foundation Trusts themselves – if they were able to incorporate a private element of their funding. This is the third arm of the reform – to allow additional flexibility by allowing some private services on top of the existing structure of the NHS, either competing with it or topping it up.

Allowing private investment

There are two types of private investment that could be allowed into the NHS without significantly changing its remit. The first is to allow private hospitals to enter the market to compete with public hospitals on certain services, especially high-volume, low-risk services with long waiting times. The second is to allow full-fee-paying hospitals to take patients from the NHS and charge them directly. Both types of facility introduce private investment into the NHS, but for very different purposes.

The first of these exist now, and are used by the NHS to handle their waiting list problems. For some simple surgery (like cataract surgery) when someone’s waiting time for the surgery goes beyond 3 months, the NHS pays for them to be treated at a specially established private facility. These clinics typically handle things like cataract surgery that are in very high demand and easily handled. These clinics exist now, and could easily be allowed to expand and compete directly with NHS hospitals for all patients on a fee-for-service basis. If they can provide a better service than neighbouring hospitals, then those hospitals might be able to close their cataract surgery wards and focus on something else that they do better – or contract them out to the private facility, thus gaining income they can spend on other things. Foundation Trusts might even want to invest in setting up such facilities themselves, pooling the cost with neighbouring hospitals so that they can cast off their own high-demand services to a single specialist clinic. In such a case they might need to petition the government for support, but they could probably also just get investment from a private provider of some kind – not in a flawed private finance initiative, but in a straight out for-profit business plan. Because the Foundation Trusts are not for-profit services, any profit they make from this new service will be ploughed back into their own investment programs.

The second type of facility is more controversial, because it means splitting the NHS into a private-for-profit and a public section. The NHS could allow private health providers to establish new hospitals or facilities, that provide a range of services at a cost above the NHS tariff. Patients can choose to enter these hospitals instead of the NHS hospitals, but the NHS will only pay for the standard tariff portion of their service. The rest comes from their own pocket or from a health insurance program. Essentially, this allows private investment in the NHS, but prevents the private costs from blowing out so much that no one can afford the care. The advantage of this is that it relieves the physical pressure on the existing hospitals that leads to waiting times, enabling wealthier people to essentially jump the queue through private health insurance, but by allowing the NHS to pay some basic part of the service it extends this queue-jumping option beyond the realms of the super-rich, the only class of people who can currently afford private insurance covering full hospital care in the UK. Because people are already paying through their taxes for public care they won’t also pay for private insurance unless it is very cheap – and the best way to make it cheap is to make the costs it covers a top-up on the basic tariff, rather than the whole cost of hospital attendance. Of course the NHS could refuse to pay the whole tariff to private providers – so a private hospital patient receives, say, 80% of the NHS tariff and pays the rest plus the hospital’s additional private fee out of their own pocket.

It’s possible that Foundation Trusts would be the first organizations to establish such private facilities, so that they could take advantage of excess demand for certain common procedures and turn the money back into their own services. But it would also be possible for private companies to build these facilities. I imagine that this would take a long time and build up from very humble beginnings – a cataract surgery here, a hand clinic there – but over the long-term it would bring much needed funding into the system, as well as a small amount of private spending. Essentially it would enable the NHS to increase the volume of services it provides without a concomitant cost to the government. This partially tariff-subsidized model of private care is essentially what the Australian primary care system works on, and it seems to work well to both keep down costs and expand capacity – exactly what the NHS needs.

Effects on Inequality

The system described here wouldn’t fundamentally change the patient experience in any way, except to increase hospital choice, but it would lead to some mild increases in government costs – short term investment in small facilities and long term increases in services paid for. But it would lead to increased private funding and expenditure, and potentially the competition over services would enable the government to reduce the unit-cost of those services, leading to overall efficiency gains and long-term cost reductions. I think it would also have potential benefits in reducing inequality. For example, the diabetes clinic example would likely be implemented in areas of highest demand for diabetes services. In the UK, this demand is in primarily poor areas with large South Asian or black Caribbean minority populations, which suffer an unnecessarily high burden of diabetes illness. By establishing both government run and private facilities in these areas, and allowing neighbouring hospitals to consolidate and refocus services, it is likely that a significant health inequality problem in the UK could begin to be tackled, without necessarily incurring large cost burdens. By the same token, hospitals in poor areas suffering large waiting lists and underinvestment could close facilities that aren’t in demand but are being kept open for political reasons, or simply move services between hospitals so that they are run more efficiently, reducing waiting times and improving outcomes in these areas. The system remains largely publicy funded but more flexible, potentially enabling inequality to be reduced without introducing new inequalities through avoidable market failure.

The benefits of simplicity

The other major benefit of this reform idea is that it is achievable through gradual change, builds on existing structures, and can be done with minimal political risk. Whatever party introduces these reforms (and I think it is more likely Labour than the Tories that would do this) will be able to argue that it is building new hospitals and increasing investment, but that this comes with the cost of reorganizing existing clinical arrangements. This may be a risky sales task, but it’s a lot easier than “you’ll be better off once we’ve flogged the lot!” And the gradualism enables the government to experiment with the changes and adjust them as it sees problems arising. Nonetheless, many of the changes – especially ward closures and moving specialties – will be controversial, and until a government gets a strong majority and acts decisively, even change as minimal as this is unlikely to happen. Especially after the Tories stuff up their current plans and make anything with even the vaguest aroma of privatization off-limits for a generation. But I think this approach is the most likely to be successful in the UK, and is both achievable and capable of significantly improving the NHS.

The first suggested reform idea in my series of ideas to reform the NHS will start with this, the most radical. This reform plan presents a way to raise a large amount of money to pay down government debt, expand private and public investment in the health system, make the health system more flexible and accessible, and directly tie hospital funding to health outcomes, without changing the annual cost structure of the NHS at all. It sounds too good to be true, and so it probably is.

As I observed in my post on the current Conservative privatization drive, lack of private providers in the UK health market and central planning of all services are significant problems with the system: they affect the quantity of investment available, the efficiency of investment, independence of investment from political goals, and flexibility of response to changes in health care demand. The simplest approach to this is to allow new private entrants into the market and to fund them just as if they were public hospitals. This is very hard to do under the current system, because current block funding methods don’t work well for contracts with the private sector, and it will take a long time for new hospitals to be approved and built. A faster, simpler approach is to shift all the hospitals in the UK to a fee-for-service payment system (like Medicare in the USA) and then privatize them.

Shifting to a fee-for-service system

Fee for service systems have disadvantages that are well understood, but one significant advantage they offer is flexibility in response to demand. They also make the insurer paying for service able to purchase services from any provider, rather than having to be locked into contracts with specific providers – this potentially allows prices to be at least partially set by market forces. The main disadvantage in a stable health system is that they encourage over-provision of services, which leads to rapid cost growth for the payment provider (in this case, the government) and excessive healthcare attendances for patients – something that is potentially fatal in the case of e.g. prostate cancer. However, despite their disadvantages some systems – such as Japan – that use them have still managed to get good healthcare outcomes with low cost, so they aren’t the end of the world. Shifting a system like the NHS to such a payment process shouldn’t be impossible – in fact they’re already starting to do this in some ways using Healthcare Resource Groups. So let’s assume that this can be done, and all public hospitals can be switched to receiving payment on the basis of a fee-for-service system. Prices are set by the government, and hospitals paid for providing services. In theory there is no service the government won’t fund at a specified rate (we’ll return to this below), so everyone will get treatment. Some hospitals will provide some services at a cost below the price set by the government, so will profit from these; other services they provide at costs above the rate will either be subsidized by the more efficient ones (if the hospital is a not-for-profit) or closed (if the hospital is a private company). We’ll see the latter risk is one of the big problems with a fee-for-service system, but we’ll cross that bridge when we’ve burnt it.

So the essence of this scheme is to shift to a fee-for-service system and then sell off all 200 hospitals in the UK.

Privatizing all the hospitals in the NHS

We want a rapid influx of investment in the NHS, and we want to free up the NHS itself from investing in hospitals, and shift it to being purely a purchaser of services. The fastest and simplest way to do this is to simply flog off all the hospitals. This would potentially raise an enormous amount of money for the NHS very rapidly. The total cost of hospital care every year is about 20billion pounds, I think, spread over about 200 hospitals; that’s 100 million pounds per hospital on average. I think a private company that could be guaranteed an approximate 100 million pound income stream with, say, 10 million pounds a year profit would be willing to invest probably 100 million pounds in a hospital, so flogging off all 200 hospitals would raise about 20 billion pounds. This would be enough money to pay down about 10% of government debt and have 10 billion left over, which I propose be put into a health future fund. This future fund contributes to healthcare research and funding of new investments through its profits, and uses the principal to provide investment loans to the private and public organizations involved in the healthcare market (so that, e.g., if a union decided to buy a hospital for 100 million pounds it would be able to get a loan from the healthcare future fund to do this). This fund would thus support continuing investment in healthcare, and provide grants for research into new treatments as well as emergency funding to save struggling hospitals in the immediate aftermath of the privatization[1].

These privatized hospitals are then paid for their services from the existing NHS budget, which is about 20 billion pounds a year. But where previously this 20 billion pounds a year was split between hospital services and capital investment, now it is devoted only to services. I think this is the equivalent of increasing the hospital services budget by probably 5 or 10% (the amount of the existing budget that was being diverted by the hospitals to investment). Additionally, we have a huge short-term private investment of as much as 10 billion (the maximum value of the loans from the future fund) and then any other investment that the private owners want to put in. Having purchased a 100 million pound a year operation for, say, 100 million pounds, they might be willing to invest a bit more in improvements, I’m guessing.

Even if my numbers of hospitals and total hospital sector budget are incorrect, it should be clear that the privatization would raise a lot of money that, if disbursed between debt repayment and setting up a healthcare future fund, would be of significant benefit to the UK economy and health economy.

Allowing new entrants into the system

Of course subsequent to this privatization the government could also allow new entrants to the system, that would probably set up specialist services in areas where specific services were lacking. These entrants would be able to get start up funding from the future fund, of course, and would be entirely private investment. Thus over time the size of total investment in the health system would grow, and important consideration in improving levels of care in the UK.

A further, more radical entrant into the system could also be allowed: hospitals that charge an upfront payment. These hospitals would be additional to the current complement of hospitals, but would be able to charge fees to their admitted patients in addition to the standard service. They would, essentially, be luxury care centres. Unlike the current system, though, which does not allow the NHS to fund these kinds of providers, the hospitals would be allowed to charge the basic service to the NHS, and then charge only the top-up payment to the patient. Patients could pay out of pocket or cover the co-payment from a private insurance fund. This would allow private insurers to begin covering healthcare in the UK market, expanding the amount of per-service funding (and thus the proportion of GDP devoted to healthcare financing), but without requiring the private fund to cover the whole cost of hospitalization. Funds that have to cover the whole cost of privatization – as happens in America – have to be prohibitively expensive, and will not be able to compete in the British market.

These private entrants would have to be additional to the current complement of hospitals, and clearly labeled as private hospitals. They would need permission from the government to be established, and would only be allowable in areas that have already got a decent supply of healthcare. This is necessary in order to ensure that people don’t have to travel too far to get free care (a fundamental constraint on the NHS). As a result they would be unlikely to ever form a major component of the UK hospital system.

Consolidation and closure of existing services

After privatization, I expect many hospital owners would look at the cost structure and efficiency of their new purchases and decide to shut down some services because they can’t provide them competitively. For example, if a hospital in East London is providing cardiac services it is unlikely to be able to compete with Bethnal Green, and would probably close or restructure those services in order to remain profitable. Over time this would lead to a reallocation and consolidation of specialist services into better, more efficient hospitals, leading to efficiency gains and cost minimization, as well as improved health outcomes. This is very hard to do in the NHS as it is constructed now due to political influence. There is a risk that in the short term at least – until new hospitals are built or capacity is otherwise expanded – that this would lead to a loss of overall service levels, so it would be necessary to require hospital owners to seek permission for closures in the first, say, 5 years of their ownership. It might be necessary for the government to fast-track establishment of new hospitals in order to overcome this problem, which leads us to the possibility that some hospitals would remain in public ownership.

Partial privatization and gradual change

It’s probably best if the biggest and most important teaching hospitals remain in public ownership, so that the government retains some direct power to intervene in the provision of health services and also in the teaching and research capacity of the hospital system. This could include using the proceeds of privatization to build new hospitals, probably specialist, providing specific services in some areas of the country. These hospitals would be funded under the same arrangements as the privatized hospitals, though obviously they would also need some form of block grants in order to support investment and to maintain loss-making specialties that the government believes they need to run for research or market-failure reasons. They wouldn’t be precluded from opening private wings (in fact, their reputation for excellence might make them the best option for starting this process), but they would probably also be held to stricter rules on service provision (for reasons of access and equality) than the private providers.

As a general rule, rapid privatization is a dangerous prospect so the model proposed here might require a long time to complete, perhaps starting with smaller hospitals and building on their experience. Reform of the general practice system to allow private companies to enter their too would probably also be necessary, in order to prevent the primary care system putting a brake on the development of the tertiary system. Gradual privatization would mean that when the really big services were privatized there was less risk of mistake; it would probably also increase the amount of money gained, since flogging off all the hospitals at once would probably require selling them at bargain basement prices. This would also allow the system to be expanded as the privatization happened, convincing the public of the benefits of the process as they see new services open and waiting times drop.

Risks and disadvantages

The worst risk in this system is that immediately after privatization the new owners will close unprofitable specialties without opening new ones, leading to a general reduction in services provided across the NHS. This would indicate either that the NHS was over-stretched and incapable of providing many of the services it was providing, because the prices set on privatization would have been based partially on pre-privatization activity, and may have been set too low if the NHS had been operating massively under-budget for years. There’s also the associated risk that with prices set too low, the new owners struggle to make a profit, go into administration and then have to be re-nationalized. That would be a political disaster of monumental proportions, as well as costing the government a huge amount.

Another possibility is that the closure and reallocation of services will see a massive loss of service provision in poor areas, where profits will be lower. This will increase the inequalities already inherent in the British system and is one of the main concerns of the advocates of retaining central planning in the NHS. Careful choice of which hospitals to privatize will help with this, as will the simple expedient of providing additional funding in some form (block grants, contractual rewards, or special loans) to companies that retain services in these areas. If this risk does eventuate, the government may find itself having to increase the total healthcare budget to support its goals of reducing inequality – but this is likely to be the case in any healthcare system in the UK that is serious about reducing inequality, and although politically unpalatable in the UK it’s essential if the UK ever wants to reduce inequality. Sadly, this is never going to happen (and if it does the money will be misspent anyway).

The final disadvantage of this plan is that it requires the government of the UK – which couldn’t organize a root in a brothel – to manage the biggest privatization of services since the collapse of the USSR, to set a realistic and practical pricing structure for healthcare that is affordable but sufficient to enable private sector organizations to make a profit, to not to squander the result of privatization, to be willing to commit to a 5, 10 or even 15-year long period of massive health system reform (this would require bipartisan support, which is almost impossible in the toxic political environment of the UK) and to be able to sell the whole thing across multiple elections. So to actually implement this program in the UK would be inviting disaster.

The Final Picture

If successful, the final health system that emerged from this reform would very much resemble that of Japan, with an entirely public purchaser of services (the NHS) purchasing services from a largely private market place of hospitals and clinics. Prices would be set by the government at first but could potentially be set purely by market forces in the long term as capacity increased. Because the UK system is more centralized in larger hospitals than Japan, and because our remit requires all patients to be able to get any service free at the point of care, the system would probably have more publicly run providers (primarily large teaching hospitals) than in Japan, and would probably still be slightly more shambolic (due to the lack of private payments). The healthcare future fund would be unique to the UK, and there would probably be a large number of direct grants and subsidies (at least in the short term) to maintain the system and prevent growth of inequality. The final outcome of this process is not unrecognizable in the current range of healthcare systems, though, so it’s not impossible to imagine that a well-run privatization and reform program could get the NHS to this point. And if it worked broadly similarly to the Japanese system, it would be a vast improvement on what the UK has now.

fn1: I think this would be necessary because even a mind as great as mine would be likely to make mistakes in pricing services or estimating long term service levels

Having criticized the approach the UK government is taking to reforming the NHS, it seems only fair that I should make a few suggestions of my own. Unburdened as I am by the responsibility to be serious or to come up with a proposal that actually works, I’m going to write up a few perhaps crazy suggestions this week and next. For my reform ideas, I’ve decided to set the following arbitrary constraints:

  • The basic remit of the NHS must not change: that is, any reform plan must preserve the ability of the NHS to provide quality care accessible to all and free at the point of delivery
  • The patient experience must not be changed, so that if a reform plan were enacted wholesale today, a patient attempting to use the health system tomorrow would not notice any practical effect on their lives or patient experience[1]
  • As much as possible, red tape and administrative barriers to healthcare access should be reduced at the level of the patient, so e.g. we should try to abolish lists and restrictions on hospital attendance
  • The system should allow cost containment
  • Where possible, the system should reduce inequality, or at least not make the current system worse

I will of course add extra rules wherever possible.

The four ideas I have so far are:

  • Radical privatization, which looks too good to be true and probably is (this is essentially a radical shift to a Japanese-style marketplace but with no private up-front payments)
  • Minimal privatization, in which minor changes are made to the hospital system to allow new entrants and private investment (essentially the Australian model hospital system tacked onto the British GP system)
  • A license system, with trade in licenses slowly opened up to allow increased privatization and resource reallocation (this is completely new but probably just a mechanism to achieve a mixture of the other three ideas)
  • Reform of the GP market only, to significantly improve the function of the primary care system while leaving the tertiary care system unchanged (essentially, the Australian model)

I hope these ideas will show that it’s possible to radically change the structure of the NHS without changing its essential relationship between patient and system, its fundamental funding arrangements or its main outcomes. I don’t claim that any of my ideas will work, of course, nor do they have to since I’m writing on a blog. But I suspect that even the most minimalist of them would be politically unpalatable in the UK now (and even more so when the Tories stuff up their current round of reforms).

Any other ideas in comments would be appreciated, and I’ll try and write them up too!

 

fn1: This rules out care budgets and vouchers and some of the crazier ideas floating around in the UK and USA, that require patients to become active participants in health service planning

Yesterday the UK government passed the Health and Social Care Bill, which institutes sweeping changes across the National Health Service (NHS) that some observers claim will see it completely transformed from its present form into a privatized health provider. Depending on who you ask, we are about to witness the dawning of a golden age in health gains for ordinary Britons, or the unravelling of Britain’s healthcare system with terrible consequences. Those of us who don’t currently depend on the NHS for our healthcare get to watch the fascinating spectacle of the world’s largest centralized healthcare system (and I think according to some reports the world’s largest single employer) being dismantled piecewise from the comfortable vantage point of our functioning universal healthcare systems (unless we’re American, of course – you guys just get to be jealous that the UK has a universal health system to dismantle).

The Health and Social Care Bill contains, in  my view, one of the most appalling pieces of healthcare reform that a human being can conceive of inflicting on an otherwise functioning system, but it also contains at least the seeds of some important reforms that are long overdue for the British system. The former is, of course, the ludicrous idea of “clinical commissioning,” in which about 60 billion pounds of NHS funding is to be taken away from area health services (called “Primary Care Trusts”) and given to family doctors, who are expected to form up into consortiums that will then determine what care gets funded with the money they’ve been given. The latter is the decision to split the health system into providers of care (hospitals and health care services), who offer services that then purchased by the NHS (or the afore-mentioned godforsaken GP commissioners). If it were possible to achive this latter reform successfully, the NHS would have been transformed so that it worked along lines similar to almost every other universal health care system in the world, and would also open the way for significant private investment in healthcare infrastructure in the UK. I’ll give some examples of how simple and profound that could be in this post.

What’s Wrong with the NHS

The biggest problem with healthcare in the UK – and the problem that governments on both sides don’t want to talk about – is that it is underfunded. The UK spends just under 10% of its GDP on healthcare, compared to between 11% and 17% for France and the USA[1]; before Labour’s reforms in the early 2000s, it spent closer to 8.5% on healthcare. You can’t expect modern health outcomes with this level of funding, though the NHS has shown that you can still do pretty well. The reason that this funding is so low is that the UK system is a centrally managed, entirely publicly-funded service, from which private providers have been excluded since its inception. With no ability to participate in the NHS, tax rates high, and the NHS goal to provide all services free at the point of care, private providers cannot make money and are left providing boutique services to the very rich. Hence, private investment in health is low. But it’s extremely difficult for the government to make up this shortfall – it’s likely doing so would require the government to increase spending on the NHS by potentially as much as 20% (to take it from the 9.5% of GDP it is now to the 11 or 12% other countries enjoy). Obviously such a funding boost is politically impossible, and so the NHS has languished.

Funding isn’t the only problem though. A centrally-managed organization of this size is inflexible, conservative and inefficient, and forcing efficiency gains from such a behemoth is extremely difficult. Centralized decision making forces diverse organizations in diverse regions that have individual priorities to commit to goals and priorities set nationally, and leads to the classic inefficiencies and inflexibility of a centrally-managed utopian institution. Other health systems leave much regional flexibility and priority-setting to be determined both at a local level and privately, and force at least some health organizations to respond to patient needs by going out of business if they can’t. Classic examples of this kind of inflexibility abound in the NHS: until recently patients didn’t have a choice of hospital, but had to go to one that was linked to the area in which they lived. You can’t shop around GPs (in theory) but need to “register” with a GP and visit only one – you can’t, e.g. have a different GP for sexual health needs vs. chronic disease management, which is pretty common in other countries. Furthermore, GPs can refuse to accept new patients if their list is full, and many GPs require you to register before you can attend for health care, which is inflexible. There is no incentive for GPs to invest in their own services, since they can refer patients to a hospital for almost every condition, and have a largely captive audience, so the UK has an abundance of one-doctor surgeries with archaic opening times. At least a portion of their renumeration is based on their list size, so there’s no incentive for new GPs to enter the market or to try and increase the amount of services they provide: their ideal business model (financially) is to have a large list of patients and very short working hours, and there’s no incentive for them to merge to form larger GP clinics that might, e.g., provide out of hours services. This all changed slowly under labour since the mid-90s, but GPs – the gatekeepers into the health system in the UK – are very highly paid for a very poor service model.

The hospital sector in the UK is also under-funded and subject to the kind of rigid service models one expects of a centrally-managed system. The outpatient system is over-burdened from the broken gatekeeper model, and many of the hospital systems are lacking investment and modern infrastructure. This is a throwback to years of underfunding but it’s also a consequence of current funding constraints: both recurrent costs and capital investment need to be funded from the government’s budget, but they can’t contract out e.g. pathology services that would be routinely privatized in other systems, so where much of this investment is done by private companies in Australia, in the UK it’s all part of that 9.5% of GDP. The system is plagued with waiting times and archaic technology and systems, and everyone is overworked.

Hospitals can’t consolidate or specialize, which is a key method of improving efficiency, quality and safety of care. We know that larger facilities tend to have lower death rates and better success rates, but to achieve such benefits hospitals need to shut down under-performing clinics or specialties and focus on a more limited range of services – and some hospitals need to shut altogether. But in the UK there is a direct relationship between the government and the hospital sector, so every time a hospital plans to close even a single ward you see protests aimed at the local member, followed by political blowback, taken up with gusto by the press (who love an NHS scandal). The government inevitably buckles, and under-performing or inefficient (and sometimes dangerous) smaller facilities can’t relocate or close. In fact, the whole system is vulnerable to political campaigns – on nurses’ or doctors’ pay, on hospital closures, or even on particular treatment methods – in a way that a more mixed model is not.  So it creaks along, unable to consolidate for modern efficiency gains, unable to reform its failing gatekeeper model, and unable to inject the capital required to modernize. Plus, even if it did inject the capital, much of it would be subjet to political debate and delays that would mean it was inefficiently used.

A Model Example: Privatization of General Practice

For these reasons, the system needs to be diversified and decoupled from the political pressures that currently constrain its operations, and doing so is inevitably going to mean privatization. There is no reason, for example, that the entire primary health system (that is, GPs) couldn’t be thrown entirely to the whims of the market, with GPs offered payment only on a fee-for-service basis and the market opened up to corporate investors. If the government did this, international health care companies would be in faster than greased lightning, setting up large, efficient and modern clinics with heavy capital investment, bringing in overseas doctors or buying in the local younger doctors, incorporating allied health care services and providing a huge injection of capital to the GP market overnight. Older, settled GPs would hate it because they would be drummed out of the market, but this is exactly what is needed – get rid of these little shoddy one man clinics operating 9-5 and no weekends, and replace them with large, bustling services that provide evening and weekend medical care, physiotherapy, dental care, public health nursing and rehabilitation under one roof. It would immediately take pressure off of hospitals and make healthcare far more easily available for the majority of the working population. These services are the norm in other developed nations but still held back in the UK by the lack of private investment or public vision.

The Political Mistakes in this Bill

With these ideas in mind, the government has started outsourcing NHS services, and the Guardian reports on a controversial example from Devon, possibly the first in the UK: privatization of children’s health services. These services will be purchased by the NHS, but provided by either Serco (a private prisons company) or Virgin Healthcare (a branch of Richard Branson’s Virgin empire). This is a classic insurer/provider split: the NHS collects insurance from everyone in the UK and then purchases health services from a private provider. Unfortunately, from what one can tell of the process in the article, it’s going to go down the classic British privatization pathway: give the contract to a single provider without a fee-for-service element and then hope they don’t cock it up. The NHS, with no expertise in contracting from private services, is going to be writing a 100 million pound contract with a famously predatory company like Serco or Virgin. And not just for any services, but for the most controversial possible service they can find: child protection. This isn’t just a political risk but a healthcare risk, because these services are far more complex than say, radiology or pathology services, and there are very few private contractors with any experience in them.

The linked article on children’s health services makes the people bidding for this contract seem like very reasonable people driven by a genuine desire to provide decent health care and an awareness of what is holding the NHS back. For example, the Serco spokesperson says:

It has to cut £20bn a year. It can’t invest, but we can invest to improve quality and generate efficiency. We have to bid to deliver at prices that are a lot lower than the NHS to win contracts and that gives the NHS more money to put into the NHS itself.

This is a good example of why efficiency gains are important. They don’t just benefit the profits of the insurance company doing the purchasing, but also the health of all members of the plan, since they enable the insurance company to fund a greater number of services, and/or to extend its funds to new services. Unfortunately the Conservatives aren’t selling these points, but are instead talking up the need to save money.

Ideally, the privatization program the Tories are running would start with something simple – pathology or radiology services, or a small rural hospital – and be trialled over several years before being introduced nationally, and the most complex and controversial services (large teaching hospitals, prison healthcare, children’s services) would be privatized last or not at all. Lessons learnt in the initial small trials would be incorporated into the bigger privatization program, and where things failed they would be kept in public hands until better privatization methods could be trialled. Also, the system wouldn’t be privatized in a one-contract-per-service method as is shown here, especially not in rural areas where locals can’t easily choose another service not being provided by the sole contractor. Rather, services would be offered competitively to the lowest bidder, thus allowing the NHS itself to compete. The risk with solo contracts such as planned here are that they don’t actually exert a competitive pressure on the provider – they’re only as competitive as the tendering process. Patients as well as commissioners should have the ability to shop around.

Unfortunately, the Tories seem to have decided to push forward recklessly, implementing clinical commissioning and hospital privatization at the same time. There’s a risk of chaos, poor contract management, and cost overruns or service failures without any significant benefits to patients, at least in the short term.

The Most Likely Outcomes

The privatization of children’s services in Devon is a good example of the radicalism underlying the Conservative Party’s agenda on this topic: they don’t want to see a gradual unravelling of the NHS, starting with the easiest services and building up, and instead want to sell off the most complex bits while simultaneously managing the mish-mash of clinical commissioning, and cutting funding to the NHS by something like 20billion pounds over 5 years. The obvious result is going to be a 5 year torrent of bad news stories, and the public perception that health system privatization is both a kooky agenda (tainted by the confusion and chaos that clinical commissioning will bring) and driven only by the need to cut costs, rather than the very real need to improve the NHS. Thus, when the Conservatives finally lose power, the privatization agenda will be inevitably linked with their other policy radicalism and the agenda of “the cuts” (oh how I hate that term), and the chance to reform the NHS so that it actually works will be lost.

Furthermore, the Tories aren’t actually testing a health system reform that has any pedigree. A single payer insurer offering fixed payments on a fee for service basis to primarily private providers has been tried and tested in the USA (Medicare) and Japan (kokumin hoken). A weird system of ordinary family doctors holding millions of dollars in health system funding and using it to contract services from private providers on a block funding basis – that is unheard of in modern health systems. Why test it?

Mistaken Ideas About Health Inequality

Much of the debate about healthcare in the UK still revolves around this issue of central planning versus US-style free market models. In February the shadow (Labour) spokesperson on health, Andy Burnham, penned a piece for the Guardian in which he criticized privatization. There he claimed:

In the US system, for instance, it is possible to find some of the world’s most advanced and innovative examples of care. But, alongside it, we find very poor or non-existent care. The question we must ask is not which system produces the best individual examples of treatment, but rather which is best for everyone. On this test, the centrally planned NHS wins hands down.

This is a completely unreasonable comparison. The US has “poor or non-existent care” because it doesn’t have universal health care. The US could do away with this problem tomorrow by nationalizing all the insurance companies, forming one national insurance company funded by taxation, and then funding all medical care on a strictly fee for service basis. The system would be completely unplanned, with no government hospitals involved, but it would be pretty likely to eliminate “non-existent care” overnight, since all Americans would be eligible for care. Burnham also claims the NHS

provides the precious ability to set standards and entitlements to services at a national level. Market-based health systems do not afford a similar ability to control costs at national level, and allocate resources in a fair and consistent way.

But this is also not true. The government, providing all funds for purchasing health care services, can decide exactly how much it will pay, and provide it is not stupid or unrealistic, it is likely that the private sector will fall into line (we’re talking about 100 billion pounds a year of essential services here – people will be shoving into line to get a piece of that). Similarly, the USA has the ability to “set standards and entitlements” even now – for example, it’s very hard for a US health insurance company to refuse someone a policy because they’re black. The problem in the US is that the government won’t set those standards well enough, and by refusing to provide a universal health coverage model, has lost the ability to compete financially in this market place or to control it through its own considerable financial muscle. There have been many models proposed that would reform much of the US healthcare market without making it centrally planned, and would improve both its equality and its ability to contain costs – and in fact some private US organizations (especially HMOs) are famous for good cost containment. The tragedy of the US political system is that many of the education proposals coming from moderate republicans – voucher systems and the like – would significantly reduce health inequality if adapted to the health market, yet even relatively rational and minimal reform plans that would otherwise be favourable to their right wing are rejected out of hand because they involve “government intervention in medical care.”

The problem in the UK is that this debate about access to care has been framed as a debate between the NHS and the US system for so long that even experts and well-intentioned politicians with a strong understanding of the system (like Burnham) have fallen into it. But the reality is that centrally planned systems don’t necessarily reduce inequality. This is because inequality is not purely a function of inability to afford healthcare: it arises from the interaction between individuals and systems, the design of systems, and the inevitability of resource constraints. Wherever resources are restricted one finds that the wealthy, the educated and the powerful are better able to seize more of these resources, or seize them sooner (an important consideration in health systems). For example, in 2010 I showed that poor and older people tend to receive less referrals or take longer to be referred for a wide range of conditions within the NHS – this despite the fact that the NHS is free to all. This is because the referral system is a type of resource management system, and for reasons we don’t entirely understand, the wealthy and the educated are better able to negotiate any such system. So central planning doesn’t solve these problems, though the way the NHS is constructed makes these problems less life threatening than they would be in, say, the USA (where many of the people whose health outcomes I studied would simply not have access to health care at all).

Another reason that centrally planned systems don’t necessarily reduce inequality better than other systems is that health inequality is caused by factors outside the health system. It is, simply, a function of inequality, and there’s only so much that even the best health systems can do to reduce the effect of problems created in broader society. The UK is a very unequal society, and the NHS has to deal with the human consequences of that. The goal of health planners concerned about inequality is to find the best system to provide good healthcare to everyone that will also reduce inequality. Balancing these two goals in a resource-constrained setting is difficult, and I see no a priori justification for the idea that central planning is always the best way to do this.

Some Theories About Modern Healthcare Systems

Once the NHS and the US’s overly private system are done away with the world will essentially be left with a range of mixed-market models, largely based on the idea of a central universal insurance provider and a partially- or completely- privatized marketplace of service providers. Some, like Canada and Australia, will tend to be more heavily publicly run than others, like Japan or Germany. There will be a few unique hold outs, like China, Cuba and Switzerland, but largely the ideal form of health provider will have been settled. This decade the WHO is focusing on universal healthcare as a central policy theme, and the goal will then be to expand models like Japan’s to encompass the developing world – a pressing problem given the resource constraints there. There is no place in health policy for a purely market-based model and, as far as I can see, there is equally no place for a fully centrally managed model. The debate now is about how to extend the most functional mixed-market models to the rest of the world (including China and India) as a development goal, and how to resolve pressing issues of cost containment in the developed world.

Given this settled state of policy, it seems now to me that there are some central lessons that have been learnt since the expansion of universal care systems across the developed world over the past 100 years:

  • Governments and markets can’t go it alone: models based entirely on one sector running the whole show don’t work, because health systems are enormously complex, requiring market-based flexibility and government intervention to prevent market failure and enforce standards and access
  • Cost containment, universal access, and timely access are hard to balance: Most health systems can’t manage all three of these at once. The USA has managed timely access but not cost containment or universality; the UK has managed two of the three; Japan, Germany and France have probably got all three down but Germany is heading into financial trouble and Japan has inherited a unique set of social factors (a very healthy population and a very equitable society). This trio of goals for modern health systems are going to become harder and harder to balance as populations age and more expensive health care is developed
  • You can’t fix inequality just by throwing money at it: obviously achieving universal care is an important part of reducing inequality, but that’s not the end of it. How your system functions and how people interact with it is important in determining where inequality arises and how well it is reduced. A complex system with non-financial resource constraints (like the NHS) can create or perpetuate inequality even though on paper everyone has access to care
  • Centrally planned systems don’t solve inequality: Central planning can be an attractive way to reduce inequality, but it doesn’t necessarily work that way. In health systems, inefficiencies or inequities in one area inevitably produce problems and workarounds elsewhere, and centrally planned systems may be able to stamp out some inefficiencies or inequities, but they don’t necessarily have the capability to react to (or even notice) the problems their solutions create
  • Muddled political visions produce muddled outcomes: They may claim to be friends of the NHS but the Tory political program in health is not just about improving the NHS. They also want to cut costs (to the government), and they want to reduce government interference. I think they also have an ideological goal of increasing the role of the private sector in healthcare, and I don’t think this view arises purely from a belief that this will make the system better – they have an ideological commitment to reducing the size and role of government. This muddled goal will produce a partially privatized system that doesn’t work because it wasn’t privatized with the goal of improving the system. Similarly, the Labour party may be friends of the NHS but they also had a goal of privatization with the intention of improving services, but they couldn’t separate that practical plan from their commitment to a centrally planned and government run NHS. The result was a series of aborted privatization plans that satisfied no one.

Health systems planning is where ideologies go to die, and the NHS is the classic example of this. It has long since proven that the centrally planned, socialized system envisaged in 1948 is insufficient to the long term management of a health system, but subsequent interventions to improve it have been hampered by ideology and have inevitably failed when they meet reality. The latest attempt by the Tories, though it has some good qualities and has the potential to take the NHS in a good direction, is highly likely to meet the same fate. If they do fail the rapidity of the changes, their timing and their entanglement with the Tory cost-cutting agenda could permanently damage the idea of introducing a mixed market system to the NHS, setting back much-needed reforms for a whole generation. This will leave the British people very poorly served by their health system, and continuing to fall behind the rest of the OECD in health outcomes. It will be sad indeed if the country that introduced the modern, free health service is overtaken by even the post-Obamacare USA as a model for health service provision.

fn1: These figures taken roughly from the Commonwealth Fund’s annual report on health care comparisons between the UK, Germany, Netherlands, NZ, Australia and USA.

Japanese people in general seem to have excellent skills in data visualization, as well as quite advanced mathematical ability and a robust approach to science. Japanese appreciation of data visualization, particularly, seems to exceed anything similar in the West (at least, that I’m familiar with). In my favourite magazine, Tokyo Graffiti, for example, ordinary people are regularly asked to describe their hairstyle or their favorite shoes in terms of spider charts, a form of data visualization also used to describe the fruit and vegetables at my local supermarket. The local guide to hot springs in Steamy Beppu contains a chart that plots key ingredients of the hot spring water on two axes, and then clusters the data into areas through different coloured data points so that you can easily judge which tourist area to visit depending on your health needs. Most pamphlets about health issues in Japan include a brief description of the epidemiological evidence, and usually a chart or two that lay out the data in a visually attractive way.

Of course it’s not the case that these representational methods are unique to Japan, but what is unique is their degree of dissemination, with ordinary shops using them to depict basic information about their products, and information that would be reserved for the fine print (or not presented at all) in the UK or Australia being given front page, graphical representation under the assumption that even the most ordinarily-educated of individuals is capable of understanding it. This is both a refreshing assumption about the mental capacity of the average consumer on the part of ordinary companies, and a huge bonus for your average statistician. People not only understand the basic idea of what I do, but they appreciate it and think it’s cool. This is, to say the least, a novelty.

Of course this has come to the fore in the last week, when the nuclear “crisis” hit. The Japanese media have been very quick to present detailed diagrams of the nuclear plants, and used all sorts of cute charts to give clear presentation of the risks of radiation, in a refreshingly straightforward and unpatronizing way that assumes the best of the audience. The channel I was watching in Beppu, NHK, even had a guy whose official job was “Explainer” (説明者)。They also presented a variety of basic charts and pictorial representations (especially the triangle describing risk) clearly and directly. But the best example I’ve seen so far of presentation of this data is this visualization, which unfortunately for most of my readers is in Japanese. Here is an explanation:

The visualization has 12 little pictures in 3 lines of 4. The top 4 show (left to right) the world average hourly exposure; the upper limit for a worker who deals with radiation; the amount required for a 0.5% increase in cancer risk; and the amount at which you should run for the hills. The next 8 boxes (left to right, top to bottom) are places in Japan. The first (left-most of the middle row) is the Western edge of the Fukushima exclusion zone. To its right are three towns heavily affected by the Tsunami. On the bottom left is my colleague, Ms. Middle-of-the-River’s hometown of Saitama. Next is my friend Miss Wisteria Village’s workplace of Chiba; then is an area near me; and lastly is a town near Yokohama to the Southwest of Tokyo. These places are all in the Greater Kanto area so some distance from the plant, but as you can see from the falling dots, they have a similar amount of “rain” to those in the area around the plant.

This is classic visualization material, giving an engaging presentation of key facts in such a way that visual comparisons are easily done without losing key basic information. It’s also done with the classic Japanese minimalist aesthetic, and somehow manages to produce an overall calming image, while giving a clear sense of panic to the danger zone image while smoothly contrasting it with the reality that surrounds it.

I don’t know why the Japanese are so good at and familiar with visualization, but I think that their writing system, being pictorial, must be connected in some way. Is this also true of China and Korea? They are also countries with world famous mathematical education, and a pictorial writing system, but I don’t know enough about them to judge. I am, however, confident that less foreigners would have run away from Tokyo if the English-speaking world were more comfortable with this sort of representational style.

Come on baby, you know you want it!

Today, while preparing lessons, I was reminded of one of my two favourite journal articles of all time, which reminded me of the other one, and  thought I’d give a brief review of both of them here. One is an example of the kind of research that is often sneered at for its social sicencey-content, but is very important for public health, and the other is interesting for no other reason than that, well, it’s very interesting. The two articles are Highway cowboys, old hands and Christian Truckers: risk behaviour for human immunodeficiency virus infection among long-haul Truckers in Florida, by Stratford D et al, published in Social Science and Medicine; and Autoerotic fatalities with power hydraulics, by O’Halloran RL, published in the Journal of Forensic Science. Here is my brief review of each. Both reviews are based largely on memory (I don’t yet have full versions), but my memory of both is pretty clear.

Highway Cowboys, Old Hands and Christian Truckers

Overview

This article is a classic example of good quality, detailed research into the social determinants of unsafe sex and HIV risk. From memory, it stemmed from research done as part of a project in the late 1990s aimed at identifying HIV risk behaviour on trucking routes in the US. As such it is an interview-based extension of some snowball-sampled research of truckers on a long-haul route starting in Florida, so the article combines some basic tabular information on unsafe behaviour (condomless sex, gay sex, drug use) and some interviews to flesh out the research from the original questionnaires. The authors have gone further, however, using the findings of the study to divide the truckers they meet into three key groups, who will probably be accessed by different health promotion methods, and one of which may be useful for peer education training.

The research identified several types of high risk behaviour amongst long haul truckers, which are generally understood to exist but which aren’t easily quantified and which they explored in detail through interviews. Before we examine these three types of risk, it’s worth bearing in mind that truckers are actually a pretty hard-to-reach group, and although we have anecdotal reasons to believe they are high-risk for certain diseases (injury, HIV, sexually transmitted infections), getting details on this risk can be hard. The three risk types are:

  • Unsafe heterosexual sex: truckers use prostitutes, and the particular type of sex worker who serve the long-haul trucker market are cheap, transient and extremely vulnerable. This gives truckers the opportunity to negotiate unsafe sex easily, and they do. For example, one type of common sex work on long-haul routes was euphemistically referred to as the “lot lizard,” young women who move from truck to truck at truck stops, knocking on doors and offering sex for cash in the cabs of the trucks. These women are sometimes retained by the local truck stops and sometimes independent. Some of them exchange sex for transport, that is they need to move interstate so they pay for the trip by a night in a cab. This type of informal sex work is, classically, the type most associated with unsafe sex and least amenable to safe sex messages.
  • Drug use: some truckers use a lot of speed to maintain their hectic schedules, especially if they have a young family to support or are new to the industry, and these guys may shift to injecting the drug, a high risk activity for HIV, though probably in the case of truckers sharing is uncommon and injecting in groups is unlikely. The risk, of course, is that they will share their needle and drugs with a sex worker, creating the classic combination of vectors for HIV
  • Gay sex: all the truckers interviewed “knew someone” who has gay sex, but they all refused to identify the person in question as gay; the person in question was a trucker, and axiomatically truckers aren’t gay (it’s impossible). But men who have sex with men are the highest risk of unsafe sex, since they aren’t being accessed by community-focussed safe sex messages, and in recent years most HIV-related health promoters have been recognizing this problem and addressing it through more diverse and targeted safe sex messages. One of the messages of articles like this one are that the range of sexual behaviour people engage in is much greater than the range of easily definable human beings; but health promotion messages are much easier to broadcast successfully if targeted at easily identifiable categories of person (such as gay, sex worker, rugby player, doctor). It’s not the fault of health educators, but it’s often the people who fall through the cracks who are the most at risk. Truckers who define themselves aggressively as straight, but have sex with other men, are a classic example of this.

In addition to identifying these risk behaviours, the authors also, through the interviews, identified three key groups of truckers for whom safe sex messages could be, or needed to be, targeted:

  • Highway cowboys: young, working very long hours at high intensity with few breaks, often taking speed, supporting a young family but also using sex workers and taking all sorts of drug-, sex- and driving-related risks, the highway cowboys were the key risk group who needed safe sex and safe injecting information pronto
  • Old Hands: Men who have passed through the cowboy stage, learnt the ropes, have less responsibilities and a better grasp of how life works, these men were respected by other truckers and less likely to engage in extreme work and recreational activities. They might still see sex workers but were much less likely to take drugs or risks. These men are the best candidates for peer education outreach; that is, they can be taught to proselytize for safe sex and drug use
  • Christian Truckers: highway cowboys who have found god and think the behaviour of other highway cowboys is reprehensible. I recall a quote from one trucker complaining that he couldn’t sleep because of all the sinful activity going on in his parking lot, and sneering at the lot lizards for their role in it. These guys are beyond risk, but not so well respected by their fellows that they could provide outreach or education

The tone of this article is consistent throughout; amused, but respectful of the research subjects and their particular needs. It manages to convey the authors opinion of the truckers’ attitudes to their own milieu, while maintaining a respectful distance and offering non-judgemental commentary on the public health issues. While the truckers themselves may say quite nasty things about the women who service them, the article refrains from judging the truckers’ opinions or from giving negative opinions about those women, while recommending practical and sensible suggestions that will improve the health of everyone involved. My main criticism of the content of this article is that a) it suffers from the usual problem of interview studies, that you don’t know how objective the interview component is, and the number interviewed is small; and b) it misses a chance to also describe injury-related health problems (the focus is very much on HIV). The latter is not a big deal in my opinion, and the former an inevitable problem with interview studies; but this one also has basic questionnaire data on risk behaviour to back it up. Also, the sample is a snowball-sample, I think, which is bad, but this is unavoidable with these kinds of studies – you can’t do a random sample of truckers.

Public Health Value

This is a classic example of the importance of social research for public health. It identifies high-risk behaviour and the groups of people who do it; fleshes out the culture underlying the risk-taking through interviews; and identifies the groups who can be most effective at changing it or are most resistant to change, as well as the key public health risks. It gives information for both sexual health practitioners and health educators, and gives basic data on what the risks are. Note, too, that although it might seem amusing and trivial, the topic here is, fundamentally, deadly serious. HIV is a serious disease and truckers (and the sex workers with whom they inevitably interact) are a key vector for its transmission. HIV probably entered France on trucking routes from Africa, and probably also Haiti; it has spread rapidly through Africa and no doubt truckers were a key vector of transmission. In the USA, where there are areas of high HIV prevalence, truckers are one of a small number of key vectors by which the disease can break out into a wider community. Truckers travel from high- to low-HIV prevalence areas, engage in multiple risk behaviours, and have families with whom they practice unsafe sex. This makes them very important to understand, but their particular workplace culture also makes their community very hard to penetrate. This paper achieved that through careful, meticulous research, and deserves credit for providing a powerful insight into a very hard to reach group.

Full reference

Stratford D, Ellerbrock TV, Akins JK, Hall H. Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long-haul truckers in Florida. Social Science & Medicine, 2000: 50(5); 737-749.

Autoerotic fatalities with power hydraulics

Again, I’m reporting on this article from memory, but I think the abstract speaks for itself:

We report two cases in which men used the hydraulic shovels on tractors to suspend themselves for masochistic sexual stimulation. One man developed a romantic attachment to a tractor, even giving it a name and writing poetry in its honor. He died accidentally while intentionally asphyxiating himself through suspension by the neck, leaving clues that he enjoyed perceptual distortions during asphyxiation. The other man engaged in sexual bondage and transvestic fetishism, but did not purposely asphyxiate himself. He died when accidentally pinned to the ground under a shovel after intentionally suspending himself by the ankles. We compare these cases with other autoerotic fatalities involving perceptual distortion, cross-dressing, machinery, and postural asphyxiation by chest compression.

Unlike the previous article, this article is presented in an entirely professional and medical tone, just like reading medical notes. I can still recall reading a phrase like, “The family were somewhat surprised to discover the case’s sexual habits,” presented as if the sexual habit were completely normal and merely unknown to the wife, in a dry tone that doesn’t contain any indication that the activity in question is, well, unusual. And it’s pretty likely that it was a family member who discovered the victim in both cases – and in the latter I seem to recall there was a complex arrangement involving a broomstick to the anus and some rubber tubing to control the digger machinery. This is not the sort of thing you want to see when you go down to the shed to collect your husband for lunch.

The dry tone provides its own humour, but at the heart of both stories is an unavoidable tragedy of forbidden love, shame, stigma and auto-eroticism that would leave Shakespeare flabbergasted. Truth is indeed stranger than fiction, and presenting it as a medical case report just makes it … stranger.

Public Health Value

Pretty limited, really, but it’s worth noting that there is a lesson in these deaths that extends to much more risky and epidemiologically relevant tales. Shame, stigma and the need to hide one’s inclinations don’t stop one from doing them, they just make one do them secretly and dangerously. Unable to discuss one’s habits, one hides them, works out how to do them oneself and, if doing them unsafely is possible, one learns to do them unsafely. This is what these two men did, with sad and fatal results. This is why in public health we should always be concerned about the health consequences of an activity for the person, rather than what the activity says about the person themselves. Which isn’t to say that personally we should approve or disapprove of someone fucking their tractor; but our public health concern is to stop them dying, not to stop them doing it.

In this case, of course, there was no hope that we could help these people share and control the risk of their behaviour, since sharing inevitably involved loss of family connections, a powerful inhibitor to honest discussion of “deviant” behaviour. But it tells us a story about exactly what the consequences of secrecy are, and reminds us that if there is a way that we can reasonably prevent people from experiencing these costs through revealing their behaviour, we can make a huge difference to the risks they face and the risks they inflict on others. So next time you feel like judging someone else’s victimless behaviour, ask yourself: “how would I feel if it was me fucking my tractor, and my jury-rigged shovel control had broken?”

Full reference

O’Halloran RL, Dietz PE. Autoerotic Fatalities with Power Hydraulics. Journal of Forensic Science. 1994 Sep;39(5):1143-4.

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