Guest post: Slice away a tiny bit at a time
Originally a comment by Steamshovelmama on The NHS may not survive as we know it.
As someone with a 20 year background of working for the NHS I agree almost completely.
Ignore the four hour waiting thing – it’s a red herring, a target that was centrally imposed by a government wanting something tangible they could use to “measure” performance. It is not appropriate for every patient to be shunted to a ward bed within four hours of admission to A&E – sometimes better care will be had in A&E from appropriately specialised doctors and nurses who are actually on the spot. Stabilisation of an emergency condition does not always follow a nice consistent pathway. Sometimes weird shit happens and the process of making the patient safe takes longer than four hours.
The junior doctors problem, on the other hand, is a real issue. Jeremy Hunt (who has taken over in the UK from the irritating but generally harmless James Blunt as “the only man alive who is his own rhyming slang,”*) has decided that hospitals should offer a full seven day service as opposed to a full five day service and emergency cover at weekends. That’s fine. I actually agree. So he’s increasing NHS funding to cover the costs?
Well, no.
The things is, employing more junior doctors is expensive, but it doesn’t stop there. You also have to increase the numbers of the 9-5 plus on-call services – radiographers and X Ray techs, phlebotamists, Scientific Officers to staff the labs and process samples, Endoscopists, Transplant Coordinators, Dieticians, physiotherapists, occupational therapists – the list goes on and on.
It doesn’t include the nurses. We’ve been providing a full 24/7 service since forever. We’re the only group that does so.
For those of us who do or have worked in the NHS it is very, very clear that the service is under political attack. Funding is being cut, services are being whittled down. In the words of the great “Yes, Minister”, “salami tactics” are being employed. Slice away a tiny bit at a time, a bit so small, so insignificant that no reasonable person could really object. Then slice again and again. Argue that private companies run things more efficiently (I’ve worked in the private and public sectors in the UK and my response to this is a stunned, “Buh? Wha?”) so bring in private companies to manage sections of the NHS. Amazingly enough, these sections rapidly run into problems when a style of management is installed that is more used to measuring performance by profit.
Study after study has shown that clinically the NHS is actually extremely efficient. That’s been the case since the late 1970s when an efficiency rating of over 90% was calculated. Money has been wasted by being diverted to a plethora of “management consultants” and senior managers sucking down what is, by NHS standards, huge amounts of money. Of course, they aren’t actually good managers – if they were they’d be earning at least twice the amount in industry.
We spend less per capita on health care than any other western European nation. The big problem we have is that we have just lost the last generation to remember what things were like before nationalised health care, where if you were ill you just got on with stuff (and got iller and iller and sometimes died) because medicine and hospital care was for the privileged classes. People now have quite literally no idea how much their birth control, antibiotics, insulin and surgery will cost them in insurance if we move towards (god help us) a US style (lack of a) health care system.
The politicians don’t care (except for Corbyn) because they are all rich boys with Daddy’s money to fall back on. In their eyes the NHS is just a drain on the national purse. Think of all the handouts they could give to their cronies with that cash!
The depressing thing is that the media folks, being generally from a privileged background themselves, are uninclined to question this too deeply. No one is looking at what the dissolution of the NHS would mean for ordinary people. There is a sad lack of incisive investigative journalism.
So, yes, those of us who recognise this covert attack on the NHS are deeply worried.
*yes, I know, but it’s a common UK joke.
As a Brit who moved to the US, I can’t recommend this post enough. Growing up under the NHS, you can’t appreciate the anxiety that descends the first time you need some kind of urgent care – how much is this going to cost? I was lucky, I had good insurance, but I had literally no way of knowing how good it was until I used it. Obscure jargon (co-pays, co-insurance), byzantine decision making on what would be paid or not paid and utterly opaque charging structures by doctors and hospitals, not to mention good old-fashioned human error adds layers of additional stress exactly when you don’t need it – you’re really sick and kind of freaked out anyway because you don’t know what’s wrong with you.
They say you don’t know what you’ve got till it’s gone. When I watched the Opening Ceremony for the Olympics back in 2012, I was rather stunned by my home country’s pride in it’s health service. To watch it slowly be dismantled from afar is heartbreaking, not least of which because all I can do from here is urge my fellow Brits not to let it slip away. Because if the Tories dismantle it, it ain’t never coming back.
I know. I detest our system, and bitterly envy you the NHS.
My US health insurance actually covered my recent eye exam for the first time in over a decade because now, with the ACA, my employer is obligated to provide an actually usable insurance plan, instead of one that nobody where I live would accept. It was nice to pay a $10 copay instead of $280, for the first time. Moreover, my new frame will be covered by this insurance, so I’m going to splurge and get a backup pair, even though I have to pay out of pocket for the backup.
That is absolutely the only positive thing that I can say about the US healthcare system. Everything else about it is rotten to the core. You folks in the UK with your NHS are so very, very lucky.
That there’s a problem with the way in which public health care is financed cannot be denied. Calls to cut costs are always being heard here in Canada. Also, the attempts to privatize certain services claiming that the private sector is more cost efficient are often in the news.
That said, there is another side to this as well; the public and its attitude towards the health care system as well as its attitudes towards its own health. Hospital visits should be free…but they should also be as rare as possible. However the existence of free healthcare makes people indifferent to the role THEY should be playing in an effort to remain healthy. People no longer fret about getting sick. The knowledge that a visit to the doctor can be had at any time for little or no cost has diminished the sense of responsibility people have towards their own health and well being.
Enough of my finger-wagging.
Another aspect of financing healthcare revolves around scientific and technological advancements. Innovative and effective treatments, medicines, therapies and equipment are all arriving at breakneck speed and their cost can be exhorbitant. Tools for internal medicine, for example, were once limited to X-rays. However, with the arrival of ultrasound and MRIs and other diagnostic tools the costs have skyrocketed. That factor was never really anticipated and it has driven the cost of healthcare dramatically upwards. Were Canada’s health system to avail itself of the very latest in this, that and the other thing ( and this is what the public is demanding ), it would go bankrupt in very short order.
Yes stingy financing is a major, MAJOR factor, but other things, many of which are ‘hidden,’ come into play as well.
People aren’t great at risk evaluation. I think you’ll find that Americans, who must pay their own health care costs are NOT any better, and are in fact WORSE, about preventative care (in part because preventative care is also out of pocket, and paying for vaccines and tests ‘feels’ less necessary than paying for more expensive care once one becomes sick.
I hear this all the time, but it doesn’t follow. I have had occasion to do some various cost-benefit comparisons on public vs private projects. The public almost always came out cheaper, and in many cases, there was either no difference in quality, or frequently the public had the better quality. In one project in which I was involved, doing it with public employees would cost less total than the extra we were paying the private to do it for us (their profit, in short). This was interesting, because when it was done by a public employee, that person had to drive a long distance and stay overnight, all at per diem costs. Figuring the cost of travel, the overnight stay, and the per diem, it was still cheaper to do it with the public employee, and the lab being used was a far better lab than the one the private operators were going to use.
There are several reasons for why it costs less. First, public employees typically make somewhat less than private employees in a similar position (the discrepancy seems to be the biggest in the professional classes, since minimum wage is minimum wage). Also, the government can purchase supplies tax free, and often get a better deal on the supplies (well, Pentagon does not apply – the rest of us are stringently accountable in many cases, and don’t have the funds to waste anyway). The government can do the project for cost, without needing to make a profit. When we turn things over to private companies, the profit is essential. (If they don’t make a profit, they won’t be able to stay in business).
In addition, while there are high-profile cases of government foul-ups (FEMA and “Brownie” come to mind), most of what the government does they do well. The way you can be sure they are doing it well is that you don’t even realize they are doing it. It isn’t on the TV with horror stories, it goes along (mostly) smoothly and you might notice a bit of inconvenience if the road is torn up longer than planned, but overall, things run pretty smoothly in government land. Most people have very little idea how much the government does for them, and how well they do it, and for how little money compared to what it would cost if we did it through private corporations and just paid for it out of all that money we would get to keep if there were no taxes.
In the end, there is not a single project I did a budget sheet on that ever came out cheaper to do it private. I haven’t evaluated health care, but the fact that the amount spent in the US per person is so much higher than in England or other countries with national health care plans suggests to me that the boogeyman of cost might be a bit…overhyped.
It seems to be a strange (and possibly convenient) article of faith that the private sector is cheaper while centrally funded public services are bloated and inefficient. It’s not my experience at all.
My partner, who is a Lecturer in Paediatric Nursing at Birmingham University, has pointed out to me that many of the contracts for running bits of the NHS that are being handed out are already going to “Cameron’s Cronies”. Most of “New Labour”, who are in practice indistinguishable from the Tories, would handle things in exactly the same way and regard the NHS funding as a potential cash cow in the same way. That’s because they are the same class of youngish, rich, white dude professional politicians.
Jeremy Corbyn could change things (for US readers not familiar with Brit politics, think of him as our Bernie Sanders). Unfortunately he’s likely to be assassinated by his own party before he gets anywhere near power. He’s pretty much our only hope.
I don’t know how much each US citizen pays, on average, for their health care and I know that you have a much higher standard of comfort and attractiveness in your hospitals and clinic whereas much of the NHS infrastructure is old or pretty ugly. I also know that if you see a health care professional you can negotiate a time suitable for you rather than being handed an appointment that slots you in anywhere there’s a vacancy. I do know that it’s higher than what our government pays per capita based on our varying tax contributions. For that we get medicines free, except for in England where we pay a nominal “prescription charge” (£8.20 or about $11.90 per item). And most prescriptions are free. You don’t pay the charge if you have any kind of chronic illness. (except asthma for some reason).
For that, any UK citizen gets whatever healthcare they need, free at the point of access. Multiple chemotherapy treatments? Yep. Four triple bypass operations at five year intervals? Yes. A bed because you’re a homeless alcoholic who drank a bottle of meths? Absolutely. And then we’ll do our best to get you into some kind of addiction treatment regime and at least discharge you a bed in a shelter, even if you don’t stay there. Pregnant fourteen year who has been too scared to tell her parents? Yes, you’re covered by their tax contributions, even if right now they want nothing to do with you. We’ll sort you out, get you some counselling and find you a programme that will look after you. That’ll most likely be run by the NHS too.
Illegal immigrant without UK citizenship? yes, of course we’ll treat you. You’ll get exactly the same care as our own citizens The only difference is (and the right wing press always miss this bit out) we have people who will claim the costs back from your government – who usually then take steps to claim the money back from your family.
The areas where UK welfare can be fairly criticised is – amazingly enough – in those areas which have been turned over to private companies. Like the utterly disgraceful situation with financial support for the disabled and chronically ill. You only have to look at that debacle to see where the NHS is heading if we can’t stop it.