(Click on pictrure to enlarge)"12 months to save the NHS" was the election slogan used by Tony Blair. When Labor took over the running of the NHS in 1997 there was undoubtedly a problem. Doctors had been complaining for years about underfunding, but all their complaints had done was to trigger yet another reorganization. Make the pips squeak, said Tory Chancellor, Kenneth Clarke. It was felt that by increasing efficiency more could be obtained from the same amount of investment.
In fact, the NHS was very efficient indeed. The graphs demonstrate that health spending in the UK lagged far beyond similar spending in Europe and North America, yet the quality of care was not that different. At its best the NHS was the equal of any health care provider, and if you were acutely ill it pulled out all the stops. The major problem was waiting. You could get everything for free, but you had to wait for it. At one time a hip replacement meant a 5 year wait. A prostate operation might mean an indefinite wait unless the whole thing seized up, in which case you would be in as an emergency and operated on the next day. In 1997 there were over a million people waiting for operations. Of course as my son has pointed out, it's not how many who are waiting that matters but how long they wait. Ten million waiting for two weeks is not a problem; 100,000 waiting for ten years is. Nevertheless, a million waiting for operations is a powerful political slogan and the government targeted this. A lot more money went into health care, but if you pay a lot more you will need to make sure that the money is well spent. Hence a massive increase in bureaucracy.
What started out as an attempt to remedy a political slogan ended up a bureaucratic nightmare and more and more targets accrued. It's not just the total wait that matters, but how long you wait in the ER to get seen, how long for an outpatient appointment, how long an ambulance takes to get to the scene of an accident. And cancer patients are a special case; they need to be sen quicker than someone with a hernia. So the targets multiply.
With more targets there is a diversion of resources from providing good health care to meeting targets. As in Education they teach to the exam rather than educate the child, so in medicine they respond to the target rather than the patient. Thus we see cancer specialists who must see a new patient with cancer within two weeks of a referral complaining that their clinics are full of patients with benign breast lumps (which might remotely be cancer) and patients with more serious non-cancer diagnoses being delayed.
Those who run services spend time gaming the system rather than improving the service. If patients in the ER must be admitted within 4 hours of being seen, it's quite simple, you rename a trolley a 'bed', and call a corridor a 'ward'. If an ambulance must be on the scene within eight minutes of receiving a call then you re-designate the time that the call was received to eight minutes before the ambulance arrives. The polite term is 'gaming'; the less polite is 'lying'.
In the days of the USSR nail factories had targets to produce a certain number of nails; they responded by producing millions of very small nails. When the target was changed to a certain weight of nails they responded by producing one very large nail. This analysis sees the problem as central direction. One solution sees the answer as introducing more competition. Let the market take care of the problem. The difficulty with this solution is that a free market depends on certain providers going out of business. Imagine no hospitals in Philadelphia; all the business has gone to Wilmington because the taxation scheme there is more favorable.
Then there is 'post-code prescribing'. Yesterday I emphasized the importance to our Lords and Masters of Equality. Despite all claims to the contrary, people are not equal. Some are more beautiful, some are more intelligent, some are richer, some are more athletic, some are fatter, some are predisposed to sickle cell disease, some to diabetes, some to certain types of cancer. Whatever health system is established, some will do better out of it than others. If you live in Bournemouth you will live longer than if you live in Middlesborough. Why? 1] You are likely to be richer. 2] You are likely to have had a less strenuous job. 3] You are less likely to have come into contact with toxic chemicals. 4]You are less likely to be a smoker 5] You are likely to drink less 6]You are likely to be in a higher social class. 7] You are likely to have a better doctor. (Doctors like to live in nice parts of the country too, so there is competition for jobs here. You have to be a saint or an immigrant or to have been born there to want to practise in Middlesborough.)
Allocation of funds for health care might be thought simple. Just divide the available money according to the number of people living there. But old people are much more likely to get ill, so there needs to be an age weighting. One in three living in Bournemouth is over 60 while it is one in six in the rest of the country. But then other factors are relevant. Some ethnic communities have a greater need - sickle cell disease and thalassemia. Poor people use the health service more. Do you compensate for that by putting in more health care money or deal with the social factors separately?
I have mentioned all these drawbacks, not because I think that the NHS is a bad thing, quite the reverse. But Sicko makes it sound like paradise, which it is not. Don't think that the ills of the American health care system can be remedied just by changing to a single purchaser or (heaven forefend) asking for advice from Fidel Castro. Every country is going to have difficulties providing health care for its citizens and there are problems and solutions that are common to all.
Tony Blair has put billions more into the NHS yet funding still lagsfar behaind that of other countries. Tomorrow I will discuss why health care keeps costing more.
20 comments:
As a writer for the New York Times (whose name escapes me) has pointed out, what is more important to spend money on but health?
The US spends more on health care than anyone else in the world.
So?
I don't hear anyone here urging for worse care. Are more tests than necessary being run? Perhaps, but ruling out disease is as important as ruling it in.
I've had an exercise treadmill stress test for chest pain upon exertion. Turned out negative. Useless test? Not for my peace of mind.
Modern medicine is expensive, bottom line.
If and when we can cure cancer and other serious diseases (diabetes) the increase in productivity will more than offset the cost in finding those cures and administering them.
And costs should not escalate when the end is near. People who die of 'old age' usually have a brief illness and then pass away. One of my relatives did just that at 94.
We are never going to be a society where people are kept alive only on machines. People don't want that for themselves.
Consider the high cost now as an investment. There is much more right with the American system than is wrong.
There is a lot of truth in what you say, but despite the American government (leaving aside what is spent by insurance schemes) spending a greater proportion of the GDP on health than teh British government, life expectancy is greater in the UK. from that statistic I suspect that the money is not spent effciently.
The lack of Healthcare for all in USA is a disgrace. USA is the last Super Power, it is perhaps the most progressive country in the world. One of the main tenets that USA measures other countries by, is how they perform in Human Rights.
It is my belief that any civilized country should provide healthcare for all it’s citizens, because healthcare is a human right.
I believe that the size of USA and the diversity of its administration infrastructure, inhibits the introduction of universal healthcare, compounded by the gridlock of the two party system.
I also believe that in the past, there must have been a countrywide brainwashing against Socialized Medicine. In my view that is what Medicare is. The only thing I find wrong with it, it kicks in when one becomes a Senior. In Europe, Healthcare is free from 0 to18 yoa and from 65 yoa onwards. One pays for Healthcare during ones working life.
If I am not mistaken, the poster above is British. For him to be disparaging the US system is a disgrace, IMO.
One must read the life expectancy numbers with a grain of salt.
These data are misleading because different countries measure mortality differently.
For example, in Japan live births are defined as newborns who are
able to breathe. In the US, live births are more broadly defined,
and include newborns who may not be breathing, but have a heartbeat
or are moving. Obviously, babies who are not breathing have a high
mortality rate. In Japan, those babies would have been designated
as stillborn, and not counted among those who are not successfully resuscitated.
Some countries do not report deaths in babies who are born weighing less than 500 grams (1 pound 2 ounces). The United States
aggressively attempts to keep these babies alive. This boosts
infant mortality rates, as most of these babies (sadly) later die.
The United States also have an extremely diverse population and a large rural, remote population. From Eskimos in Alaska to Navajo in the desert Southwest to the illegal immigrant Mexican, all of these are counted in the statistics.
Yet, healthcare obviously is not as readily available to a person living 50 miles from the nearest road, or to someone hiding from the Immigration and Naturalization Service.
In England, you don't have frozen tundra, vast, remote deserts, and villages accessible only by snowmobile. That's a fact, and a heart attack patient in Alaska isn't going to get as prompt of care as one in London.
Our obesity rate is also very high, though Europe is fast catching up. Fat people don't live as long as average weight persons.
Is this the fault of the healthcare system?
Liberals hate to see disparities in anything. Everything, healthcare, wages, IQ must be brought down to the lowest common denominator. That's just 'fair'.
Research is rewarded in the US more so in Europe. That's a fact. More drugs are developed here than in Europe, or in, say, China, in spite of equivalent or higher populations.
England's NHS has horror story after horror story after horror story. NICE won't approve a dozen cancer drugs because they are 'too expensive'. Could you get, say, CFAR as first-line (if at all) in England? Chlorambucil is more like it.
Just yesterday I read that there was a protest because NICE said patients in danger of going blind had to already be blind in one eye before they could have access to sight-saving drugs.
You in the UK can save your healthcare pennies. We in the US value sight, and life, more highly.
"Restricting sight-saving drugs to patients who have already gone blind in one eye is "unacceptable", say experts.
An editorial in the independent medical journal Drug and Therapeutics Bulletin (DTB) condemned draft guidance from the National Institute for Health and Clinical Excellence..."
It hardly seems fair to disparage the comments of someone who has had experience of health care systems in two countries when you have only had experience of one. The idea that CFAR should be used front line in CLL when it has never been shown to have an advantage over any other treatment for CLL yet is certainly more toxic is not only bizarre, but reckless.
For an American criticism of American health care go to http://www.thehealthcareblog.com/the_health_care_blog/2007/06/policy-the-dart.html#more
My comments are not to give answers but are simply impressions that feed my many questions and concerns about health care issues.
1) Seems like we are rapidly divided between the haves/have nots. I know many who have had to go without insurance.
2) As an HR person I see how rapidly employee/employer costs are rising.
3) As a CLL patient I see how much care I get and feel very blessed.
4) Last year I saw my sister fall between the cracks because of Medicare Part D. She had been pretty stable for decades, her anti-psychotic medicene was cut and she went into a full-blown psychotic episode. It shouldn't have happened...she suffered greatly (was hospitalized for at least six weeks). More to this story but it was HORRIBLE to see and painful. I wasn't sure we would ever get her back but we did.
5) I have seen one person without insurance go to England for a "Hernia Holiday" because it would be cheaper to go there even with airfare than to have the surgery locally. I find this bizarre.
Okay, now the idea of chemo holidays to England is sounding good (maybe coordinating with some of the fun people in the CLL community!)
I've never lived under Shiria law, but I know I wouldn't want to.
Actually I have had health care in a socialized medicine country, and it was just OK. The hospital was dirty. The physician barely spoke English.
Is the American healthcare system perfect? Are any human endeavors perfect? No, and no.
Thanks to the internet, I can read about the abuses of 'NICE' (a fun Orwellian touch of inverted language, as NICE is anything but...)
Here's a quote from Annals of Oncology (May 10):
"In the US we have found that the survival of cancer patients is
significantly related to the introduction of new oncology drugs.
From a European perspective, we have found differences in access
reflected in patient outcome in the five major western European
countries: France, Germany, Italy, Spain and the UK."
Of these five European countries, France had the highest five-year
survival rate for all cancers (apart from non-melanoma skin cancer):
71% for women and 53% for men. Spain had five-year survival rates of
64% and 50% respectively, in Germany it was 63% and 53%, in Italy
63% and 48%, and the UK had the lowest at 53% and 43% respectively.
The report also shows that in France, Spain, Germany and Italy 51-
52% of cancer patients were treated with drugs launched after 1985,
but only 40% of patients in the UK had access to these drugs."
The authors concluded, "The authors report that uptake of new cancer drugs is "low and slow"
in New Zealand, Poland, Czech Republic, South Africa and the UK."
Where there is unlimited demand for medical services that are 'free', but a limited supply, such as in England, the only solution is rationing.
There are horror story after horror story after horror story of the wait time for operations in socialized medicine countries.
My favorite is this statement (speaking of Canada):
"This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.")
I live in Sedgefield, the constituency of our late lamented PM, and just nine miles from Middlesbrough. (Which is spelled like I have spelled it, not how you spelled it. Not that thats important)
Just thought you should know.
I am a terribel speler.
OK make it Hull.
I have also visited an ER in America. The hospital was dirty and the physician barely spoke English. The wait was inordinate and the quality of care poor.
Just as comparisons between US and Japanese infant mortalities is flawed, so comparisons between cancer survival rates in different countries are also flawed. Often they are not measuring the same thing. There is little evidence that access to expensive cancer drugs affects overall survival. One very expensive drug used for bowel cancer improves median survival by 3 weeks. The difference is statistically significant, but is it of any value? It is perfectly reasonable for you to spend your money on that if you want to. What is less acceptable is for you to spend my money on it. That's why NICE is there. Nobody is denied any drug in the UK. Anyone can take out private insurance or use their own resources to pay for it, but all taxation-funded expeniture must be subject to public scrutiny. Army commanders might like a gold plated Jeep, but I won't pay for it out of my taxation. However, I would happily pay for vehicles with more protection against roadside bombs. NICE might get individual decisions wrong, but they can be challenged in the High Court - as their decision of Aracept is being challenged.
"As a writer for the New York Times (whose name escapes me) has pointed out, what is more important to spend money on but health?" As long as its your money spend away. If its my money I want chapter and verse.
The same argument really applies to insurance based systems since my abuse raises your premiums.
I'm glad you brought up the example of drugs which only give an median survival improvement of weeks or months.
The median includes non-responders, who are only treated with the drug because there is no way now to tell if a subpopulation will respond to the drug in greater numbers.
It is apparent that genetic differences mean that some patients will not respond, and others will respond, sometimes very, very well.
It is misleading to speak in these terms of 'median survival'.
If I put two twenty-year olds in a group, one healthy and one who has fallen off a cliff, the median survival for both may be thirty years. That doesn't mean both will die at 50. That means one will die in hours, the other at 80.
And beyond that, even a few months improvement in survival can mean much to the patient.
In clear cell renal cancer, the new drug Stutent gave a median time to disease progression of 11 months, compared with five months for those treated with IFN.
Over-all survival improvements are similar.
So let's say the new drug gave the average patient six more months of life.
Six months is a significant time for a dying patient, wouldn't you agree? This gives time for patients to mend fences, get affairs in order, see children, and so on.
And this is only the average patient. Some don't get as long of a survival span, but others get a much longer survival span. Some patients can live for years.
The point is that (1) average survival is significantly improved, and (2) some patients can now go years on these drugs.
Is this an improvement, or not?
Another way of looking at the cost-benefit is the Quality Adjusted Life Year. It is a commonly accepted figure of $50,000 per QALY. Many cancer drugs, even new ones, meet this definition.
I suppose you are willing to say 'no' to a patient who asks for these drugs. I'm not willing to do so.
Scott
You are getting your medians and averages confused. :)
I am well aware of the problems of median survivals. I am on record several years ago as arguing for 5-FU + Folinic acid for colon cancer despite there being no improvement in the median survival, based on the finding that there was a 30% tail who did much better than when untreated. In fact NICE approves cancer drugs that give one QALY costing $60,000. Sometimes they approve drugs that cost more depending on the circumstances - it is only a rough guide. For example they would be more likely to approve a drug that saves some lives rather than one that shortens the symptoms of a cold. Recently they have approved Velcade for myeloma, but only in those patients in whom it works. The drug company was happy to go along with this, knowing that patients who were resistant would have the drug stopped very early by their doctors. I have already heard of other companies preparing to strike similar deals. I agree that just looking at medians is a flaw in the system. What these studies show us is that some cancers have characteristics that make certain drugs unsuitable. CLL patients will know that p53 deletions make fludarabine, chlorambucil, cyclophosphamide and rituximab ineffective. Treating patients with these agents would produce toxicity without benefit. They need Campath or high dose steroids - or perhaps Revlimid or flavopiridol or an allograft. I think the story is a little more complicated than that but it serves as an example. Iressa works in a small proportion of lung cancer patients - Asian women who have never smoked. When you isolate groups of responders from non-responders even the most expensive drugs become cost-effective.
The situation in America is that if you are insured you can usually get anything that is FDA approved. If you are not there are various mechanisms by which you can get what you need - Medicare if you are over 65, Medicaid if you are poor, VA if you are a veteran, and for the desperate, ER rooms in county hospitals. In real life there are many drawbacks to the system. Your insurer may well limit what you are covered for, and will probably place restrictions on which specialist you can see. It is for Americans to decide which health care system they favor. Value for money is not a particular American concept - why else would they drive SUVs? However, the facts are clear - the American system of health care as it now is, is not good value for money. You could get more bangs per buck if you changed things. I see the foreign exchange markets price the pound at more than two dollars today. Were I an American I would worry about that.
I think the point about Value for money is the really important one here. There is a realisation that the level of expenditure on healthcare is unsustainable in the US, but the approaches taken to reducing expenditure are irrational and reflect the fragmented nature of the insurance system.
The two approaches are limiting the coverage of insurance by actually not providing access to drugs etc. This is why the idea that Americans can get access to any drug they want and Europeans can't is false. And it is not the uninsured who are unable to access but the insured who's insurance companies have worked out that the easiest way to be profitable is to deny some treatments. The trouble is that the insured aren't being told about this so are unable to act as rational consumers at the point of purchase, because they can't know how the product will meet their needs until these needs become apparent. Of course once these needs become apparent the cost of product that meets their needs (particularly if the are self-employed or otherwise in the individual insurance market) become prohibitive. This is Moore's thesis, and with the usual caveats about his emotional manipulation, false comparisons, and arguing from anecdote, he is broadly right.
The second approach is to shift costs directly onto the patient with higher co-pays, deductibles, and the genuinely appalling consumer directed health plans, all of which are leading to a situation where I think a genuine consumer revolt is likely.
Interestingly two easy suggestions that would alleviate some of these problems without creating a socialised system are impossible because of the fetishisation of the market in healthcare. First the massive bureaucratic costs could be reduced by investment in a common information system. No one will do this because the investment will benefit all, and provides no competitive advantage - but this would slash the bureaucratic costs associated with chasing the money around. Second, US pharma spends twice on marketing what it does on research (in excess of $70bn per annum - never mind the cost of using branded rather than generic drugs) - largely because of TV advertisement of drugs - every other country in the world bans this (apart from New Zealand - but New Zealand has a NICE with serious claws which minimises the effect). Anyone who has seen a Nexium advert knows this does nothing to create informed consumers, but the model of healthcare being a market like any other means that consumers must be informed...
There are several comments I would wish to make. I think I will post them separately.
Besides acquiring extensive experience of the UK NHS over the last eight years I have a modest knowledge of the German system.
The anonymous poster from the USA wrote about the NHS that it has horror story after horror story after horror story. He should be wary of what is reported in much of our press. Whenever people are polled about the NHS they report their view that it is falling apart but when users of the NHS are asked about their recent experiences it gets very high ratings! I will like to return the NHS in a later comment.
Germany is shown on Terry's graph as having the second highest level of health expenditure. It has a system of compulsory social insurance. My nephew is a doctor in Germany and he tells that traditionally there was an open ended supply of money. It was just added to the insurance bills. As a result there a splendid hospitals and a surplus of medical staff and my sister-in-law and her husband, who retired from modest jobs, pay £320 per month for their health insurance.
This system could not and did not last. My nephew tells me that if I need any kind of treatment I should go to his hospital and would get the treatment, no questions asked, as they are desperate for patients to justify remaining open.
What does this mean. Just that there is no obvious, or perhaps even unobvious best way of providing health care.
I would like to say something positive about NICE, the reviewing body for treatments in the UK.
Assuming that there is a finite supply of money for health services then how is this to be distributed? In an open market the answer that anyone with the money can get what they want. But how do you deal with those without the money?
If you have open system like the NHS and money is reasonably tightly controlled then how do you make the decisions?
NICE has the virtue that it is open. Anyone can go to their website and read how the decisions are made. The expert advice is published and the reasons behind the judgement are made explicit.
Any party to the judgement, such as patients' groups or drug companies can and do appeal against their decisions.
Of course you get horror stories in the media about worthy patients being deprived of life saving treatment. Whenever I see one of these stories I read all the evidence. And that seldom justifies the press stories. But the drug companies or their ally, a compliant patient group, are not intested in the evidence.
The horrors of the UK and other socialized systems are from the UK press, not the US press.
Here's an interesting article:
New Cancer Drugs Prove Their Worth
They may cost more, but they extend lives, improve quality of life, studies find
HealthDay
MONDAY, June 25 (HealthDay News) --
Two new analyses of two new breast cancer drugs found that they are indeed worth what you pay for them.
The aromatase inhibitor Aromasin (exemestane) and the monoclonal antibody Herceptin (trastuzumab) have already been proven in clinical trials to improve survival.
As new breast cancer drugs exit the pipeline and enter the market, the U.S. health-care system, including the insurance companies or governments paying for therapy, want to know if the drugs are economically, as well as clinically, viable. And new drugs are almost always more expensive compared to the usual standards.
"This is always important to do when you have a drug or a procedure or intervention that is expensive compared to standard care," said Nicole Mittmann, senior author of the Aromasin study, and a scientist with Sunnybrook Health Sciences Centre and assistant professor of pharmacology at the University of Toronto. "The clinical data still drives the decision to use the medication, and this is another piece of the puzzle in the decision-making process."
Dr. Jay Brooks, chairman of hematology/oncology with Ochsner Health System in Baton Rouge, La., said, "The clinical research trials we've done in the last 50 years have been spectacular, and we know how good or how not good our treatments are, and because of the excellent clinical research that's been done, we can then ask ourselves can we afford these treatments.
"These two studies involving Herceptin and Aromasin clearly show that doing these two maneuvers are very, very cost effective in certain subgroups of women with breast cancer. When insurance companies come to you and ask why are you doing this, you have excellent studies to back them up," he added.
As far as the marketing costs go, how are companies supposed to market their drugs? ESP?
I'm not exactly sure of your point here. NICE approved Herceptin for advanced breast cancer in 2002 and for early breast cancer in 2006. The provisos were that the cancer must be Her2 positive (it wouldn't work otherwise) and the woman should not have heart disease, because of the cardiac toxicity of herceptin (the same proviso applies to anthracyclines).
Aromatase inhibitors were also approved by NICE for early stage breast cancer in 2006.
I think that NICE takes too long in considering some drugs, but very few decisions have been wrong. One that I was involved with was changed between the interim recommendation and the final one, largely because of my evidence.
Big Pharma spends a lot more on advertizing than is strictly necessary. In particular, I believe direct to patient advertizing is dangerously misleading. I accept that they spend a lot on research, but they present a skewed view of this. The FDA criticized the companies for the fact that 75% of prescriptions for Rituximab were off-label. How did they manage this?
Incidentally, it is often forgatten that monoclonal antibody technology was develped in an MRC lab in Cambridge University, but Cesar Milstein declined to patent it, believing that it should be available freely for the whole world. Had he patented it, the Britisg government's investment in medical science would thereafter have been unnecessary.
On medians:
There was a comment here comparing medians and means.
Medians are a funny way of evaluating cancer endpoints.
A median is the halfway point of a range of datapoints.
If you have a series of survival in months of 1, 3, 4, 278, 288, the median is four months. Reading just the median survival of four months terribly ignores the two patients who had incredible survival spans!
The mean (average) survival span in this fictitious example would be 115 months (rounded). Quite a difference in appearance of outcome.
To be sure, most samples would be larger (but sometime not by much).
So, why median and not average? Most patients are not going to fall on a discrete point in a series.
There are three types of 'average'. The mean is the sum total divided by the number entries; The median is the middle entry and the mode is the commonest value. They all have their uses. Median is most frequently used for survival curves when it tells you the time when half are dead and half are still alive. It is not the be all and end all of survival curves, but it gives you a judgement of what is happening; far better to look at the survival curve itself.
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