Thursday 20 August 2009

How healthy is your healthcare?

Max the Cat has been to Michelle the vet this week for an eye ulcer — cost £45 (drugs), & £45 for 3 consultations. But why use the same system as a basis for Human healthcare? There’s been all kinds of blogosphere buzz around the US healthcare debate, some of it comparing our own National Health Service.

Like any system it has its ups and downs, its challenges and pitfalls. Amongst its personal ups as I have experienced them over 54 years are Dr MacArthur, our GP when I was 12. He was an old fashioned Scots socialist who refused to take private patients, and got me a hospital bed in 10 minutes at a weekend because I needed it. He saved my life, and would have been insulted to be offered money over and above his pay for doing such a thing.

Stephanie’s birth as an undiagnosed extended breach in a strange hospital (she arrived early and unexpected on Christmas night) was supervised by one of the finest obstetricians in the world, who gave Lucy the choice, then delivered her faultlessly without a C-Section, using an old midwives’ routine called the Burns-Marshall technique. Both these ace bits of effective medical care were delivered with nary a credit card or insurance policy between them, and I would take a lot of persuading that the kind of medical system we use for Max the Cat would have served us any better.

But if you’re comparing healthcare systems across whole populations, the big statistics are the place to begin. Make no mistake, a system which allows people to die earlier and risks more children’s lives, across a whole population is not as effective as one that delivers higher life expectancy and low child mortality. Efficient use of people’s resources is a bonus, given the inherent and spiralling costs of modern healthcare.

So here are the figures, and the comparisons for the UK, France, Singapore and the USA.
No system is free of glitches, failures and compromises, Every system is challenged by spiralling costs, but what works best is surely an empirical, rather than ideological question. It’s unfortunate that the US faces tough basc choices about healthcare at a time politics has been so snarky and partisan. The basic systems of medicaid and medicare was put together at a time there was a higher level of bipartisan respect and public service ethic. All good systems involve public and private elements, but the clever bit is in how they are belnded for the good of all. With any luck something can be done — why should US babies suffer three times the mortality rates of their counterparts in Singapore?


Anonymous said...

1. US expenditure on healthcare is x2 the UK's because:
a. Americans are wealthier and spend more on their health (and vanity - but the UK is catching up). They also spend more than anybody else in developing new drugs and therapies. American health science is the best in the world, partly because the best scientists in the world end up in the US, lured by pay and conditions.
b. Trial lawyers, tort laws and ignorant juries award massive damages, driving up the cost of insurance, which in turn means many pointless and expensive CYA tests etc. Have you any idea how much malpractice insurance fro the ordinary physician is?
c. Anti-competitive laws restrict out of state insurance purchase.
d. Healthcare has been unhealthily linked to employment packages, instead of an individual's health account.
2. Singapore is a highly educated, strictly controlled city-state of c. 4 millions, not a continent of 305 millions. You need to compare like with like.
3. Infant mortality in the US is highest among the families of illegal immigrants and amongst blacks (70% born out of wedlock). By the same token, the main cause of death among young US blacks is gun and knife violence, associated with drugs and gang culture. Of course these things have to change, but you're talking about transforming a culture, not just healthcare provision.
Macro statistics like life expectancy don't tell you much, because once you make it into adulthood, life expectancy is pretty much the same from Kosovo to Kansas. The question here is, who has a happier old age?
4. The agenda driving this is political rather than altruistic. It's about expanding government at the most fundamental level. That is why there is a breakneck rush to bring in changes.

Anonymous said...

lucky Stephanie!
Our child was born at a provincial
and now has epilepsy and Cerebral Palsy the consulatnt could be botherd to come in and that decsion cost our son his (normal life) and the nhs 4.5 million pounds
consequently we have seen a lot more of the NHS than most people.
it is staffed by some fantastic people,despite some appalling managers, but if any one suggests it is better than it once was I think they havent seen much of it ,and if anyone thinks its the best system -they are simply wrong
All the best

Anonymous said...

Further details on infant mortality and life expectancy, and arguments that differences have a lot to do with lifestyle choices and differences in what data means.

Bishop Alan Wilson said...

Thanks for views all round. I sometimes wish people would use their names, to help disambiguate if nothing else, but here goes:

Anon 1: I get your point, and also recognise a certain extent to which the UK is becoming more litigious and catching up. I am sure high crime areas have bad health stats, too, anywhere in the world. The wider the social gulf, the more the health divide. Doing anything in any society in the world is political. That's what politics is. I suppose the two questions for those opposed to reform in the US are around doing something for people who are insured but nor as well covered long term as they had hoped, particularly those on more modest insurance schemes, and curbing the litigious tendency to which you draw attention, given its tendency to shovel ealth money towards lawyers and insurance companies. If all attempts to provide a comprehensive system were suddenly off, I wonder how these two sensible aims could be achieved.

Anon 2, Lucky Stephanie, indeed. I am so sorry to hear of your Son. I agree with your assessment of the difference between dedication in front end staff and poor management. I have never understood, for example, how or why nurses are rostered as they are in most hospitals. I'm not sggesting it is better than ever — I don't actually believe that. The issue for me about the NHS is how to set staff freer to do their jobs better in a mixture of dirigiste and internal market models. Like any healthcare system, the consequences of things going wrong can be terrible.

Anon 3, Thanks for sharing your argument and supporting blog ref. It all sounds to me like a rerun of historic UK "Fecklesss Poor" arguments some have gone in for since Tudor times. Blaming the punters, however justifiably, has certainly fuelled complacency and ignorance over here for a very long time. The fact is we have greatly enhanced lives over the past century by not forcing people to live in Victorian poorhouses because we thought they deserved it...

Erika Baker said...

I'm always slighty bemused that the debate seems to revolve around a Britain vs US model of healthcare.
Is it because you share the same language and therefore find it easier to understand each other's systems?
Neither country is in the top 5 health providers in the world, although Britain is much higher up than the US, but we also know that we are at financial breaking point.

Wouldn't it be a good idea for both countries to look at those higher up the list models that appear to be able to deliver quality at reasonable costs, instead of trying to score points against each other?

Bishop Alan Wilson said...

Thanks, Huw, for a blast of cool conceptual thinking this issue through in terms of positive foundational American values, here ( ). Really helpful.

Anonymous said...

#4: For all its merits, the state-run NHS in the UK doesn't guarantee equality of treatment (or non-treatment).
- if you live in Glasgow, your life expectancy and state of health are probably much poorer than those in the south of England.
If you live near a specialist teaching hospital, your chances are better than those in the sticks.
- cancer survival rates in the UK are much poorer than those in the US.
- no US hospitals have (to my knowledge) developed massive MRSA rates. They would be closed down if they did. Contrast the death rates in Staffordshire hospitals.
- I don't think *anybody in the US is "against" 'healthcare reform'; it's Obama's state centralization plans which are not trusted.
- 'feckless poor' or not (and today's poor are pretty wealthy compared to their Victorian counterparts), it's obvious that 'lifestyle choices' (smoking, drinking, overeating, dental care, wrong eating, drug taking, sexual behavior, [lack of] exercise, sleep, ways of dealing with stress etc) are hugely signifcant in our state of health for most of our lives (most medical expenses are incurred in the first and last few years of life). These are more educational rather than medical matters.

Bishop Alan Wilson said...

Anon, the NHS is surely not perfect, and does not guarantee perfect equality — just a significantly higher degree of equality than the US, but substantially lower than, say, in most Nordic systems. And, you're quite right, one of the things it suffers from is so-called "postcode lotteries." Many of the anomalies that have developed within the system, however, have resulted directly from attempts (sometimes on right wing ideological grounds) since the eighties to introduce elements of privatisation into the system, for example, by making it possible for trusts to "economise" on cleaning.

Which brings me on to resoundingly agreeing with you, Erika. I think you're right. We should be aspiring for the best standards of care in the world, not contenting ourselves with US or UK mediocre. There could be some debate about what output criteria described the highest standards of care, but I think in general we all know the basics of what's involved.

I think I come back to the reflection that historically the most effective US total provision plans have tended to be made out of bipartisan public spirit, not ideological wrangling. I just don't get this whole idea, that I sometimes hear American friends seem to espouse, that the government is, in itself, some kind of sinister Communist conspiracy to make people live longer. If you don't like your government, why not go out and vote for another one? Some of us thought that's what you all did last November. Bashing out the details of how they do what they were elected to do is, of course, a matter for political process. But permanent stalemate about basc decent public services serves nobody, I would have thought.

Steve Hayes said...

Bishop Alan,

I share your empirical experience. Our daughter was born at a small provincial hospital, and our cat had kittens at about the same time. Because the cat had had previous obstetrical problems we took her to the vet, and the kittens cost us four times as much as our daughter did.

General healthcare has deteriorated somewhat since then, largely due to the Thatcherist ideology. I'm not all that well-versed in the empirical side, apart from my own experience, but among people in the US I find the ideology quite repulsive. I found, on a reputed Christian blog, the statement "Universal healthcare is theft", with nary a blush. Clearly with that ideology, Lazarus is the villain and the rich man the hero of the gospel parable. I blogged about it here: Health, disease, theology and politics � Khanya

Bishop Alan Wilson said...

I fear you're right, Steve, about the resuts of eighties business thinking in the NHS. Number of administrators has balooned since partial privatisation 1980-2000. Standards of care for staff at work are not what they should be. Thanks so much for the blogref, to which two hearty thumbs up, in every way!

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