How doctors strikes save lives...

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It's OK dear reader, I'm not getting all soft in my dotage, I still think that doctors - give the oaths they swear and the moral high ground they inhabit - shouldn't go on strike. But, slightly ironically, the strike may save a few lives:

Curiously enough, it has been shown that patient mortality typically falls during doctors' strikes, a finding replicating on a number of occasions across different nations. Cunningham et al's meta-analysis is the most notable recent review of this peculiar fact. In one of the most entertaining studies in the literature, the researchers interviewed the directors of major Israeli burial societies, who seemed slightly disgruntled at the loss of business associated with a major doctors' strike in 2000.

One, bemused, reported a 39% drop in funerals as compared to the same month in 1999. Another, much more confidently, was sure that his loss of custom was due to the striking doctors, because he had been in business long enough to see the exact same phenomenon occur in 1983, the last time Israeli doctors had walked out.

As they say - most peculiar. And it raises the question of whether it's all that expensive medicine stuff that's driving our longer, healthier and happier lives or something else.

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The case against modern public health

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Public health is not healthcare. It is the authoritarian encapsulation of a nebulous concept usually called "wellbeing". Public health assumes that we, as humans, seek wellbeing and that our understanding of the concept is the same as they have determined.

...it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Occasionally invoking the force of law (immunizations, seat belts), it prescribes and proscribes for both individual patients and the general citizenry of every age and stage. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.

Worse still this idea of 'preventive medicine' offers a further false prospectus by suggesting to the purseholders of health care systems that by embracing interventionist public health those systems will reduce their costs.

...the report also makes an economic argument for preventive care, highlighting the possibility of reducing healthcare spending -- which in 2011 reached $2.7 trillion, just shy of 18 percent of gross domestic product -- by billions of dollars. And that has health economists shaking their heads.

"Preventive care is more about the right thing to do" because it spares people the misery of illness, said economist Austin Frakt of Boston University. "But it's not plausible to think you can cut healthcare spending through preventive care. This is widely misunderstood."

As that quote indicates this argument is entirely false:

Despite the costs associated with the ageing population, it is sometimes claimed that people who are at risk of premature mortality due to lifestyle factors are a 'drain on the taxpayer'. Smokers, drinkers and the obese, in particular, are blamed for rising costs to the general taxpayer.

These claims do not stand up against evidence. If one looks at the lifetime costs to all public services, it is clear that the 'longevity-related' costs of healthier people are considerably higher than the 'lifestyle-related' costs of less healthy people. Acute healthcare costs are usually higher, long-term healthcare costs are invariably higher, and welfare costs (eg. pensions) are vastly higher.

And this, of course, assumes that the public health or preventative health measures are effective. The sad truth is that many of them - smoking cessation programmes being a good example - are expensive and largely ineffective. Local authorities are funding weight loss clinics - in direct competition with a huge private sector - when, again, the evidence of their effectiveness is pretty limited.

However the main objection to public health programmes isn't their cost or that they don't work, it is rather that their advocates seek to direct your choice - to urge you to eschew pleasure - in the expectation that you will see the benefits in a possibly longer, healthier life. Although the proponents of public health have laid claim to the idea of wellbeing, their approach to its promotion is to remove pleasure and happiness in order to impose an approved and safe form of wellbeing, a sort of dull, dreary '70s Sunday afternoon contentment.

Public health is an ideology of control not a healthcare programme. It dulls the senses of health management by suggesting their inevitable cost pressures will be relieved by patients embracing an approved lifestyle that eliminates the risks contributing to the growing number of people living with chronic conditions like type-2 diabetes. Above all public health represents a crusade to promote a moral and righteous life to the populace - don't smoke, don't drink, don't stay up late, do the right amount of exercise, eat the right diet, avoid salt and sugar. This lifestyle is promoted through the use of public funds to appeal, on one hand, to our fear of mortality through talk of cancer, heart attacks and dementia, while simultaneously suggesting that beautiful, successful people adhere to this stultifying, dull set of consumption behaviours. Across all this runs the argument that, if we want our children to be one or those beautiful, successful people - or even to live - then they mustn't be exposed to these sins of diet or pleasure.

It is hard to think of a section of government that so completely (and for its practitioners unconsciously) embraces the warnings about soft totalitarianism set out by Orwell and Huxley - and especially the latter with his observation that totalitarianism would be a matter of acceptance not something violently imposed by a powerful, all-seeing state. Restrictions on our lives - repeat the mantra of don't smoke, don't drink, eat the right food - are accepted because the experts with their evidence tell us that embracing these restrictions is the right thing. Just as as self-appointed stasi helped enforce the smoking ban, we will see similar as new fussbuckets arise to challenge those who drink openly, who eat sugary or salted foods.

The truth about public health spending is that nearly all of it is wasted, is money spent on promoting an ideology of control. No lives are saved by public health's actions. No money is saved for the wider health system by the interventions of public health. No-one's wellbeing is improve by public health. Indeed for many thousands the actions of these ideologues result in a worse life. Yet in my city of Bradford over £30 million is spend on public health programmes, money that could fix the roads, could provide care for the elderly, could smarten up parks. Instead we'll spend it on nannying the hell out of the population, on promoting an unpleasant controlling ideology founded on a myth of wellbeing that has no basis in fact or substantive value to the poor masses it is being imposed upon.

It's time to stop all this. There is no case for public health as practiced today.

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Whose NHS is it really?

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We hear it time and time again. Repeated almost ad nauseum.

"Save Our NHS"

"It's Our NHS"

"Protect Our NHS"

All this, in the ultimate marrying of popular culture and political sloganising results in a bunch of NHS employees forming a choir (helped by the chap off the BBC), releasing a sinlge and getting the Christmas Number One. Helped along the way by Justin Bieber and every second tearful person on social media.

On Christmas Day, five minutes before the Queen’s speech, a video displaying the best of our NHS was played on BBC1’s Top of the Pops. For better, for worse, for richer, for poorer, in sickness and in health, ran the messages on the screen as scenes of the NHS in action played out. It was a poignant moment for all who were involved in running the campaign - our song had got to No 1.

I'm really pleased for the people who were involved in this 'campaign'. It's always fantastic to see a project succeed, a message crack through the shell of public resistance, make a difference. But it got me thinking about 'Our NHS' and whether it sends out the right message. For sure we can show thousands of examples of how the brilliance of doctors, nurses and other medical folk, the smiling faces of families as their loved one pulls through, of mums delighted as their child's eyes open again, and of seemingly miraculous applications of medical technology to saves lives.

But is this really what "Our NHS" is about? Surely those same live saving, uplifting scenes are commonplace in every hospital everywhere? Aren't medical miracles performed by doctors and nurses in France, in Germany, in Spain - even in India? Places where "Our NHS" doesn't exist? And all these places - all these systems - are less than perfect, filled with error and mistake, lacking in resources and subject to failure? Just like the NHS.

The word 'our' implies possession - collective possession for sure but still possession. I wonder whether I - as a mere customer - can truly call the NHS mine. I do not control or influence its actions or activities beyond that moment when I put a cross in a box on a ballot paper every five years. I have no choice - there is only one NHS, that's it, like it or lump it. Decisions about when it's open or closed, about where it's located, about what services are available - these decisions are political decisions made (in theory if not in fact or reality) by those MPs we elect. We no more possess the NHS than possess the police force or the army. It is a huge, unaccountable bureaucracy directed by ministers and the officials they (sort of) employ. It really isn't ours yet the lie that this is the case is central to sustaining the NHS as Britain's sacred organisation.

Instead of talking about 'our' NHS, those doctors, nurses and so forth should be speaking of 'your' NHS. Where 'your' means the patient, the customers, the 'service user', the ordinary member of the public. If the NHS is to mean what these people claim it means then that is where the ownership should lie. But it doesn't and we are conned into believing that 'Our NHS' somehow means something - our heartstrings are tugged, the emotional buttons are pressed and, lo, the interests of those who really control this organisational behemoth are duly served. All those people who, sparkly-eyed, extol the virtues of 'Our NHS' are patsies for the nearly millionaire consultants, the trust bosses with their jaguars and barn conversions, and the 'system leaders' whose every act is to resist any change to an organisation that, for all the efforts of front line staff, fails far too many people.

It's 'Their NHS' and we shouldn't forget it. The 'Our NHS' campaigns do not serve our interests.

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Thoughts on NHS finances - and why some doctors don't like privatisation

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I've felt for a long while that there is something of a problem with the distribution of money within 'Our NHS' (this is, I understand, the official and approved title of the august organisation). Some of this is down to the pseudo-market created and elaborated upon by governments since the 1980s - the idea that instead of people making choices in a free system we use a proxy of commissioning. But another problem is that the money flows to the producer of healthcare (primarily doctors and senior administrators) rather than to benefit the consumers of healthcare (patients and their families).

This isn't to say that doctors should be paid less. I'm sure, like me, you're pretty cool about the way in which the high status and high income associated with medicine attracts the very brightest young people. Not because they are especially caring or sharing but because medicine offers the best rewards.

So it's clear that becoming a doctor is, at least partly, driven by the prospect of that high status and high income. And, like you dear reader, I have no problem with this (any more than I have a problem with the best and brightest being incentivised to go into other important work by that same high status and high income offer) but it carries a risk where the level of that remuneration is under the control - wholly or partly - of the particular high status, high income group.

And this, quite simply, is the problem with putting doctors in charge of the NHS. It remains in this groups interest to maintain, indeed enhance, the status and income of the group. Again I'm not making doctors out to be ghastly mercenary exploiters merely suggesting that they will always behave as any group behaves - in their own interests. Much of the time this is not a problem - the high status, high income stuff means we get better doctors clearly something that us patients desire. But the problem comes when the choice is between specific care and the remuneration of doctors.

Over the past year I've sat on Bradford's Health and Wellbeing Board and have tried to get my head around the way in which the budgets for health operate. We read about different parts of the NHS system 'making a loss' or 'overspending' but never ask how this is so given the nature of the system. I recall having a conversation with a senior council officer about this problem. Essentially the pseudo-market requires 'commissioners' to guess how much of a given type of health care is going to be needed. Obviously, for elective care this can be rationed - once we've used up the 100 knee operations the next patient has to wait until the next period for his op.

For non-elective healthcare the problem is that the commissioner has to contract for enough geriatric care, cancer treatment and emergency heart operations to meet the actual need. And this mean commissioning more rather than less. So every time - up to the number commissioned - a patient arrives at the hospital there's a big 'kerching' sound. The problem comes when the commissioners guess is wrong - either too many or too few patients access the service. If too many the commissioning body (currently 'clinical commissioning groups') has an overspend and if too few the hospital makes a loss because it has set on doctors, nurses, beds and so forth to meet the commissioner's guess.

If you're a doctor in a hospital - typically these days a Foundation Trust - then you want the hospital to do more very predictable and controllable elective surgery so as to protect from the financial unpredictability of emergency medicine. But if you're a doctor in general practice you want more of those knee operations and hip replacements for the money you've got to spend on them. And using general hospitals for this work therefore makes less sense - far better to pay efficient specialist (often private) organisations to do the elective surgery. You may call this 'privatisation' but it is clearly intended under the pseudo-market that more of this commissioning will be used - good news for patients wanting hip replacements, great news for the surgeons who do those hip operations and pretty good news for GP-led commissioning groups.

But if you're an oncologist working in a general hospital (or for that matter a doctor in accident and emergency) this 'privatisation' is bad news because it means less money coming into your hospital but little or no change in the numbers of patients. To add insult to injury those surgeons doing the elective surgery are earning fatter wages for doing (however efficiently) a repeated and routine operation. The hospital doctor (assuming he doesn't have a lucrative private practice) looks at the world, sees his peers getting fatter pay packets for a nine-to-five job in the private sector and wonders what he did wrong.

The responses to this disgruntlement vary. Some doctors swallow their pride and switch to the private sector, others focus on specialisation in the anticipation of building a private practice and a third lot get all political and oppose 'privatisation'. Even though the evidence seems to suggest that we get slightly better health outcomes from a mixed economy in healthcare. And it is absolutely in the interests of those hospital doctors to oppose privatisation because under the pseudo-market the big bucks are rewarding efficiency rather than skills or expertise. Because the private sector saves the commissioners money, the owners of those businesses are prepared to pay lots of money to doctors (and other health professionals) who can allow them to remove more cataracts, do more hernia operations and fix more knees.

All of which brings us back to those incentives. If we're right and the high status, high income thing matters then perhaps we should worry about a system that rewards doctors performing routine operations efficiently rather than doctors who manage more complicated care such as treating cancers. But the answer here isn't necessarily to simply oppose 'privatisation' but to create a market in those skills needed to provide complex surgery and multi-faceted care.

Much of our debate about healthcare is useless. Instead of asking how we will meet the demand created by an ageing population while continuing to innovate what we do is shout pathetic slogans at each other and make gushing pledges of loyalty to 'Our NHS'. It seems to me that the current financial system within the NHS privileges some doctors but not others and similarly rewards cost efficiency in medicine better than it does innovation and skill.

Currently about 80% of the NHS budget is spent in the acute sector - mostly by general hospitals and mostly on paying the staff of those hospitals. The problem is that the people spending this money (by doing whatever medical thing it is they do) in the hospitals have little say over how it is distributed with the result that there are places filled with sexy medical gizmos and gadgets while other places are making do with old - even jerry built - equipment and too few staff.

I'll be honest here and say that I don't know the answer. However, I also feel - with some good evidential support - that further liberalisation and a slightly less pseudo pseudo-market remains the right way to go. Not because I want to 'sell off the NHS to the highest bidder' but because we need to find a better way than central planning to manage the flow of money through the health system. I also feel that the commissioning of places rather than people sits right at the heart of the problem - we buy services from a big Foundation Trust not from a doctor or group of doctors. Yet it's the doctors' expertise that is central to the health care us patients demand.

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Some thoughts on a £364m question.

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The front page of Bradford's Telegraph & Argus was splashed with the terrible truth about health spending - a £364m 'spending gap':

Bradford’s health and social care services face a funding shortfall of a staggering £364 million over the next five years, health bosses have warned.

And one health board member has said the district faces some “really hard” decisions, including possible hospital restructures, as it tries to balance the books. 

Now that 'one health board member' was me - pointing out that something should be done now to address the problem. Indeed the longer we leave the hard decisions the more painful those decisions and the greater the prospect (as neighbouring Calderdale is discovering) of those decisions being imposed rather than agreed locally.

The instinct of observers is to start talking about 'austerity' or 'cuts' and to calling down opprobrium on the evil government for not protecting health services. And this instinct is wrong - however much Labour may pretend with their jobs tax to fund the NHS. The problem isn't maintaining levels of funding but increasing demand for health services. An increasing demand driven by two factors - the wonderful truth that we're all living longer (around three-quarters of NHS spending is on the over-65s) and the equally wonderful fact that clever scientists, doctors and surgeons are discovering ever more creative ways to improve medicine.

In the article where I'm quoted the issues raised are whether we need to review hospital provision in the District (we have three general hospitals) and whether there is the need for reform in primary care (there are still a lot of single-handed GP practices especially in the inner-city). But there are some other issues to explore including the application of technology to reduce the cost of healthcare - this could be telemedicine such as that pioneered at Airedale Hospital in partnership with the Prison Service. In the emerging model remote consultation removes the cost of transporting patients to hospitals for consultation and can be extended to supporting nursing homes and even the management of treatment for people in remote locations (Airedale's catchment includes the Yorkshire Dales).

We also need to consider that the funding gap in question is not a cut but rather an estimation of the shortfall in cash resource if nothing changes - there is no prospect of the roughly £1.2bn spent currently on health in Bradford getting smaller. Indeed the £364m estimated shortfall assumes that this figure will rise. This means that we need to find ways to increase productivity - getting more treatments than we currently get from a given budget, for example. This again makes for tough choices - for routine elective surgery do you commission private sector provision? And do you continue to improve the speed at which patients are released from very expensive hospital beds?

The other aspect of this productivity lies with self-care - or rather people being healthy enough not to need expensive medical support. Most of the population do not place much burden on health services (and, despite what the nannying fussbuckets say, this includes most smokers, drinkers and consumers of hamburgers). It is only as we age that this burden increases. If the age at which we become regulars at the doctor's surgery rose then this would represent a significant improvement (even though the long-term cost is unchanged as we will live longer).

We also need to direct investment towards things that really will reduce the health bill - chiefly by reducing or eliminating things that result in expensive hospital treatment. At present the public health budget is dominated by two things - treating people with drug and alcohol problems and running public health campaigns such as smoking cessation, weight management and alcohol awareness. We perhaps need to rethink some of this focus and to switch attention to environmental factors that contribute to those long hospital stays (typically by the elderly).

These factors where a sensible public health approach would concentrate would include:

• Reducing trips and falls especially in the home
• Programmes to reduce damp and cold conditions for the elderly
• Initiatives aimed at improving air quality in urban environments
• Actions to improve road safety

Alongside new technology, greater productivity and further private sector involvement, these sort of actions will help close the terrible spending gap - there may still be some tough decisions but we will have bought ourselves some time to make those decisions and implement them with care. I fear, however, that the producer interests dominating the health economy (most notably the medical profession itself) will act as a brake on many initiatives meaning we could end up closing hospitals, clinics and services rather than facing up to the challenges of improving the system's productivity.

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Merit, opportunity and the reduction of poverty in Bradford

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Yesterday I was at a 'development session' for Bradford's Health and Well-being Board and getting a bit irritated by the interminable mission creep (not to mention bucketloads of nannying fussbucketry). I appreciate that we have to 'tick everyone's box' in drawing up a five year strategy but there seems an almost wilful blindness to the big challenges facing Bradford's health economy. The first of these is a challenge everywhere - the rising cost of healthcare is outstripping society's ability to pay - but the second, while not unique to Bradford, is more specific. It is poverty.

And I say this in capital letters with flourishes and knobs on - the main reason for Bradford's poor health outcomes is poverty. It's not drinking. It's not smoking. It's not a big south Asian population. It's not obesity. It not illegal drug use. It's not road safety. It's not air quality. It is quite simply that being poor, always and everywhere, leads to a shorter and less healthy life.

Then I was corrected. Oh no, it's not poverty but something called "health inequality". Mostly, it seems because we have a strategy on combating "health inequality" but no strategy for reducing poverty. And this raises a very important issue by exposing again the conflation of poverty and inequality. With the result that we attend too much to enviously looking at how much richer, happier and healthier the residents of Burley-in-Wharfedale are compared with their counterparts in Barkerend.

What we should be doing is attending to the fact that people in Barkerend are poor not to the gap between their circumstances and the circumstances in Ilkley. But the conceit of the left (and of too many public services planners and managers) is the view that inequality and poverty are either inextricably linked or essentially the same thing. With the consequence that policy becomes about withdrawing from universal services in wealthy areas rather than the intelligent direction of resources to the alleviation of - with the end of eliminating - poverty.

This conceit - and its associated false dichotomy - is exemplified by this profile of Simon Willis who runs the Labour-supporting think tank, The Young Foundation:

"Let's say that we had a vigorous debate," he says. "The most important point Young made is that the opposite of inequality is not equality, it's fraternity … it's community and cooperation."

There we have our essential error about inequality. To say that the opposite of inequality is something other than equality is a deceit. It may be that fraternity, community and cooperation are more prevalent in a more equal society but it does not follow that equality leads to these things - nor do I see any supporting evidence. It also repeats the myth - a myth exposed time and time again only to be warmed over and reissued - that your riches are the cause of my poverty. But this time it is worse - Willis argues that the problem is 'meritocrats' because:

"They mistakenly think all their power and money and success is down to their own individual brilliance and hard work."

Again a familiar argument. Except that I've never met a successful person who didn't credit his or her success to a whole host of exogenous factors - from schools and parents through great colleagues to sheer good fortune.  Moreover we should consider what the alternative to meritocracy might be - presumably this is the 'fraternity' Willis alludes to as the opposite of equality. But isn't that a pretty stagnant society, a sort of land of 'meh'.

So I return to my earlier point. It is poverty that should challenge us not inequality. In the short-term part of the response to poverty is redistribution but over a longer period we need to alter the opportunities available to poor people, to allow them to play the meritocratic game along with everyone else. And these solutions are educational and economic - put bluntly better schools and better jobs. To say, as Willis is saying, that meritocracy is a problem is to deny the poor opportunity. Or rather to replace the chance to be independent, self-reliant and achieving with a sort of commune-like fraternal society.

This is just the intelligent articulation of the problem with community development - the idea that we can 'work with' communities from outside and that growing vegetables on roundabouts is somehow a substitute for education, skills and jobs. This is the world of the cuddly left where hugging the poor and saying 'there, there' is seen as a satisfactory response to the fact that they failed at school and haven't got a job. Or worse still giving them a hug and saying their problems are all the fault of those rich people in Ilkley (or bankers, or big business).

So back to Bradford and its health challenges. To make a difference we have to do a couple of things well - target interventions where they work best and recognise that improving the economic lot of people in Holme Wood or Barkerend is the best way to improve their health. For the targeting it's not about nannying because we know nannying doesn't work. Instead it's about real improvements - warmer homes, fewer chances to trip and fall, more pedestrianised areas, support for self-employment, training in today's skills and better outcomes at school. But this wouldn't suit The Young Foundation because what we're saying to those people is that they have skill, talent - genius even - and that we're going to release it, to allow them to achieve. Not from entitlement but from merit.

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Pregnant mums, you've every right to drink in moderation

In an especially nannying article, Emma Barnett, "Women's Editor" of the Daily Telegraph (do they have a "Men's Editor"?) has a go at pregnant women who have the occasional drink:

I am no fan of judgement. I think people are, by and large, a law unto themselves. Last month, however, I was at a dinner party in a painfully cool (both in temperature and temperament) East London warehouse when I noticed a friend’s eight-months-pregnant wife happily knocking back a bottle of beer. “Don’t stare Emma,” hissed my husband. “It’s just the one.” I silently scolded my horrible self. He was right. But then this successful lawyer moved onto the Pinot Grigio. Two great goblets of the stuff. And I found myself in full judgement mode.

Our writer transformed from a gentle, non-judgemental luvvie to a judgemental nanny in one short paragraph. She wheels out some doctor's estimation of the impact of drinking complete with the obligatory scary number:

Last week doctors revealed that up to 7,000 babies a year in Britain are showing signs of developmental damage because their mothers drank during pregnancy. 

In 2012 there were 729,673 live births in the UK so, even at the upper end of Emma's unreferenced estimate, that's less than 1% of total births. Emma then goes on to quote some doctor pal who suggests having a glass of wine is worse than smoking! This doesn't seem to me, however much we should be concerned about those 'up to 7,000' children, that drinking in pregnancy is a major problem.

So what the evidence? The answer is best given as mixed. Some studies show a small negative impact of moderate drinking on birthweight but the most substantial studies really show no significant negative impact of moderate drinking:

The bottom line, according to study co-author John Mcleod, is that "[there's] certainly no evidence that moderate alcohol use by pregnant mums is good for their kids, and [there are] reasons to be cautious about other messages around 'benefits' of moderate alcohol use by pregnant mums. But equally, [there's] no strong evidence for important harmful effects."

So a sort of researcher 'meh' there - probably best not to drink but if you have the odd glass or two during pregnancy it's probably not having any harmful effect on the baby.

More recently a significant study challenges the prior consensus on alcohol affecting birth weight. This is a multi-national study involving 5,628 women who were pregnant for the first time between 2004 and 2011and it concluded that:

Rates of premature birth, babies with low birth weight or small size, and preeclampsia—a potentially life-threatening condition in which a pregnant woman develops high blood pressure—were similar across the alcohol consumption categories

The studies quoted above looked at child development after birth whereas this study only looks at the situation at birth. Again there appear to be few if any negative effects from moderate alcohol consumption during pregnancy.

It seems to me that the proper advice is exactly the advice given to mums now - go easy but if you're out don't feel that you can't have a glass of wine.

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"We find that the effect of competition is to save lives without raising costs."

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But the NHS! Competition is evil, etc. etc. ad nauseum. Mostly from those whose comfortable positions might be affected by a bit of honest. Or maybe these are the sort of academics who - because their conclusions challenge the current anti-competition orthodoxy - are not to be believed:

The effect of competition on the quality of health care remains a contested issue. Most empirical estimates rely on inference from nonexperimental data. In contrast, this paper exploits a procompetitive policy reform to provide estimates of the impact of competition on hospital outcomes. The English government introduced a policy in 2006 to promote competition between hospitals. Using this policy to implement a difference-in-differences research design, we estimate the impact of the introduction of competition on not only clinical outcomes but also productivity and expenditure. We find that the effect of competition is to save lives without raising costs.

And it's worth noting that this isn't the first such finding about competition and public service delivery.

So people will shut up now and support more competition in UK healthcare provision?

(h/t ASI where there's comment here)
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So what is a charity?

We've been used to the debate about defining a 'charity' mostly through discussion of the beneficiaries - should Eton have charitable status? Or the Royal Opera House for that matter?

However there's a different debate - sometimes it might be called the 'sockpuppet' debate - where the organisation with charitable status is, essentially, a delivery agent for the government.

Here's a good example:

The accounts show that St Andrew’s increased its income from £168.7m in 2011/12 to £178m last year. Expenditure rose from £156.2m to £161.2m and the charity increased its funds carried forward from £175.4m in 2011/12 to £192.6m last year.

The charity received donations totalling £22,000 in 2012/13, down from £30,000 in the previous year.

Note that last line. This multi-million pound 'charity' raised just £22,000 in what I would call voluntary income. And the rest?

The charity, which employs about 3,100 people and receives the majority of its income from the NHS...

And, as a result, this organisation:

... has 57 employees on salaries of more than £100,000 a year

Including a chief executive paid £653,000.

It seems to me that this is a large and successful business paying its senior people very well and I'm sure providing fantastic care for its mentally ill clients. But is this what we mean by charity?

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British healthcare needs more than reform. It needs a new health service.

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The NHS as we know it must go if this is how its defenders react to criticism:

One caller told her they hoped ‘she dies on the way to hospital’ and she received a card ‘thanking’ her for her “hard work in closing Stafford Hospital”. The card, which has been passed to police, reportedly read: “Thank you for closing Stafford hospital, Ha, Ha, Ha, you better now spend more time watching your mother’s grave.”

We now know the full consequence, these self-appointed defenders of the NHS didn't stop at unpleasantness or rudeness, they drove Julie Bailey out of town:

“I am having to leave my home, my livelihood and my friends because a few misinformed local political activists have fuelled a hate campaign based on proven lies. The final straw for me was the desecration of my mum’s grave.”

There is something seriously wrong with an organisation so dysfunctional that its supporters resort to violence - to the desecration of graves. I know you'll tell me it's a few misguided nutters but they swim in the rich waters of the NHS or rather the unquestioning worship of the NHS and all it does.

Bristol, Maidstone, Mid-Staffordshire, Morecombe. There's a pattern here, a pattern that will be repeated again and again so long as critics of the NHS face what Julie Bailey faced, so long as healthcare 'professionals' hide behind committees of the great and good or run sobbing to overpowerful unions and similar clubs. And so long as people think it acceptable to attack people personally for the crime of criticising - or even asking for improvements to - one of our most important public services.

We need a new health service. One that isn't complacent about failure, defensive when faced with constructive criticism, unaccountable and secretive. A health service that really is for the people who use it not for the power games of the people who run it.

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Health fascism meets equalities mongering - a battle royale!

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In the USA, as 'Obamacare' rolls out, a new battle is taking place as the desire of the health fascists to charge smokers more meets the desire to provide healthcare for all:

But city officials in the District of Columbia recently decided to charge them the same rate as nonsmokers, joining Rhode Island, Vermont and Massachusetts. California is considering following suit.

Those places argue that the purpose of the health law is to insure all Americans and that includes smokers, who are disproportionately old, poor or minorities all populations that the bill is trying to make sure get coverage.

Oh dear, immovable object and irresistible force! Some folk aren't happy but most of those planning the new systems see no value at all in charging smokers more for the new insurance schemes:

Timothy S. Jost, a health policy analyst at Washington and Lee University School of Law, said charging a 50 percent smoking surcharge on premiums doesn’t make sense mathematically.

“Smokers die younger, but I have seen no evidence that they cost 50 percent more than nonsmokers,” he wrote in an email.

In truth, when it comes to lifetime healthcare costs, those smokers are probably a good sight less costly than that super healthy non-smoker. For sure, the smoker costs more now, but he's going to die young which means he won't be filling up the wards for new knees, hips and shoulders or consuming his body weight in heart drugs for 20 years.

But one has to smile while the health fascists encounter truth - and that other left liberal obsession of positive discrimination for "minorities" of one sort of another!

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NHS response to criticism - blame the patient

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Yesterday "The Doctors" were out in force. All over the airwaves, in every newspaper. Telling us that the reason we don't live as long as the Spanish is because of our terrible lifestyle decisions:

But the problem is only in part to do with hospital care – much of it is about the way we live. Our diet, our drinking and continuing smoking habits all play a part, according to one of the report's authors, Prof John Newton, chief knowledge officer of Public Health England, which assumes its responsibilities on 1 April.

The problem is that this really doesn't stack up when we look at the figures. The evils thing - the targets of nannying fussbucket disapproval - are smoking, drinking and being too fat.

First smoking. According to the OECD, the UK sits pretty close to the average (indeed slightly below the average) at 21.5% of the population smoking. The two top countries for happy and healthy life - Spain and Italy - have smoking rates of 26.2% and 23.2%. Clearly it's not the smoking.

So it's the drinking then? Well here - again - the UK is below the European average with a per capita comsumption of 10.2 litres of alcohol per capita. And those long-lived Southern Europeans? The Italians are Europe's soberest folk at just 6.9 literes per head. But the Spanish - they love the stuff and stick back 11.4 litre. Not sure it's the booze then.

Maybe is the obesity - all those Latin folk are slender and snake-hipped after all, aren't they? Well for Spain:

Adult obesity rates in Spain are higher than the OECD average, and child rates are amongst the highest in the OECD.

And Italy:

Obesity rates are low in Italy, relative to most OECD countries, but are very high among children. 1 in 3 children is overweight, one of the highest rates in the OECD.

Doesn't look like the fatness.

Just for completeness, it isn't taking illegal drugs either:

National rates range from 0.8% to 11% with the lowest rate recorded in Malta, followed by Bulgaria, Greece and Sweden. Italy has the highest rate, followed by Spain, the Czech Republic, and France. 

It really is a problem for our fussbuckets, isn't it? This I mean:

The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action.

You see the problem really isn't our lifestyles - or not so much as "The Doctors" would have us believe. The problem lies elsewhere. Perhaps we should point the finger at the scandal of Mid Staffs, the weakness of our primary care system and a health service that is over-centralised and producer-controlled?

But that wouldn't suit the producers - that would mean them stepping up and accepting responsibility for the failings of our health system. It would mean turning their cosy little world upside down and putting patients - you and me, the users of the system - in change. It would mean looking at how our neighbours run their health systems. As BoM points out:

What this study really highlights is that when it comes to health, we have a lot to learn from our neighbours. None of them have a nationalised health system, yet most of them enjoy longer healthier lives than us. Instead of pretending our healthcare system is the envy of the world, we should have the humility to look and learn.

 In the meantime we can anticipate another episode of doctors, "health professionals" and supine politicians who daren't challenge these nannying fussbuckets telling us that it's all our fault.

Faced with criticism, the NHS always blames the patient.
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Today's nannying fussbucket is another Tory MP: Dr Phillip Lee

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Welcome to the world of judgemental government, to nudging with a baseball bat. Welcome to Phillip Lee MP (he's a GP too so this comes as less of a a surprise) and the punishing of people for their lifestyle choices:

Tory MP and GP Phillip Lee made a striking call this morning for patients suffering from lifestyle-related diseases such as type 2 diabetes to pay for their prescriptions as part of a larger shake-up of the NHS. He was speaking as part of a series of presentations from members of the Free Enterprise Group ahead of next week’s Autumn Statement on their proposals for spending cuts which would allow George Osborne to meet his target of having debt as a proportion of GDP falling by 2015/16.

But Dr Lee's proposal isn't for everyone with a lifestyle problem - he's not suggesting that horse riders pay for having their broken legs plastered or Sunday morning footballers for patching up their sprained ankles. No these punishments fall only on "Officially Disapproved Lifestyle Choices". And the good Doctor gives us a clue:

‘If you want to have doughnuts for breakfast, lunch and dinner, fine, but there’s a cost.’

Choose the things we disapprove of and you won't get free treatment on the NHS. That's the message from Dr Lee MP.  So Dr Lee wants a world like that proposed - and rubbished by one of his colleagues - by Katie Hopkins, the well-known former apprentice contestant.

Former Apprentice contestant Katie Hopkins argues that people who eat, drink and smoke more than is good for them should pay more towards the NHS health care they need, as she sets out her calls for additional payments for some health services.

Please Dr Lee MP, just will you shut up with your fussbucketry, with your judging of folk for lifestyle choices and leave us alone. And if you want people to pay for healthcare, say you want them to pay rather than picking on the few who choices you don't like.

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In which we are reminded of the terrors that NHS privatisation would bring...

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In a blog post on another matter Anna Raccoon describes the experience of France's semi-private health system:

...a chauffeur driven limousine pulled up outside my house, precisely on time, in order to drive me in comfort some 100 miles to the specialist Cancer centre in Bordeaux; the scan was carried out within minutes of my arrival, leaving me half an hour to enjoy a cup of freshly brewed coffee and a fag before the consultant appeared smilingly at his door to greet me by name at the allotted time. I cannot tell you what hell and deprivations I must suffer now that I am safely out of the all embracing  grasp of the NHS.

I'm sure there's a reason why the NHS can't deliver this sort of service. The words "monopoly" and "government" spring to my mind.

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One wonders why?

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...people in Bradford are using a walk-in service rather than their own GP?

Dr Damian Riley, medical director at NHS Airedale, Bradford and Leeds, said: “This change was needed to make sure the walk-in service is used to its best advantage and continues to provide real value for money.

“More patients than expected, especially those who already have a GP elsewhere in the district, have been using the service, even though their own GP has been available.

Perhaps getting an appointment with their own GP is a living nightmare? Maybe people want a "turn up when you're ill" service from their GP?

So who is the service for then, if not Bradford people? Ah, yes...

The change allows appointments at the walk-in service to be prioritised for patients who are not registered with a GP, and in particular communities such as asylum seekers, homeless people, travellers and refugees. A service will also be offered for people who are temporary residents in the district and not registered at a Bradford and Airedale practice.

So it's back to the same old lousy GP service then folks!

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In which the NHS begins to learn about targeting...

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In a previous life (so to speak) we proposed this to Bradford Health Authority some 21 years ago. Back then targeting was a no-no. It seems the NHS is learning - for example about the impact of alcohol:

Targeting 'risky' male drinkers could save NHS £120m - report

Note that, rather than the usual target,alcohol itself, the proposal is to target the actual problem - the alcohol abuser. And with sensible intervention too:

A 10-minute advisory session with a doctor or nurse can reduce alcohol consumption by up to five units a week.

So much better, fairer and more effective than minimum pricing, bans of advertising and sending out hyperbolic press releases to the Daily Mail!

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More from the New Puritans at Benenden...

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We've met Benenden Healthcare Society before when they spread a few myths about drinking and misrepresented some research. And they're back!

More than one-third of British adults believe that a person's healthcare treatment should be affected by whether their lifestyle is healthy or unhealthy, according to latest research.

A poll by healthcare provider Benenden Healthcare Society found that 29% of people believed that those who lead healthier lives should receive priority treatment over those with less healthy lifestyles.

I'm guessing therefore that two-thirds of the population - between six and seven out of ten - don't think those who lead healthier lives should get priority on the NHS. Indeed, the researchers at Benenden tell us that even with the ultimate pariah - the smoker - most people (61%) don't think that they should be 'deprioritised' in receiving NHS treatment.

There is some hope - but not if folk like those at Beneden get their way!

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Lower than vermin - a Tory muses on "Our NHS"

A while ago I celebrated 35 years of being Tory Scum, of knowing that the ease with which Labour tribalists and, indeed, the left in general reaches for insults demonstrates the complete absence of any rational arguments in support of their contentions.

Today the passing of the Health Bill through the House of Commons has brought out another version of that insult - a version introduced by the original bigoted Welsh windbag:

No amount of cajolery, and no attempts at ethical or social seduction, can eradicate from my heart a deep burning hatred for the Tory Party. So far as I am concerned they are lower than vermin.

Well down here with the rats, life is good. At long last we are seeing the great monoliths of British socialism - a sclerotic health system, a school system that fails the poor and a planning system that favours the rich - gradually moved aside in favour of the patient, the parent and the worker.

You see Nye Bevan was wrong. Comprehensively wrong about almost everything. But this did not matter as this man could wallow in ignorance and bigotry, could opt for the insult above the evidence and could paint his opponents as evil. And his Party loved him for it. Loved him for his insults, for his uncompromising hatred of not just the Conservative Party but of Conservatives.

Men like Bevan set the tone for the manner in which Socialists debate - not just the 'lower then vermin' gibe but the genesis for "Tory scum, here we come". All this ferocious insult mixed in with hyperbolic predictions of gloom and despondency - or what the layman might term "outright lies".

The Health Bill is taking a small step - putting the tiniest of tippy-toes into the waters of freedom. Moving us a small way - not enough but a start - towards a public health service that actually serves the public well. A service that isn't hung up on the financial interests of doctors, that doesn't prosecute a New Puritan 'nanny knows best' approach and which focuses on the basic care and medical support that the public want.

And, yes, that might mean some competition. It might mean that GPs no longer had a local monopoly but must compete a little with eachother. It might mean that some treatments, operations and interventions are provided by the private sector (as an aside it seems odd that the left are so supportive of private sector abortions while steadfastly opposing private sector hernia operations). And it might mean that the numbing, duplicating, obsessive and incompetent bureaucracy that is the dominant feature of "Our NHS" begins to go. Replaced, I hope, with some customer service and maybe, just maybe, a smile or two.

I sat in a meeting at which the health reforms were discussed. Not one person there mentioned how to improve the patient experience - instead it was the same old discussion about who was chair of this and chief executive of that, how to manage and organise the process so as to sustain the same old faces round the same old tables. I came away profoundly depressed - this is the NHS that the Labour Party (and the truly awful Dr Evan Harris) want to "save". A place of favours and fixes, of discussions in closed rooms and of make-believe boards with no real power that discuss matters of no real moment.

If I'm 'lower than vermin' for wanting a public health service that responds quickly to patient needs, that presents choice where choice is right, that is accessible and flexible and that stretches the value from that inevitably limited public purse as far as it will go, then so be it. I'll get down with the rats and make sure ordinary people stand a fighting chance of getting an accountable, efficient and effective NHS.

The changes that might be coming - there's a while to go yet before they're law - aren't enough. But they are a welcome start. And I hope we will start now calling for it really to be "Our NHS" not an NHS owned and controlled by the bureaucrats and the medical mafia (including their big pals in the drugs industry).

Lower than vermin I might be. But it's good down here where real people live real lives and want a decent health service from the government they pay so richly from their meagre earnings.

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Not exactly a nation of drunks - but we like a tipple!

Benenden Healthcare has done a little survey - have no idea about its provenance - into the drinking habits of Brits. And they've found this out;

In liquid terms, the average Brit will down more than 5,800 pints during their adult lifetime, as well as 8,700 glasses of wine and 2,900 bottles of cider - translating to around 456 drinks a year, costing £962. They will also suffer from 726 hangovers.

I was especially taken by the hangovers figure - after all we're banging the stuff down. That's about ten a year - assuming we live to a decent age. The research tells us we start on the gloriously slippery slope at age 14 and that most people - 57% - prefer to drink at home rather than down the boozer.

Sadly, the fussbuckets at Beneden Healthcare see this as evidence of our "dysfunctional" relationship with alcohol:

Andrew Meredith, Medical Director at Benenden Hospital, an independent hospital and subsidiary of the Society, said: ‘This survey highlights the dysfunctional relationship many of us have with alcohol. The results can be seen in our town centres every week-end, in A&E departments where alcohol related conditions and injuries are a large part of the workload and the increasing numbers of admissions with alcohol related liver disease.’

Oh shut up already, will you. We get enough of that from the government.

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How health reform prompts innovation....

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A striking initiative from Christies:

Specialist cancer hospital The Christie Foundation Trust is considering plans which could see it open branded treatment and diagnostic centres across England, in partnership with a private sector provider.


If the proposal goes ahead, the Manchester-based hospital could become the first in a wave of high profile FTs to use joint ventures with the private sector to develop national “chains” of providers.

Chief executive Caroline Shaw said the NHS reforms offered the Christie the opportunity to use its joint venture with private hospitals group HCA International to expand beyond its regional boundaries.

And probably good news too!

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