What headline would you use for this article on lifestyle illnesses?

A BBC article on lifestyle related illnesses caught my eye today, ‘Illnesses associated with lifestyle cost the NHS £11bn’.

The article mentions the real health problems of type 2 diabetes and chronic obstructive pulmonary disease (COPD), both illness that are significantly related to individuals’ lifestyle choices, including diet, smoking, alcohol and exercise.

Freeport, a once prosperous fishing town in Lancashire, is used as a case study. It is the home of Fisherman’s Friends, has one of the UK’s cheapest outlet stores and still smells of fish but is economically deprived in a region that has not thrived in recent decades. The correlation between economic deprivation and poor health is well demonstrated, and causation has been demonstrated in areas where the economy suddenly deteriorates due to collapse of local industry.

One of the solutions discussed is a community project that has transformed waste ground into a community allotment run by those with learning difficulties and brain injuries (Willow Garden Project). This charity seems to be locally run and receives money from the Lottery, so, regulatory barriers to lottery startups aside, is funded from less coercive sources than central taxation. It is I believe, the right approach to improve the wellbeing, health and empowerment of those locally. National economic disincentives are also to blame, such as variable rates of housing benefit, but that is beyond the scope of this discussion.

My main concern about this article however is the headline itself. Illnesses associated with lifestyle are horrendous. Slowly suffocating in your own CO2 as your lungs deteriorated over decades is arguably as bad as an 18 month death with lung cancer. The sexual dysfunction, eye problems, kidney disease, chronic limb pain and risk of limb amputation with type 2 diabetes can be horrendous. The impact on work and independent living affects individuals and their families. Depression associated with multiple medical conditions is real.

None of this is captured in the headline however. The headline only mentions the ‘cost’ to the NHS. That NHS which is a payment and organisational / control system for healthcare in the UK. That NHS that is not a person and will not suffer the ailments listed above. The NHS that is forced (through taxation and crowding out effects) on all of us in the UK yet delivers worse outcomes than many mixed systems in Europe (OECD Health Systems at a glance 2015). The NHS that by design will always be political yet will only tend towards cheapness.

The underlying message in this headline, of which this is one example of the tone of the narrative, is that if you become ill, particularly if you are poor, it is your fault and you are not only harming yourself but the institution of the NHS itself and your fellow UK citizens.

As the NHS fails to cope with the supply/demand mismatch of an undifferentiated one size fits all system expect this narrative to continue. And as it continues expect policy to follow the narrative. A collectivised system will start to choose who is ‘eligible’ based on various lifestyle and social factors. And when individuals are forced to be in the system, through tax and crowding out, yet find the system judges them ineligible at the point of use, the net result is social division and the hardening of resulting systems to control individuals. As social and benefits records are further integrated with health records the potential for such centralised control increases dramatically.

Thus we live in a country where healthcare demand is expressed as a cost, where individual choice is demonised yet alternatives are poor for the economically marginalised. I saw an advert for a general practice role in Australia recently. The tagline was ‘high demand area’, as GPs would have lots of customers for their business. In the UK NHS however a quiet day is a victory and a queue of people waiting to be seen is a failure.

Such is the result when the state intervenes.

 

Scottish Named Person Scheme hits setback

It seems some time ago that the Scottish Named Person scheme was announced and, not living in Scotland myself, I assumed the scheme had been quietly dropped at some point. It seems however that this plan, to ensure every child in Scotland has a named professional (teacher, health care worker, social worker etc) with responsibilities for their welfare, has been merely delayed due to legal challenges.

The Supreme Court ruled this week that the scheme needs amending as it breaches rights to privacy and family life under European Human Rights laws. This is a welcome judgement. The proposed law is an astonishing overreach of state power, giving the state snooping rights, including the inevitable leaky obsessive bureaucratic data collection that goes along with that, over every child in Scotland.

In my GP work I am involved in Child Safeguarding and I am confident in the efficacy of external intervention in some cases of neglect and abuse. However, I am constantly aware of the risk of normalising state intervention and of mission creep and feel that maintaining a constant state of uneasiness and self-reflection is necessary to prevent this. Intervention in the lives of others should be an exception with strong qualifying conditions rather than the norm.

Sadly this intervention (‘think of the children’) reflects the broader conceit of statists everywhere I look, including sectors such as healthcare organisation, teaching and concepts such as democracy itself – that is the idea that an educated elite knows best and that individuals are not to be trusted. This institutional mistrust applies to parents, the poor and even professionals themselves in the way they are regulated.

Freedom supporters therefore need to promote and support the concept of the individual as the default person to make decisions about themselves in opposition to the notion that the default is state intervention and mistrust of free thought and agency.

Whexit

‘The thing is,’ Rolfe declared whilst setting down 3 pints of Old Thumper, ‘I like people from Portsmouth, even went out with one once, but wouldn’t want them all coming to live over here.’

Howard moved over on the bench to allow his friend to sit. The 3 friends didn’t look at each other much during their sessions, preferring to sit abreast whilst watching the Solent as the evening sun started to fall to the East.

Masters took a deep, audible, satisfied draught from his pint. ‘I agree, but you can’t complain about the New Forest beer. And what about jobs, those tourists from the mainland spend will spend money on anything.’

Howard coughed but said nothing. He wasn’t sure a vote for the Island to leave the United Kingdom would necessarily lead to fewer tourists, after all a ‘Whexit’ vote wouldn’t cause Brighton beach to suddenly turn from pebble to sand overnight.

‘Tourists are welcome,’ conceded Rolfe, ‘but I just don’t like it when Brummies come and live here, undercutting our ice cream vans and bringing their whole family over.’

He gestured to the distinctive Red Funnel ferry entering Cowes harbour, ‘All those mainlanders, getting off the ferry without even showing their passports, it’s a disgrace. Probably a terrorist on that very ferry.’

Masters nodded before playing his ace, ‘The chancellor says caravan prices will crash if we leave.’

Howard coughed again and frowned. He has 3 caravans and had just bought 2 more off plan. He wasn’t convinced this was valid, after all the chief treasurer of the Island, Urquhart, had the right to allow Funfairs to print more IOW ‘Chitties’, the official currency of the Island, each emblazoned with the phrase ‘I promise to pay the bearer one cuddly bear on demand’. Urquhart had used this right on numerous occasions over the last decade and had just announced a new wave of her ‘New Caravan Leg Up’ scheme that would no doubt stoke prices further.

Howard looked at Rolfe finishing his pint and thought he was going to talk about crab legs next.

‘The London government is full of idiots,’ Rolfe obliged, ‘they pass laws saying our crabs have legs that are too bent! We’d be better off without them. And whilst we’re talking about London I went there once. The streets around Islington stink of quinoa and goji berries. I just don’t want them here.’

Another coughing fit overtook Howard. He should really go to the doctor but unfortunately there had been a shortage and long waiting times since the ruling party on the Island clamped down on Indian immigration visas, and candidates from the UK didn’t want to live and work on the island. Across the water the flames from Fawley power station brightened as the dusk strengthened.

Rolfe and Masters’ conversation had descended into banter about the time they went to Newquay and Rolfe had found it hard to make himself understood whilst ordering Cider and Pasties in his best West Country accent.

Howard retreated into his thoughts as he watched a Dutch blue steel hulled 50 foot ketch running before the light cool Easterly that had developed as the sun fell. He didn’t like the London government and hated being told what to do by that opaque, far off bunch of bureaucrats in Westminster. On the other hand he felt people should be free to travel, to settle, to trade, love and live where they pleased, without arbitrary borders and the need to show papers. He didn’t much care for the local small minded numpties who would gain control even as London rule was cast off.

In truth he resented any man who had power over him, and more than anything hated those who sought out that power to use over others.

He considered the Ketch again and, not for the first time, plotted an imaginary journey, out into the channel and past the shipping lanes, down to Gibraltar and the Mediterranean for the summer then across to the Azores and on to the Caribbean for the winter. Such an existence would be under the fickle whims of the waves and the sea yet somehow would be a world removed from the petty rules of his fellow man. He would be free.

Perhaps freedom comes from within, he thought, as he went to the bar to buy his round. Perhaps this year would be the year he finally made the journey himself.

Let’s imagine an alternative to the NHS in this best of all possible worlds

The NHS is on strike today with 4000 operations cancelled in a dispute over pay and conditions. The government’s contract negotiations with junior doctors became more bitter recently with the publication of emails between the Department of Health (DOH) and Sir Bruce Keogh, the medical director of the independent body NHS England. The emails document how the DOH suggested, and made, revisions to Sir Keogh’s widely publicised letter to the BMA that was sent in the week after the November 2015 Paris terrorist attacks. The letter included a request for assurances about how junior doctors would respond if there was a terrorist attack. The changes were made in order to be more ‘hard-edged’ about the terrorism risk and the DOH planned that this point would be ‘pressed quite hard in the media once the strike is formally announced’.

It is not surprising that the DOH, as a government department, is trying to use fear and spin to win its political cause. It is saddening that a senior clinician, Sir Keogh, who has championed patient safety and the use of data to improve outcomes in heart surgery, has allowed himself to be manipulated this way, but perhaps it is also unsurprising, given the pressures on those in power. The concern raised by Sir Keogh is utterly invalid and we sadly have history to demonstrate this – has he forgotten that only 10 years ago in the 7th July bombings the actions of the off duty doctors at BMA house in Tavistock Square? Has he forgotten the doctors who rushed to work to staff the A/E and surgical departments? Given the 1st strike was meant to be a ‘Christmas Day Rota’ why has he not raised hysterical terrorism concerns each December 25th for the past few years? Even the most amateur of psychologists could understand that accusing professionals of a disregard for terrorism can only lead to a hardening of the resolve in those you are trying to negotiate with.

Much has been written about the junior doctor contract. To summarise: ‘junior’ doctors includes all doctors who are not consultants, from early 20s to late 30s and above; the banding payments are not optional overtime, rather they are a supplement based on the intensity and timing of the rota with an intentionally punitive supplement to reduce unsafe working; junior doctors have little choice of employer as there is an NHS monopoly on training; the market has shown the pay and conditions are too low, with dangerously understaffed rotas, rising emigration and increasing locum rates. The government’s proposals would reduce staff pay for an equivalent rota over time, thus hoping to delay the inevitable financial collapse of the NHS on their watch.

This industrial dispute, and the way it has been handled, however represents more than just a clash of two narrow interest groups. It is a symptom of the sickness in the NHS. This solely tax funded system, with no safety valve of patient contributions, can only tend towards one set of end points: a cheap yet inefficient system with unavoidable political input, top down bureaucracy, low patient autonomy, poor staffing practices and a public discourse dominated by emotion and clouded thinking to a near religious degree.

I am not saying that the NHS is all bad. In such a large system there are areas of excellence as well as areas that need improving. If we set our sights low enough the NHS today is much better than what came before it. We are not in 1948 however. All todays healthcare systems do much more that in 1948. We are in 2016 and live in a relatively wealthy country where people have discretionary spending and luxury way above that needed for food, water, clothing and shelter. And 2016 is a world with fast capital flows, increased movement of people, rapidly evolving technology and an increasingly ageing population. A centrally planned and funded system has no chance of keeping up in such an environment and a new solution is necessary.

Answers

For the junior doctors the problem of regulation and central contracting leads necessarily to collective bargaining and industrial action. Thus a first step would be to remove central contracting from junior doctors and allow hospitals, or chambers of specialist doctors, to offer their own services, including training, with their own T&Cs. At the same time accrediting specialist medical training should be opened up to the market. Thus training accreditation bodies and hospitals or healthcare providers would have to offer a package with training that had a reputation for being high quality, with good enough T&Cs to attract the best candidates.

With regards to low value healthcare, such as GP appointments, day case procedures or specialist clinics, a mixture of self-pay and concierge models would lead to multiple choices for patients with varying mixtures of convenience, price, access and continuity. There would still be a market for the lowest price options, but insurance based schemes could offer the ability to top up or pay an excess as needed at the time of use. Paying with one’s own money as much as possible should always be preferable to alternatives. The waste and the clash of incentives that arise when others, government or private, spend money on our behalf is responsible for many poor outcomes.

High cost healthcare is more challenging. How does one know in advance how much to pay in insurance for a rare yet potentially severe event, such as many cancers, that could cost £100,000 at the median yet could cost £150,000 in a service with higher safety, more convenience, greater autonomy? The market is so opaque the only answer for many is to pay what they can afford in insurance and hope it’s enough when they need it. More confusingly an insurance provider might take funds and use it to build a pool of money by investing in various investments which may or may not have provided enough money at the time the money is needed.

When one buys a healthcare insurance the main concern of many is that the healthcare insurance will provide enough cover when needed. This explains why historically supporting a system such as the NHS was logical for many people, as MPs will always have to vote for a certain amount of tax to be used on the service and will always vote to keep the local hospital open. There is no guarantee, however, that the UK government will remains solvent to the extent needed to fund an NHS in future, in the same way that elderly people relying on only a state pension and state nursing care already find themselves in circumstances much reduced compared to their expectations during their working life.

I would like to propose a system whereby providers of healthcare issue vouchers for their services. This could be digital voucher via a blockchain, most effectively brought into existence by ‘proof of burn’. The current market value of, for example, a prostatectomy is purchased by a cryptocurrency such as Bitcoin then destroyed in an open manner whilst creating the equivalent digital voucher for prostatectomies. Brokers could create these vouchers. Underlying this is a series of options which are tied to individuals and expire on use, or on death of the holder. This is sold as a healthcare package funded by a mortgage like product. The role of the brokers, or insurers, is to ensure they balance the number of options vs tokens so that they remain solvent. Blockchain technology would be able to ensure the reserve held by different insurers is public and comparable, whilst the rate of use of tokens remains transparent. The capital for insurers would be via investors who would buy a bond in the fund that bought the tokens.

If I get prostate cancer, and an operation is the appropriate option I can redeem my option and spend a voucher worth 1.0 the cost of a prostatectomy. But what if 1.0 x cost is not enough for provider I wish to use? What if the provider charges 1.2x a prostatectomy? In that case I could buy an extra eligible option on the open market from someone who is happier with the 0.8x service. If no one wants the 0.8x service the market response will be for the marginal price of 1.0 x service to rise. The aim of the system is for it to be self-balancing as the change in price for the 1.0x service cannot be hidden from new joiners to the scheme, as the insurance companies must buy enough tokens with the capital raised when a new person joins. The system therefore stays ‘honest’ and consumers are paying for what they want – the right to appropriate quality medical care if they need it in future. Of course one could buy 1.2 x options as standard, in the same way that someone buys the full featured medical insurances, and there could be options where there are 2 alternative yet different priced treatments, with a rebate if one chooses the cheaper, perhaps more inconvenient, treatment option.

This sounds complex but the principle is that the individual must have some stake in the money being spent, or saved, when accessing healthcare, and that the more transparent and open this market is, and the more incentives can be aligned, the great the chance of maximising value. The core idea is to envisage a system where consumers trust they will receive healthcare when needed yet do not have to appeal to regulators, whilst still incentivising insurers and health care providers to continue to provide a choice of high quality, convenient and affordable treatments.

The idea for this system is a work in evolution, and as such needs developing, but if you are an interested actuary, trader, cryptographer, insurer, mathematician or an imaginative thinker who might want to help progress this to a white paper, feel free to contact me on @MrZachCope.

Downton Abbey – Dreadfully Subversive!

As a suburban family man I do enjoy sitting down in front of my HD TV on an autumn Sunday evening to watch that exquisite example of English, class obsessed, period, property porn that is Downton Abbey. Thoughts of medicine, politics and economics are usually far from my mind during this time.

However towards the end of the 11th October episode I was surprised by two separate scenes:

The first was Lady Crawley discussing her lady’s maid Anna’s emergency procedure (cervical cerclage) done for her repeated miscarriages.

Lady Crawley: I’m so grateful for you coming out here at dawn.

Gynaecologist: Don’t worry – it will be reflected in my bill.

Lady Crawley: Of course.

It itself this wasn’t that exciting, but it woke me up a little so I was prepared for the extraordinary anti-government speech delivered by the fiery Dowager Countess of Grantham, Violet Crawley (played by the excellent Maggie Smith). In this scene the ladies are discussing the proposal for the village hospital, of whom the Crawleys are trustees, to merge with another larger hospital.

Lady Rosamund Painswick: Is it really so important to see the Crawley’s in command mama?

Violet Crawley: That is my sole motive is it?

Isobel Crawley: Isn’t it?

Violet Crawley: No, no it is not. For years I’ve watched government take control of our lives, and their argument is always the same – fewer costs, greater efficiency – but the result is the same too. Less control by the people, more control by the state, until the individual’s own wishes count for nothing. That is what I consider my duty to resist.

Lady Rosamund Painswick: By wielding your unelected power?

Violet Crawley: You see the point of a so called ‘great family’ is to protect our freedoms. That is why the Barons made King John sign the Magna Carter.

Isobel Crawley: I do see you argument was more honourable that I had appreciated.

Lady Rosamund Painswick:  Mama we’re not living in 1215, and the strengths of great families like ours is going. That’s just fact.

Violet Crawley: Your great grandchildren won’t thank you when the state is all powerful because we didn’t fight.

 

High drama? Libertarian propaganda? Veiled criticism of the BBC by ITV? I’ll let you decide.

Should Libertarian doctors strike?

Intimidation, damage to property, civil disobedience and scared children – I am pleased to say none of these things were present when I attended the junior doctors’ march in London on 17th October, in support of my junior doctor wife and colleagues. This was the first public political protest I have attended and I left with mixed feelings.

As I approached Waterloo place, just west of Trafalgar Square, on a mild dry Saturday, the first signs of the protest were the ubiquitous Socialist Worker supporters handing out various red and black top pamphlets. They were far older than the bulk of the crowd, which consisted of Junior Doctors (those who are not consultants or GPs) mostly aged between their early 20s and early 40s, and their families. My instinctive scowl at the Socialist Workers was changed to a wry smile when I saw a stall manned by those notorious market making capitalists – Locum Agencies!

We were directed to the other side of the square where we loitered with the children, occasionally bumping into friends or colleagues, and tried to hear what was being said on the stages. I’m told it was all quite rousing, although all I could hear over the PA system was ‘hmm mm brr ggg mm sqqqll bzzz NHS! NHS!’ and a few cheers. After an hour or so we slowly walked back towards Trafalgar Square, brandishing our placards and occasionally chanting ‘Hunt must go’. The placards varied: ‘We’re quite annoyed’; ‘I’m not a gynaecologist but I know a Hunt when I see one’; ‘Not Safe Not Fair’; ‘Save our NHS’.

Saving the NHS. That is where I found things difficult. You see the doctors are correct in opposing the contract changes, which will result in significantly worse terms, conditions and pay, especially for those doctors already working lots of nights and weekends. The only reason the government would push for these changes, if I discount them wanting to precipitate a fight with the world’s weakest union, the BMA, is to save money. They wish to save this money as there is not enough money out of tax alone to run a safe, effective NHS. The problem is that doctors are already taking individual action, even with the current contract, and are leaving the UK, changing careers, locuming or cutting down their hours. This is expressed as unfilled rotas and rising locum rates.

Should doctors threaten strike action? I am aware that some on the political right believe doctors should not strike as they knew they were entering a state industry. This is ridiculous. The reasons for entering medicine are complex, and at the time of entry the quality of life in a hard, demanding yet fulfilling job was still attractive for many people. Those skilled doctors who work in the NHS would be the same doctors working in any other system. As a monopsony employer the use of collective bargaining is a legitimate market response for the self-interested worker. Forcing others to strike or operating a closed shop would be illegitimate, but freely bargaining as a collective does not, in my view, make one a socialist.

The real danger, however, is that workers trying to come an agreement on pay, with an employer that wishes to have a single contract for all similar staff, will seek out those who agree and support them. Thus industrial militancy in this usually quiet cohort of professionals can end up with a movement to the political left if their concerns are dismissed.

Regarding the NHS, the most dishonest thing for doctors to do would be to accept a new contract without fighting, as this would leave to falling staff numbers and worsening quality of care. By maintaining a strong contract that may be unaffordable under the current taxpayer funded model, they will precipitate the discussion that politicians keep avoiding. 90% of the public trust doctors to tell the truth; 16% trust politicians to tell the truth (IPSOS MORI 2014). That is because doctors will tell you bad news. Here is some bad news. There is not enough money in the NHS to maintain safe services today. This applies to private services as well as NHS ones – NHS trusts are in deficit; Circle handed back their Hinchingbrooke Hospital contract; GPs I know are closing their practices.

Accepting the truth of the lack of money in UK healthcare would enable the next conversation to take place: where should the extra money come from? When asked honestly the Great British Public may surprise politicians, who look to the past more than the future. Extra taxation seems impossible in the current economic state we are in so that solutions such as co-payments or top up payments, the first step on the road to reducing government interference in healthcare, must be permitted.

One quote for those who would condemn potential strikers. It comes from Atlas Shrugged and remains prescient today as we witness professionals taking their own industrial action by leaving the country or their chosen profession. In my view a day or two of industrial action, if it is a real signal from those who might actually leave for good, is not inconsistent with its message:

“I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.” Dr Thomas Hendricks, Atlas Shrugged

 

 

When NHS charges come, please do it the right way.

I was pleased to see this briefing from the Chartered Institute of Public Finance & Accountancy examining NHS health finances.

The NHS’s own Five Year Forward View, despite its retro 60s communist sounding title, is honest enough to identify a £30billion funding gap from now until 2021, leaving £21bn in ‘efficiency savings’ to make. The official political establishment view during the election was that these new efficiencies can easily be found, and that only £8bn of extra funding is needed.

The reality however is that services are at the point where productivity does not need to increase – it actually needs to fall. Safety and quality of services are constantly under pressure due to permanently running at minimum staffing levels, without the capacity in the system for the expected pressures of epidemics, winter, staff illness and staff turnover. This leads to problems with retention of existing staff, subsequent spending on last minute locums, and a state of constant crisis. This is not just a failure of state providers in this free at the point of use system – Circle Holdings withdrew from their Hinchingbrooke Hospital contract and the rate of GP surgeries handing back their NHS contracts is rising rapidly.

Healthcare workers themselves realise this and many make the choice to withdraw their labour, not as a strike, but by reducing their NHS work, changing careers, working privately, locuming or leaving the country.

Thus in order in improve quality, and retain the skills of those who might otherwise not work at an unsafe intensity, productivity needs to fall, as more resources are put towards an individual’s episode of care.

The CIPFA report states: ‘It will be necessary, to underpin that agenda, either to add further to the NHS budget, charge users more, or reduce services. To choose none of those is not a realistic option.’

Given we are on the cusp of the next financial crisis the only acceptable option is to bring in user charges. This could easily be done in the part of the NHS where 90% of consultations occur, primary care. GPs already take money for various non NHS services, and most patients have a choice of GP practices such that competition could occur.

These charges however must be allowed to be set by the market for each individual practice. A blanket fee would only be taken back into central NHS coffers and would lead to a clamour for means tested exemptions such that the squeezed middle and working poor would take the brunt of the charges. This would damage further attempts to move away from sole government funding.

In contrast, freely floating charges would enable a mixture of providers to compete. Product differentiation, that magical process that fills in the left of the supply/demand curve, would occur, with patients choosing between options including: bespoke concierge medicine; a regular GP service with payments for convenience; services with better IT access, such as asynchronous secure messaging; a cheap system where all contacts are pre-triaged by a GP who decides which health professional will deal with your problem as per clinical need, not convenience. The NHS could continue to fund part of this according to illness burden – there are various risk profiling tools that accurately predict the health usage of cohorts of patients in various risk bands. These could be used to allocate supporting state funds for now.

Looking at the comments on social media sites such as Doctors.net and Pulse there is a real appetite for this amongst clinicians. Personally I would relish the chance to provide an excellent service with the extra funds this would draw in.

Governments nowadays don’t create policy, they adopt that of think tanks. If HMG wishes to follow the logic of the CIPFA report, they need to embrace NHS charging in the freest sense.

 

 

Image © Chris Yarzab