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.
