What should a liberal health service look like in 2016?

What should a liberal health service look like in 2016? A recent study may offer a partial answer. The study, which examined the effect of palliative care on patients with incurable cancer found, perhaps unsurprisingly, improvements in patients’ quality of life and reduced instances of depression. Those patients who had been assigned palliative care were also less likely to opt for expensive, aggressive end-of-life treatments, yet actually lived a third longer. This is a staggering result, both improving outcomes and saving money. Similarly, hospice care may cost 35% less, or save $2,300 per patient, and is linked to greater wellbeing for patients and their family.

A liberal health service would give such services far greater prominence and would be inclusive of similar examples of lateral thinking.

The slow medicine movement emerged in response to these ideas and advocates avoiding unnecessary and costly treatments to focus on nurturing patients. Proponents argue a vast number of expensive and wasteful procedures are carried out without good reason; one study found 11% of healthcare interventions have no good evidence to support them, just the desire to do s omething . Another study found nearly 90% of patients undergoing percutaneous coronary intervention wrongly thought it would reduce their chance of a heart attack, and half of cardiologists would perform one even if they thought it had no benefit. An estimated one in seven NHS treatments are unnecessary. The NHS should respond by encouraging the spread of programmes like Choosing Wisely, which could improve patient wellbeing and save up to £2 billion per year.

Hogeweyk, a Dutch model village and nursing home, offers another example a liberal health service could enthusiastically adopt. Nursing homes are often clinical and unwelcoming, but Hogewey is designed to be familiar and comfortable. Residents from Indonesia have warmer apartments and are served their own traditional cuisine, while in the apartments of residents who were upper-class or wealthy, carers dress and act as if they were domestic servants. Residents engage in a variety of social activities and move freely around shops in the village. Hogewey costs no more than a British nursing home, yet residents eat better, live longer, require less medication and demonstrate greater wellbeing. A liberal health service would support the expansion of similar dementia villages in Britain.

A liberal health service would respond to the ideas of the slow medicine movement by encouraging a healthcare system that didn’t just work in hospitals but within the community, embracing the principle of subsidiarity. This is made vastly more achievable by the tech revolution; smartphones and the miniaturization of diagnostic tools mean ever more procedures can take place outside the hospital. Australia’s Hospitals in the Home has taken advantage of the development of portable x-rays and blood tests to provide hospital treatments in patients’ homes, improving outcomes and reducing complications. In the USA, patients order their own blood tests and get the results online, making it cheaper and more convenient.

Technology could also move healthcare out of hospitals by enabling a range of co-production initiatives, substituting the traditional healthcare model for a grassroots network allowing people to share resources and shape their own care. RUILS provides adult social care, and allows users to pool their direct payments and personal budgets to increase purchasing power. Service users can vote on how the service is run and sit on the board. SUN is a scheme which brings people with emotional and behavioural problems together for both crisis support and social activities, viewing the community as the doctor. SUN has reduced planned and unplanned hospital visits (725 to 596 and 414 to 286 respectively), hospital bed use (330 days to 162) and A&E attendance (down 30%). The USA’s Chronic Disease Self-Management programme is built around peer support, lead by those with experience of suffering chronic diseases and allows patients to self-manage symptoms within the community. A trial found wide-ranging improvements in symptoms and mood and savings of four dollars for every one invested. More GPs should be encouraged to utilise social prescribing, as has successfully been implemented in Bradford, to ensure greater attention and take-up for good value co-production programmes.

Greater integration of some of the innovative developments in technology and the Internet of Things could also unleash a more patient-centric healthcare system. Google has designed a contact lens to monitor the glucose level of diabetics without the need for invasive finger-pricking. The readouts can be displayed on a smartphone or streamed directly to the patient’s clinician. Proteus manufacture a pill with sensors to monitor the patient and share data with an app. Verily has created a tremor spoon for patients with Parkinson’s, with sensors that monitor the condition. Propellor Health is developing smart inhalers for asthma sufferers, to detect the surroundings, time and air quality associated with attacks.

Conventional, top-down methods of evaluating and delivering healthcare are cumbersome and unresponsive. Many conventional tools to rank hospitals and empower patients do nothing if not the opposite. Bottom-up initiatives, growing out of the experiences of real patients, offer far more promise. PatientsLikeMe connects patients suffering similar illnesses so they can share their experiences of symptoms and treatments. Jourvie is an app designed by anorexia sufferers to help others with the same condition. Ginger.io monitors the patterns of behaviour of people suffering from mental illness to track their mood, and offers clinical support when it believes they are vulnerable. Babylon is a subscription service that allows patients to order prescriptions, text a doctor or make video consultations. Users rate their experience, and poorly rated doctors are removed from the system. For the cost of a Spotify account Babylon lets patients be far more proactive in monitoring their health, reducing unnecessary hospital visits and diagnosing serious problems earlier. This is likely to bring long-term savings, and the government should play a role in subsidising access to similar services for the less well-off in society. GPs could be encouraged to prescribe subsidised access to patients identified as most at risk, or to persistent, high-cost users of GP services.

This is what a future liberal health service should look like; preventative and interventionist healthcare delivered in homes and communities by a combination of new technology and old-fashioned human contact

The Junior Doctors’ Strike

The junior doctors’ strike kicked off which has resulted in 4,000 routine treatments being cancelled and even more appointments, check-ups and tests. The doctors are on strike in a dispute regarding a new contract and their concerns about the level of pay for working weekends and stronger limits on working hours.

Absurdities and Fallacies

For most people who luckily are not employees of the state it seems strange to go on strike to demand changes to your contract. Imagine if the whole economy was built upon such an absurd and inefficient system. Most people’s minds are so obscured by the fallacious arguments around this issue that they cannot see the absurdities:

  • Why are customers of the NHS who pay for the services (via tax) being punished?
  • Why are the customers not being reimbursed for the lack of services during the strikes?
  • Shouldn’t those who fund the NHS (i.e. taxpayers) have the power to sack the NHS or the government for such a mess?
  • Would you pay for such a rubbish service in the private market?

How does the market work?

In the market, if you pay your employers too low, your competitors will take them off you (hence why retention is a big challenge for businesses) and if you pay them too high, you will incur costs and go bankrupt. The market then- in the words of Adam Smith- gravitates the price towards what the employee is producing for the employer. It isn’t a perfect system but it is the most efficient, accurate and dynamic one known to man so far. People in the market move jobs all the time for variety of reasons; some get a part-time job to pursue a hobby, some freelance so they can work from the comfort of their homes, some move for higher pay and more job benefits, some move solely because of location etc. This is the flexibility that the market affords- if you don’t see it in some places in the market, it’s because the government is involved in one way or another.

The Free Market Alternative to the NHS

The employees of the NHS find their job location, pay packages, hours and career progression highly bureaucratic and rigid. In the free market there wouldn’t be a monopoly such as the NHS which forces you to pay for its services via the coercive apparatus of the state. Instead, thousands of companies- from big multinational corporations to small firms- would compete with each other to provide you the best service for the best price. This healthy competition is also good for the doctors. If a private healthcare provider pays a doctor too low then the doctor will simply move jobs to someone who’s paying higher or get headhunted by rival companies.

Is Private Healthcare Bad for the Poor?

First of all, the NHS is not free; it costs the taxpayer well over £110 billion. And also with the good- such as ‘free’ treatment if you break your leg- comes the bad; especially in diagnosis. Here are some stories:

 

In fact, one report warns that doctors miss one in three cancer cases.  In fact the article recounts this story which demonstrates the superiority of private healthcare when it comes to diagnosing health issues:

A pensioner saw her doctor three times about difficulty swallowing, but it was not until she went private that she was diagnosed with end-stage oral cancer.

Nigel Farage has been in a similar situation:

After six weeks, I went to see my GP in Biggin Hill. By this time, I was having difficulty walking. My left testicle was as large as a lemon and rock hard. The GP arranged for me to see a consultant that day. To say that this consultant was disinterested would be an understatement; perhaps he had a round of golf booked for the afternoon. ‘‘Keep taking the antibiotics,’’ he preached, and that was that.

I was in a terrible state by now. I phoned the office and spoke to one of my bosses. He told me that I was covered with private medical insurance and that I should use it. The next day I saw a private GP, Dr Solomon, in the City. He told me I must have a scan. I had been alarmed by the swiftness of my own GP’s referral to a consultant but, after that, no medical professional had taken me seriously. Until now. Dr Solomon made an immediate appointment for me to see a top surgeon called Jerry Gilmore in Harley Street.

 

Second of all, in the market the suppliers want to grab as much market share as possible and therefore would compete for it. If a luxury healthcare provider offers healthcare for £10,000 a month but only a 10% of the population could afford that then other providers would compete to provide slightly lower quality healthcare at a £1,000 a month to grab another 20% of the market. Other providers would provide basic healthcare for the masses for £50-£100 a month. They would all also compete for ‘pay-as-you-go’ type of treatments. Now you may be thinking can a £50 a month healthcare provider be any good but you’re forgetting one very important thing. Competition brings about low prices but high quality and also incentivises innovation. Look at mobile phones: not everyone could afford them at first but now in a market economy we have phone companies competing with each other and almost everyone has a smart phone and everyone has some sort of a mobile phone. This is because the market competition pushes for higher quality products (which entails innovation) at lower prices. This is the historical pattern of the market; products are made more and more accessible to more and more people and quality continuously increases. This is true for anything from mobile phones, cars and PCs to toiletries, meat and clothing.

This is all notwithstanding the fact that people can still pay charity if they like now that they’re not compelled to do so by the state and that medical health companies can – for sincere charitable reasons or simply because of PR/Marketing- treat the poor and unwell.

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.

The American Association of Physicians and Surgeons

For those interested in the practice of private, direct medical care in the U.K. and elsewhere, AAPS — the American Association of Physicians and Surgeons — is a national organization with chapters in several states of doctors who provide just that. They were founded in 1943 and are, at least mostly, conservativish-libertarianish. Their home page, has links to many videos of presentations presented at the organization’s various conferences. These I find quite interesting, as they give considerable knowledge about how different doctors have built their practices, the services they provide, the costs to patients, whether or not they take insurance or Medicare (most don’t, I think; instead there’s a monthly membership fee, which entitles one to free or relatively inexpensive care depending on the practitioner).

Many of the doctors make house calls if necessary, and there seems to be a general attitude that the patients will be seen and treated as Real Human Persons.

There is also a table of available physicians, and where they are located. And more.

The page of “Resources” has links to several types of content, including journal articles, the videos, the list of available physicians, summaries of government hearings, podcasts “provid[ing] weekly interviews with the top individuals working to keep freedom alive in American medicine,” and more.

The members vary in their interests and methods. For example, some are interested in “alternative” as well as conventional Western medicine; and a few days ago I watched a couple of videos, one by a young man just starting to build his practice who is bound and determined that his office will be entirely, 100%, paperless. All notes, records, memos, “charts” (meaning “files”), etc. will exist only in electronic form. The other, by Craig Wax, begs doctors to keep hardcopy of absolutely everything, and never commit to electronic storage any personal information on patients for the Feds to rifle through. Mr. Wax has more than one video on the topic. In particular, this is the age of EHR — Electronic Health Records — which he seems to see as a general Governmental dream situation in which literally nothing is private anymore. (I certainly see it that way!)

I think that even though it’s largely aimed at doctors, the site should also be interesting to those campaigning for Direct Care (“conciérge practices”), partly because of the many different choices people have made about how to set up their practices, how to charge, when to offer free care out of charity, and so on; and also to the layman who may one day have the misfortune of needing a doctor, without having to deal with the NHS in the U.K. (or ObamaCare, Medicare, insurance companies here).

 

Also, a side note: There is now a volunteer clinic and practice somewhere in Wisconsin which has no paid staff whatsoever. IIRC it was started by a minister, and equipped with funds donated by many individuals. I think that because of its status as a pure, volunteer clinic, some of the usual Federal and State medical regulations don’t apply to it. Sorry I don’t have the URL, but if I can locate it again I will post it.

Doctors threaten to flee NHS

Hundreds of NHS doctors have swarmed upon Westminster to demonstrate the seriousness of problems that could see them fleeing the NHS for jobs in Australia and New Zealand.

Apparently oblivious to the damage such a statement causes to the dependable reputation of the NHS they proclaimed that they represented “most doctors” and they described the immediate future of the NHS as “not safe”. 

   
    
 
Regular readers will know that this blog recommends a model based on monthly subscription service, with prices negotiated in the same way that accountants and gymnasiums negotiate, supplemented by insurance with a well defined scope of coverage.

Doctors chose their career knowing that the system was managed by a remote political elite who may make decisions they disagree with. That management model is unique to the NHS and it is not the only way of managing an affordable health system. It is not even the only such system this country has had.

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

General Practice “won’t get any more sustainable”

A former Bradford GP lambasts the NHS GP system in a letter to Pulse:

I [left General Practice to work in a Hospice] for several reasons. Gone is the relentless pressure to move onto the next patient. I have taken a significant pay cut, but I don’t care, this job at least does not treat me like something you scrape off your shoe. I start at 9am, get a lunch break, and I get to lavish time on my patients.

What would it take to induce me to return to general practice? Even as I ponder the answer, I know it’s futile. The job won’t get any more sustainable with seven-day opening, and a dwindling number of colleagues. No. I’m done.

Read the whole thing.