Money for nothing

I am deeply in love with the NHS. Our relationship has been rocky and we have had our fights and spats over 4 hour targets and spending cuts. But at heart we were made for each other.

Even if the relationship did only have its beginnings as a way to have a healthier population to send into battle following the disasters of the Boer war.

But in principle it is brilliant. Universal (though i’m not sure it applies to aliens from other parts of the universe – see District 9 for an example) health care free at the point of delivery.

Health care made simply extraordinary leaps in outcomes (in terms of lives saved, and saved well) from the 1930’s to the 1970s (see the wonderful Rise and fall of modern medicine for examples) but to be honest we’ve gone into somewhat of a decline in the past 30 or 40 years.

Now if you watch TV or what you read in the papers then you wouldn’t think that – what with all the sexy new drugs and fancy scanners then surely we’re moving forward. But in reality we’re not. If you take away all the fancy diagnostic technology that gives us all the pretty pictures of the tumour that’s gonna kill you (that we still can’t fix) – take that away and we may as well be living in the time of MASH.

[There are of course exceptions but the overall trend has been poor since we largely cured childhood leukaemia and figured out smoking caused cancer]

In contrast our spending on health care has rocketed. Though our outcomes are perhaps not much better.

Even the NHS (as much as I moan) has seen huge increases in its budget. My concern is where has all the money gone to…

Across the pond they have one fifth of the population with no health care insurance.

This is different from saying they have no access to health care – hospitals are obliged to provide care to patients who present to their Emergency Department (ED). This leads to

a) lots of sore throats and sore toes turning up at EDs

b) patients with serious illnesses only presenting to hospital when they’re really sick and have had symptoms for months.

This is hardly ideal.

Since the Obama health care debate got started I’ve been tremendously interested in the nonsense that it being talked about it and particular about the current state of their system.

It has made me realise how good a job we often do with health care in this country. Given the limited resources that we have (and they will always be limited in any country) we manage to do a better job than the mighty US health system. Just because you can get your coronary angiogram the next day instead of 4 weeks later does not make your health any better. All you get is choice, not better health – presumably why Americans like it so much, given the obsession with choice, individualism and self-determination.

I now subscribe to the institution that is EMA (Emergency Medical Abstracts) or the Rick and Jerry show –  a monthly two and a bit hour podcast where these two guys go through 40 studies on a wide variety of topics. And in general they tear them to shreds, picking apart errors and methods and conflicts of interest in a way that would warm the cockles of Ben Goldacre‘s heart.

They are both of the opinion that the US needs universal health care. Part of the reason they believe this (i think) is because they are emergency physicians –  they are the only sector of the US health care “market” that provides free health care at the point of delivery. There are large powerful sections of the medical community in the US who have a vested interest in the status quo. The cardiologists want to provide your angio for you the next day, whether or not best practice and evidence says you need it or not.

There are too many specialists with too many procedures in the US. You want a camera up your arse to investigate your vague bowel symptoms? Sure thing.

Emergency Physicians have no vested interest in this. We don’t have our own specialist procedure that makes us unique – we are the last of the hospital generalists.

And so when these guys speak I listen to them. Rick Bukata has a series of essays on this that i’ve just been reading and they make me want to jump and shout “preach it brother”. But I’m Irish and white and couldn’t pull it off too well.

I’ll make a few brief summary points.

What he describes as the 5 myths of the US health care system:

MYTH 1: THE US HEALTHCARE SYSTEM IS THE BEST IN THE WORLD

– It isn’t. It may be for a small minority, but certainly not in general.
– in 2000 WHO ranked the US health system as 32nd in infant survival, 24th for life expectancy and 54th for fairness (whatever that is…)
– in 2007 they paid 16.2% of their GDP on healthcare for this illustrious position
Some of the others for comparison


[Money per person spent on health care]
Australia = $2,960
Austria = $3,462
Belgium = $3,326
Canada = $3,505
Denmark = $3,643
Finland = $2,546
Germany = $3,247
Iceland = $3,285
Ireland = $2,945
Italy = $2,520
Japan = $2,529
Luxembourg = $4,223
Netherlands = $3,391
Norway = $4,233
Sweden = $3,075
Switzerland = $4,311
United Kingdom = $2,560 (data from 2004)
United States = $6,567

– So they pay more than twice as much as us for their health care yet their outcomes are no better, and probably worse.

MYTH 2: THE UNINSURED HAVE EQUAL ACCESS TO MEDICAL CARE THROUGH THE EMERGENCY DEPARTMENTS

– chronic conditions are not dealt with well in the ED. Ask me – i haven’t a notion of the best way to treat chronic high blood pressure. (I also don’t care so don’t ask)
– he quotes a study that after adjusting for age, smoking, gender, education-  lack of insurance itself lead to a 25% increase in mortality independent of income level

MYTH 3: A FREE MARKET IS THE BEST WAY TO GET THE HIGHEST QUALITY HEALTH INSURANCE FOR THE LOWEST COST

– this one makes some degree of sense but doesn’t work out in practice. When you need your gall bladder out you don’t shop around, you just go to the nearest surgeon and your insurance company picks up the bill.
– the consumer cannot influence price and quality
– for example Medicare (the government funded insurance scheme for over 65s) uses 3% of costs for admin while admin for private insurance companies was 16%

MYTH 4: WE JUST CANNOT AFFORD TO COVER EVERYONE

– every other industrialised nation manages to do so (and for a lot cheaper)
– there is huge scope to reduce costs

  • train more generalists (no one wants to do primary care cause there’s not as much money in it)
  • decrease unnecessary procedures – eg US does three times as many angioplastys as Canada with no improvement in life expectancy
  • decrease the ludicrous charges (one example of an ibuprofen pill costing $25 and an injection, not even the drug just the process of an injection costing $300)

– estimates of providing cover vary from $65 – $130 billion a year but note that half of this is already spent on the care provided to the uninsured that turn up at the ED

MYTH 5: PHYSICIANS ARE LARGELY VICTIMS IN THE CURRENT SYSTEM

– this is my favourite, it destroys the notion of the caring, decent doctor – when in fact we haven’t even got our own house in order. Perhaps… who would dare say it… that we have vested interests in making lots of money…
– doctors are the major determinants of health care costs – we order all the tests, we call the patient back for clinic visits. This is fine when it’s needed but the huge variation in physician behaviour leads us to think that perhaps some of the tests and drugs and admissions aren’t necessary
– incidentally if you read the studies and know your medicine then it turns out that that’s right – we order far too many tests or the wrong tests and use the wrong treatments
– my own personal favourite was a study that looked at how test ordering dramatically reduced at a hospital when it’s computerised test ordering system introduced the price of each test beside the tick box. I’d be interested to see how that would impact practice in the UK where we just order tests often without thinking cause neither us nor the patient will be billed for it.

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1 Response to “Money for nothing”


  1. 1 Roads September 29, 2009 at 7:56 pm

    How I love this post! The NHS is such a unique gift that we have in this country, and yet all too often we do it down.

    I don’t know why this is. Maybe it’s a part of living in these misty islands of ours. But it’s high time that we woke up and took notice of exactly what we have. And make sure that we bloody look after it.

    Keep up the good work.


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