Monday, 27 December 2010

A Clean Bill of Health?

Why health Spending and Good Health Care are Not Necessarily the Same Thing.

We are constantly told that the NHS is under-funded and that the more we spend on it the better our health will be. I used to believe it, of course, but nowadays after a lot of experience and reflection I regard the whole issue as being far more complicated.
The best health care does not necessarily take place in the most expensive modern hospitals. Gleaming new buildings, using vast amounts of lighting and heating 24 hours a day and 7 days a week, are expensive for the tax-payer. But I don’t believe that they can make up for long, difficult journeys to hospital from areas where the older, smaller hospitals were shut down. NHS managers earn vast salaries but I don’t believe they can make up for doctors who are depressed and demoralized by the amount of managerial bureaucracy they have to deal with in the course of their work.
State-of-the-art equipment can save lives, but can it make up for the loss of that vocational, dedicated attitude to their work which doctors and nurses used to have? Nowadays hospitals are usually staffed with agency nurses, or hastily-recruited foreign nurses and doctors with dubious qualifications and inadequate understanding of English. All of that has a negative impact on the quality of care. Fourteen highly paid and well-equipped professionals saw baby Peter Conolly before he died yet they failed to save him.
The cost of funding the NHS has mounted astronomically since it was founded. The model for the NHS was the simple system run by the old railway companies, whereby employees paid a few pennies per week for medical insurance. That medical insurance did not include heart-transplants, family planning, fertility treatment, hip replacement operations or gastric bands. Those are modern inventions. Nor did it include vaccination against measles and flu, or treatment for drug-abusers, or HIV sufferers. In 1945 it was widely believed that a dose of antibiotics would cure any disease. So the notion of a simple, national health insurance scheme was not problematical.
Since then, the funding has risen from millions to billions, and the health service is caught up in a seemingly endless spiral of mounting cost. The pharmaceutical companies have invented thousands of new and ever more expensive drugs, and as soon as they are invented, the NHS is expected to buy them. Most of the drugs we buy now did not exist in 1945 and cost from ten to a hundred times as much as their predecessors. This creates moral and evaluative dilemmas. Who is to say whether a particular drug produces results that justify its cost – or justify the loss of spending in other directions to benefit other patients?
The problems are aggravated by the fact that under EU rules we are compelled to sell any drug we produce to the highest bidder anywhere in the EU. So even the prices of previously affordable drugs are being pushed relentlessly upwards.
A friend of mine was suffering from a bunion on her foot, so she went to her local NHS GP. He put her on a waiting-list for specialist advice, but suggested that in the mean time she saw a private chiropodist. The chiropodist spent hours asking her about her entire medical history, cut her toenails for her, looked at the shoes she was wearing and charged her a hundred pounds. She was assured that only the initial visit would be so expensive, and future ones would be only fifty pounds, but she never went back.
When she went to see the NHS specialist, she first of all had to go to have her feet X-rayed. This took an hour, in the waiting-room and afterwards. The specialist saw her in a nice modern office with a computer system, telephone, coffee-machine, pot plants, pictures on the walls and an examination coach surrounded by curtains. He looked at her feet, looked at the X-rays, and read what her GP had written, then talked into a voice-recording-machine instead of making written notes. He thought there was no need for an operation so he did not recommend any treatment at all. His secretary typed up a letter which was sent back to the GP.
Eventually the woman with the bunions looked in a catalogue or internet site and found somebody selling a plastic gadget she could wear at night on her foot to straighten out the bunion. It cost about five pounds. It was made (of course) in China, where people have no NHS and most of them certainly cannot afford to go to chiropodists at a hundred pounds a time. Apparently it is having quite a positive effect. The cheapest treatment has been, in her case, the best and the only effective one.
I don’t know what the future of the NHS will be. If it is taken over – like all our institutions – by the EU, we can safely count on them to mess it up. But we should be very suspicious of any simplistic equation between money-in and results-out.

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