Private sector good? Public sector bad?

A common rhetoric in the UK 2010 election campaign is “private sector good, public sector bad” which gets extended to public sector costs us money, private sector makes us money. Therefore, the politicians tell us the answer is to get rid of all these highly paid public sector managers who earn exhorbitant salaries. Preferably, by stringing them up from the nearest lampposts next to the bankers who are presumably also now in the public sector as we own most of them!

However, as with most rhetoric these appealingly simple statements are simplistic as well as simple. Yes, we need to reduce public expenditure. Yes, some public sector employees are paid too much. However, there may well be unintended consequences which may end up costing us more money in the long run.

The Private Finance Initiative (PFI) is a convenient accounting fiction to keep debt off the public accounts. But it’s still debt. By transferring activity from the public sector to the private sector, in this case, you actually increase the long term cost to the country.

The Liberal Democrats have announced the largest proportion of the cuts it is estimated they will have to make. They say they will cut the Eurofighter programme, which will likely have immediate job cuts in the private sector at BAe Systems in Lancashire. The two sectors are too intertwinned these days to separate them simply. many private companies generate wealth off the back of the public sector.

In health care, IT projects are an easy target. Because they have not delivered as promised, they are almost certainly part of the problem. So cut them, yes? There are two problems with this. The first is that the suppliers who have delivered very little over the last ten years are all PRIVATE sector companies, so the idea that the public sector has not delivered successful IT programmes is largely a myth. Secondly, the NHS is charged with making 5% efficiency savings year on year. As far back as 2002, Sir Derek Wanless identified the need for the NHS to operate more efficiently to remain viable and said that better information and use of Information Technology were a prerequisite. If we cut back on information budgets further how will we deliver the required efficiency savings?

And what about those highly paid managers? Terminating their contracts is an expensive business. If a manager costs £80k but is responsible for innovations that save £10M, then their salary may be distasteful, but it is surely a good deal for the tax payer (that’s you and me). Further, if you take out the inhouse management and still require innovations and change then you will end up buying in expertise at even higher rates from private companies who will recruit the former NHS managers and sell their expertise back to the service at higher cost. At the 2010 HealthCare Computing conference in Birmingham, there was already evidence of this on the speakers list.

Election campaigns are not the place for complex informed decision making. Let us hope that after the election, the necessary tough decisions may be a little more informed.

Better Health Must Cost More, Right?

Bob Evans, Health economist from British Colombia Canada coined the phrase “intellectual zombies” for ideas that refuse to die in spite of all the evidence. His particular bete noire (to mix my metaphors!) is that private health care is cheaper than public health care. It’s not. All the evidence says so but some people still believe it. So here’s my latest nomination for an intellectual zombie. Better Health Must Cost More.  Of course, there are times when you need to spend more to get access to a new wonder drug or a new scanning whizzymajig.

But the evidence just doesn’t stack up that overall spending more means better health. Who spends the most on health care in the world: the US at $7290 per head per year, or 16% of their GDP. At the opposite extreme of the (developed) spectrum, Singapore spends just $1228 or 3.2% of GDP. And yet, Life expectancy at birth is 79.7 in Singapore but 78.1 in the US, and the infant mortality rate is less than a third of the US rate in Singapore. The UK spends $2992 (around 40% of the US figure) and may be a fairer comparison because of size issues has a life expectancy of 79.1 and an infant mortality around two thirds the US rate.

Health is influenced by far more than medicine and even far more than health care. In Africa with some of the direst health problems on the planet, the most effective interventions are clean water and rehydration sachets to prevent death by diarrhoea, and condoms to prevent the spread of AIDS. Prevention is always cheaper than cure,and it’s always better not to be ill in the first place. Except that we only tend to prioritise health when we haven’t got it, ie when we are ill.

One of the challenges in a modern health care system is to make improvements with better outcomes and to save money, and yes it can be done. Immunisation programmes and some cancer screening programmes are both health and cost effective. However, demonstrating financial savings can be problematic. Costs are immediately incurred and immediately measurable. Benefits accrue from events that don’t happen (much trickier to measure) in other parts of the health care system from where the costs are incurred (not my budget: not my problem!)

Take asthma management. Costlier drugs in the form of more effective inhalers prevent emergency admissions to hospitals. Surely that’s better for all concerned. The patient doesn’t have  a frightening and painful experience and the hospital saves the cost of a patient episode to manage a severe asthma attack. Except the patient doesn’t know what they have been spared from, because it didn’t happen, and the hospital doesn’t know what resources it never used. In fact if it predicted demand on the basis of old assumptions, it may have saved less than it should by putting in place services which exceed demand. On the other hand, the drugs bill just keeps on rising in primary care.

This can be seen most acutely (pardon the pun) in the Canadian system. Drugs outside of hospital are not deemed medically necessary under the Canada Health Act and therefore for the majority of people are funded privately by contribution or insurance. These costs continue to rise, and it is almost impossible to track offsetting savings, not least when hospitals simply spend savings on other things.

Better Health can be cheaper in many cases, but it’s surprisingly difficult to demonstrate it.

Does health news reporting carry particular ethical responsibilities?

In a free society, a free media is a key part of that freedom. Health care is a high profile political issue. With the advent of 24-hour news channels, there is a need to fill the available time slots. Such channels often run themed weeks and focus on a particular subject. The health care system is a favourite topic.
This can lead to pressure to find health care stories and this in turn can give stories of limited news worthiness a higher profile than they may deserve.
In general, the publication of such material is justified on the grounds of either public interest or to help an individual patient gain access to care that they are currently being denied.
However, there are some distinctive caveats to this justification. The number of cases highlighted is often a tiny proportion of the patients requiring and receiving treatment. For many of those patients who will receive treatment promptly and successfully, there may be significant harm caused by the anxiety induced by such reporting. Whilst the harm may be less than the benefit which may be derived from the case reported, it may be done to many more people. Further harm may be caused by raising expectations that the specific treatment is effective, when it may only apply to a subset of patients with a particular subtype of the disease to be treated, eg herceptin.
The second caveat reflects the finite nature of resources. There is a danger that the prioritisation of treatment will follow those who can shout the loudest, or the most articulate, or those who have the most emotive case, rather than on clinical need. A news report recently reported that clinicians felt pressurised by political and public opinion. Far from occupying the moral high ground, the media are complicit in this pressure.
The media reporting is placing regulatory authorities under increasing pressure to approve treatments more quickly. Whilst this may be beneficial, it raises the risk of an unforeseen risk factor or side effect being missed. One of the sobering facts about thalidomide was that even in pregnant women, the harmful effects could have been separated from the therapeutic effects if it had been possible to separate two different forms of the drug, in this case, the optical isomers.
The most serious risk is in reporting of cases where there are direct harmful effects arising from the public changing their behaviour as a result of the report. The most dramatic example of this in recent times has been the MMR story. Even now, MMR vaccination rates have not returned to historical levels prior to the publication of stories linking MMR with autism. The apparent evidence for any link was always not sufficient to justify the stories published. The impact has been the return of measles. Claims by the media that the crisis could have been averted by permitting single vaccinations is no defence: there was no evidence that single vaccinations were safer and some evidence that it increased risk to children.
Freedom brings responsibility: a free media has a responsibility to follow the ethical of “first do no harm”. It may not sell papers and gain viewers, but it doesn’t conmtribute to suffering or death, either.

Informed consent: a noble myth

Informed consent is required in research, in treatment and for the storage use, disclosure or sharing of personal information. For this discussion, we shall consider consent to treatment as part of the delivery of health care. The concept came to the fore in the UK at a series of high profile inquiries into adverse events at Bristol and Liverpool. Those inquiries described situations where the health care professionals were deemed to have acted  paternalistically and failed either to obtain valid consent or provide sufficient information to enable patients to make informed decisions. This was responsible for a shift in public opinion and reduced trust in doctors amongst some patients, although the longevity and extent of this shift remains to be proven.

In guidance to patients, published in response to these inquiries, the Department of Health states that:

“It does not matter so much how you show your consent: whether you sign or say you agree. What is important is that your consent is genuine or valid.
That means:
1. you must be able to give your consent
2. you must be given enough information to enable you to make a decision
3. you must be acting under your own free will and not, say, under the strong influence of another person”

The influence of this guidance is seen in every UK hospital, where strenuous efforts are made to ensure patient consent. However, it still appears problematic. Consider a patient journey of my own to illustrate some of the issues. A few years ago, I was afflicted with kidney stones. Before arriving at hospital, I demonstrated my incompetence to make informed decisions. In spite of being in extreme pain, I DROVE myself to hospital placing myself and other road users at risk. On arrival, my first priority was pain relief. My options were explained to me. I was unable in reality completely unable to reach an informed decision. My actual thoughts were,
“I don’t care. Just stop the pain. If you offered to stop the pain at the moment by chopping off my head with an axe, I would not only say “yes!”, I would grab the axe with both hands and chop my own head off”

A little later, morphine having been administered, I was asked if I would like more. Does the junkie refuse their next fix? No, and neither did I, although I had absolutely no idea if I needed it.

There can be other unintended side effects. Later in the same episode of care, I found myself awaiting surgery and was visited by a doctor seeking my consent for the procedure I was about to undergo. The first problem is that as in many cases, I had no real choice to make, there was no viable alternative. In such cases, too much information can harm the patient. If I have to undergo a procedure, is it helpful for me to know that the operation is low risk, but the required general anaesthetic is much more likely to kill me?, And if it is, is it helpful to me to reinforce this message with a second conversation shortly before entering the operating theatre? In this case, it seems to have more to do with watching the hospital’s back than looking after my welfare as a patient.

Informed or valid consent is a noble ideal, but appears a noble myth nevertheless.

Stafford Hospital: Bristol Revisited

The events at Stafford Hospital have depressing echoes of Bristol and Alder Hey in the UK and Winnipeg in Canada and King Edward Memorial in Perth, Western Australia in the 1990s. These events had a profound effect on the development of clinical governance in the UK. In spite of all the enquiries, all the newspaper inches and the indignant editorials, here we are again.

Press reports (e.g. the Telegraph, March 1^st) are suggesting as many as 1200 patients died amid substandard conditions and care. Of course, it is not known how many cases are directly attributable to the poor care. After all, many were seriously ill. Equally, many patients who did not die will have suffered unnecessarily. It now appears that carers and relatives will be pursuing charges of corporate manslaughter against individual senior managers, who have not been disciplined and have moved on, sometimes with large payoffs.

The problems appear sufficiently serious to have produced multiple and complex symptoms. Although blamed on an obsession with targets and indicators, patients and carers also point to failings in basic compassion and care, suggesting that if the malaise started as management failings it spread to almost every aspect of care. Patients, were “robbed of their dignity”, left in soiled bedclothes, unwashed and in states of undress in full view of others

The problem is now to judge the implications for the broader NHS and especially for the debate about health policy leading into the 2010 election. Stafford was a flagship Foundation Trust with 3 stars. On the one hand, it is embarrassing indictment of some of the Government’s flagship policies. Although the substandard care was eventually highlighted by the inspection regime, many patients had suffered by the time the true facts were revealed.

Whilst this may appear a gift for the opposition this close to an election, Tory plans to reduce targets and lighten the inspection regime may reduce the risk of another Stafford, but offer the spectre of taking even longer to highlight such problems. Worse, Foundation Trusts are the logical inheritance of the internal market first introduced by the previous Tory administration. Although the internal market was temporarily demoted in Government rhetoric in the euphoria following the 1997 election victory, it was never far away and may now be seen in Foundation Trusts as providers, and PCTs as commissioners (aka purchasers) not to mention Practice Based Comissioning or fund holding as it used to be called in the bad old days.

The NHS is a remarkable achievement, and has seen huge improvements in the last decade in access and outcomes for a modest increase in resources when judged against the rest of the world. We need to know what went wrong at Stafford, but it would be regrettable if it triggered a knee jerk reaction. It is too important to become an election football, and hopefully, election planning blight will facilitate cool reflection instead.