Saturday, 21 December 2013

Costs and Outcomes- NHS v/s Medicare

So how exactly does the Australian system compare vis a vis the NHS?

Does giving Drs complete freedom make them irresponsible clinicians? Do costs skyrocket?
What about outcomes- how do they compare?

Exact comparisons are of course well nigh impossible but people have made a stab at comparing health systems- each one invariably comes out with a different outcome but have a look at the link below. It talks about the most efficient health systems. I think the gym analogy ends here for several reasons:
  • The health industry is much more regulated.
  • Though there may be competition most countries will map Drs to demand. In UK the average GP has 1800-2000 patients registered with them. In Australia, the govt earmarks Areas of Need (AON) and District of workforce shortage (DWS) where it tries to match numbers of Drs to demand and actively directs Drs where there is a shortage. So unlike a gym when GP surgeries exist close to each other the number of patients is sufficient for both to exist.
Bloomberg has used what it calls 'Efficient health Care' as a means of judging success- this is based on several parametes including life expectancy and per capita costs. UK is number 14 on the chart. And Australia? No. 7. For a full list see here (Updated 2/12/14 the link has been updated and some rankings/figures are now different)

So clearly a capitation based system cannot be said to be superior in principle. There is some merit in saying that a free market economy model does lead to spiraling costs as in the USA (ranked 46) but this is an Insurance lead model and not a levy on income based model like medicare.

But, is it that important? Even UK is not badly placed and 14 isn't too bad. However, there are some compounding problems which I feel will widen this gap to the detriment of UK. UK has an ageing population and though Australia is aging too it is a)younger to begin with and b)growing older more slowly. The median age (Median age is the age that divides a population into two numerically equal groups - that is, half the people are younger than this age and half are older) of Australia is 37.5 and of the UK 40.5 (For a full list see here)
If that wasn't enough the projected number of people over the age of 65 in 2020 stands at over 19% for UK and just under 16% for Australia. Even in 2050 Australia will have less over 65s than UK (see here).

Remember what I said about 10% of your population using up 90% of resources? Well, the vast majority of those reside in the over 65 age group. So, if a country has a higher burden of over 65s and this is projected to grow; where should said country concentrate its resources? But, just at this crucial juncture the NHS has embarked on a project to save £20 billion by 2020!!

A recent kings Fund report states :From 2012 to 2032 the populations of 65-84 year olds and the over 85s are set to increase by 39 and 106 per cent respectively whereas 0-14 and 15-64 year olds are set to increase by 11 per cent and 7 per cent respectively.
That means the work force will shrink and those requiring increasing support will increase exponentially. Whilst the report states that the elderly still make a net contribution to the economy even after taking the increased health care costs it is clear that health care costs do go up. 

At precisely this time the NHS is faced with low staff morale and reduced staffing levels. The RCN(Royal College of Nursing) has identified 68,880 NHS posts marked for cuts by 2015; of these 24,836 have already gone, of which 4,837 are nurses, midwives or health visitors, and 4,042 are healthcare assistants. 
Five Psychiartry consultants from my local hospital have upped sticks and gone to Canada- this at a time when a dementia epidemic is predicted! And the number of Drs requesting Certificates of good Standing from the GMC (a surrogate marker for Drs intending to migrate) is going up.

As a clinician I can't help but feel alarmed at these changes. And as a potential patient? Is this why we are going to work longer, pay more in NHS contributions, taxes etc? The focus seems to be on short term gains and a longer strategic vision seems to be missing. 

This I must point out is not an inherent fault of the Capitation based system. It does, in my view lead to the wide variation in primary care that is evident in UK and some people think the NHS reforms were motivated by a desire to dismantle this. 

If true, it seems an unnecessarily convoluted way of doing things and may have potentially disastrous and unintended consequences

I started by ending an analogy. I'll end by starting another. The NHS reforms centered around making Drs commissioners and putting them in charge of budgets instead of managers. The presumption I guess was that as clinicians they would make sound clinical decisions and commission more cost effective services based on their local population needs. 

But is there any evidence that this is the case? You could argue that its too soon to say. But the effects of this reorganisation itself; seem to me atleast, to be having the opposite effect.

So the analogy? If we assume the NHS was the military and apply the same principle- ministers, managers, manufracturers are messing up the budget so lets give control to the soldiers. Therefore like CCGs commanders from the 3 services lead and control expenses, acquisitions, deployment etc. Makes sense? 
Now in this scenario, can you imagine a Commander from any service going up to Parliament and willingly accepting cuts? Or actually making bigger savings than targeted (for 2011/12 the NHS delivered a surplus of over £2billion!) and then accepting even bigger cuts year on year? This is exactly what Drs as commissioners are doing (my personal opinion again). So they may make cuts in troop sizes (NHS is loosing frontline staff so an apt comparison), reduce services altogether like close bases (akin to closing hospitals or A&E departments). Is that what  the armed forces do? or the police chiefs??

No- they have budget cuts imposed on them. They protest loudly and spell out the dangers of those cuts that they foresee. Then they try and deliver what they can. They are candid with the public- the police chiefs come out and say openly that due to cuts there will be less bobbies on the street for example.

But, when it comes to the NHS,  politicians promise a world class health system to the public. Yet, they allocate a budget which makes it impossible to deliver this, leave alone investing for the future. And the Commissioner Drs? Do they protest like the Police chiefs or Army generals? No! they act like they believe the cuts are justified themselves and make compromises to deliver what they have been asked to. This erodes patient confidence in their GP. This to my mind is the biggest debacle of the whole situation. If the Govt is unwilling or indeed simply unable to spend what it takes to deliver a world class health system then it should be candid about this with the public. 

We as Drs should demand more funding and expenditure per capita if that is what is required (and evidence I have presented above would indicate that it is). We are always told that there isn't an infinite pot of money- in fact there is! The spend on NHS as a percentage of GDP is not only tiny but shrinking. 

The govt will shout form the rooftops that spending per capita on NHS is increasing year on year. However, as a percentage of GDP it is falling!

Don't believe me? Look here at the figures  for yourselves. 

I ask again- with an ageing and growing population should the Govt spend more or less on the NHS as a percentage of GDP? And as Drs what is your duty to your patients. Think long and hard before you answer that if you're a Dr.

Next blog- I visit Australia!

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