Be Excellent To Each Other

Any kind of insurance based healthcare is bullshit and will absolutely lead to people getting fucked over. I'm not saying that from a political point of view, it's pure market forces. In any other business a customer exchanges money for goods and/or services. This means there's a common ground between the customer and business, namely that the customer is happy with the transaction so that they come back later and give the company more money for future purchases. And tell their friends and family about it so they also come and give the company more money of course. Insurance is different though in that the consumer and the company are betting against each other (the consumer is betting that something bad will happen to them and the company is betting it won't) so the two parties are pulling in opposite directions right from the start and it's in the company's best interests not to pay out anything on the bet. That's a weird enough business relationship when it comes to getting a replacement phone because you lost it or whatever and it's certainly not something I'd ever choose to trust my health to. To make it even approaching fair for customers you'd need to regulate the ever-living shit out of it, and if something has to be regulated that heavily to keep everyone honest it's a red flag that what you're trying to do is a bad idea to start with.

Not really. That is what some insurance has become. Not what it is, which is simply a case of pooling and leveling risks.
Would be possible to keep it at that.

I agree with much of that, Pliss, although I'm coming at it from the opposite ideological direction of course.
Thing is, I believe that if we actually attempted a radical, back-to-fundamentals, INFORMED debate in this country about the NHS, and the 'best of the [continental Europe] rest', many British people would look at the bangs-per-buck of both and decide, quite rationally and empirically, that actually we would indeed be better off starting again using French, German and other EU healthcare insurance-based, private sector systems as our model - disbanding the NHS as an entity altogether?

The keyword here is RADICAL debate, as opposed to the usual endless tinkering and turd-polishing that successive governments of all political hues attempt in this country, fiddling with fundamentally misconceived, broken systems like the NHS and comprehensive state education at their edges, instead of acknowledging/admitting/informing their public that actually, they really are broken? The healthcare of the nation (as well as education) is a big, big deal, and if it's not working anywhere near optimally, principally because it is a dinosaur of a centralised, closed, top-down, paralysed megalithic structure that no company since the '70s remotely now emulates in their management systems (which are horizontal, open and empowered), that ultimately means that many people are needlessly suffering and dying, not to mention paying too much taxes for too little in return. (The Soviet Union was the ultimate embodiment of centralised power and adminstration; people queued for hours for a loaf of bread and there were 20 year waiting lists for appallingly made, decades-obsolete Fiat clone cars. Before anyone laughs too loudly at such an admittedly simplistic analogy, don't forget that the NHS is by far the largest single employer within the UK. It is huge).

But, politically speaking, the NHS is a holy cow in the UK. People like HoE here seem to equate private insurance based schemes with people being excluded from healthcare and all the scaremongering this entails, despite the absolute truth that this doesn't happen in Germany, France or elsewhere in Europe. I just can't see any administration - let alone a fragile coalition - having the requisite political vision and courage to initiate such a debate and really do what has for so long been desperately overdue IMO. Instead, we get the aforementioned yet further turd-polishing and tinkering that virtually NO ONE, on either side of the debate, thinks is a good idea.

Indeed. Seems to work just fine in France, Germany and elsewhere.

I suppose the thinking behind breaking up the super-monolith into individual trusts is that it does at least introduce some diversity into the equation which, as has been empirically proven time and again, is very often beneficial (see last year's Reith Lectures for more on this point). But of course, it's only pseudo diversity - those trusts are still firmly within the cold grasp of the "dead hand" of the Public Sector, and are thus run and staffed along more or less the same lines as before, ergo by the same unincentivised, unmotivated and often ineffective people - so it's all so much window dressing at the end of the day. (Incidentally, I know two people who between them worked for 30+ years within the NHS. They both tell me of many instances where useless people were promoted into management roles precisely because they were a liability on the actual 'coal face', and they had to be got out of the way before they did any damage. Naturally, there was no prospect of actually just getting rid of 'em, for being crap. What sort of business model is this?)

I totally agree with you re. "choice" - it's bullshit. If hospitals are run properly and perform well against the EU's best, as benchmarks, there is no need of "choice". If you think about it, this policy is actually an open admission that there is wide variation in performance across the NHS, which just shouldn't be there at all, if things were run properly.



On the face of it, agreed, although 'postcode lotteries' were very much in evidence before these changes of course. It's yet another example of tinkering at the edges. Far better, IMO, to have one private sector company in charge of the entire UK drug budget, charged with the sole task of getting all drugs for less than NICE was able to do, otherwise they don't get paid (but they *do* get paid a handsome proportion of the savings if they do), as well as bettering procurement lead times, administration overheads and streamlining etc., which frankly should be "low hanging fruit" if ever there was.

Interesting stuff here, summary of 2012 Health Power House report which compares EU healthcare systems:

http://www.healthpowerhouse.com/files/e ... elease.pdf

So, we're about the same as Ireland, slightly better than Germany (which is a shock to me), but much worse than France, itself worse than the very best - the Netherlands being the clear winner.

Unsurprisingly I guess, the Netherlands' healthcare system is insurance-based.

UK-specific comments:



I don't know about anyone else here, but I personally would much rather see my hard earned tax dollar being spent on new cancer drugs to give very sick, genuinely ill, blameless people the chance of life - or even simply an extended life - than seeing it being pissed away on IMO entirely undeserving cases, in my name, on things that I do not in any way support or agree with, both within the healthcare sphere itself and more generally welfare outside of it, too.

So the NHS is much, much better than many private healthcare systems and improving all the time. Yes, we should definitely sell it off then. For fucking fucks sake.

Well I don't think anyone's necessarily talking about selling it off, nothing to prevent the assets (hospitals etc.) remaining as state assets. But seriously mate, I see this as a question of aspiration and reasonable expectation. Being 'about the same as Ireland' (and much, much worse than the EU best) is nowhere near good enough for me, or even satisfactory - people's livelihoods, wellbeing and indeed their very lives are at stake. More than any other sphere of State influence - even education - we owe it to the people of this long-suffering country to deliver the very best that we can to them, in terms of outcomes, standards and yes, value for money. Clearly, whilst things could be worse (although no-one is surely suggesting that, given the vast resources heaped upon health, particularly these last 10 years, that we should be comparing ourselves to much poorer ascension Eastern European states?), they could be a lot better as well. So it's just not good enough, IMO at least, and most certainly not something to allow political ideology, fundamentalism, sheer inertia/unwillingness to countenance change and/or political vanity to get in the way of. There's been far too much of those things going on these last 15 years already, most especially the latter.

The point is that the defining difference between health systems is not how they are funded. It's a whole myriad of other things, details, things which take care and attention to fix. To expect that market economics will magically fix it all is just so ridiculously simplistic.

Oh sure, I totally agree. But didn't I start this latest discussion by saying the American private sector/insurance based system is a feckin' disaster,l far worse than the NHS which is brilliant by comparison? It's not simply a case of "private = good/public = bad"; the private sector has plenty of scope to louse things up at least as badly - probably even worse. You know, fuck ideology, on all sides.

I agree it is complex, but in a sense a whole bunch of other people have painstakingly and no doubt very expensively done all the research for us already - the Dutch, it would seem. They've already empirically determined all the blind alleys and ironed out the major bugs, over many, many years. So, all we need to do is blatantly and faithfully copy theirs, and other similar, similarly successful models?

The Japanese built an enormous bike, car and other industries by simply copying the best - it works, and it can be done. After all, imitation is the best form of flattery and it's no skin off anyone else's nose if we lift our healthcare system to deliver benchmark bangs-per-buck.

But those Scandinavian countries do an awful lot of things better than us. Why are their schools better, for instance? As far as I know they aren't privately run but they are still better. I'd say they key difference is probably decades of chronic underfunding. It's a lot more complex than a car factory.

Actually that's a very good question, to which I haven't any clue as to the answer. As a pure guess, I'd suggest better funding per capita - but there again we still lavish pretty serious resources on education and have done so for decades - which would suggest structural, endemic issues, the way we do things in particular...? I don't know if the Dutch/Benelux Countries shun streaming, selection, entrance testing and the like, such as we did for a very long time and still do to a fair extent ('true' comprehensives with little or no diversity), or not. Equally, I don't know whether there is any diversity in actual schooling provision; whether or not the private sector or other independent bodies outside of local authorities or their equivalents have much, or indeed any role. I don't know how classroom discipline/disruption issues are handled, nor indeed peripheral - but important - things like school meals. Etc.

(As a complete anecdotal aside though, I learned yesterday of a school around here that appointed a teacher with a GCSE in mathematics (i.e. not even an A-Level, of any grade) as Head of Maths Dept. I *seriously* cannot see that happening in Holland).



As regards healthcare, the level of funding the NHS now receives, and has received for a very long time now, is certainly comparable to other EU states, though I can't talk specifics for the Dutch. Of course an entire nation's healthcare system is a complex animal but again, a complete overhaul (as opposed to tinkering at the edges) can be rolled out. It's just difficult, long term (much moreso than a mere parliamentary term) and costly. As to whether it's justified, that is indeed the question, but to my mind given the large variation in performance between ourselves and our EU peers (as measured by independent, international bodies with no political or other axe to grind), with the best-performing systems very largely being of a completely different (insurance based) type as compared to the NHS, it does seem as though there is a prima facie case for it at least, in my opinion. Surely it is beyond empirical doubt that there is considerable room for improvement, at the very least.

We will never agree this final point, but in my entire life and business experience, pretty much anything that is done by a Local Authority (Council), regardless of stripe, is often slow and inefficient in the extreme as a minimum, and often pretty rubbish. Personally, I have virtually no faith in the public sector at all, whereas my experience of the private sector ranges widely from the truly excellent to the appalling (i.e. is hugely mixed). I guess you could say that at least with the private sector there is the potential to get things done, in a proficient, timeous and efficient manner? That is my ideological starting point and instinct, I guess.

Regardless of party in charge, many hospitals are still lumbered with huge PFI debts. It's a ticking timebomb that would have existed with or without the Health & Social Care Act.

But at least it kept the borrowing off the books.

Higher taxes and not desperately wanting to be the USA helps. As for choice in hospitals, that strikes me as about as likely to succeed as privatising the rail system. My 'choice' in Fleet: South West Trains. And then there's South West Trains, going in the other direction.

From OECD Health Data 2012:

Netherlands' health spending as % of GDP: 12.0%
UK: 9.6% (up from 5.5% from 1997)

[1]

Not that this tells us that much, but it does show that the Dutch still end up spending more (and spend more than any other country except for the Americans).



NICE was one of the most admired parts of the NHS across the world, due to its ability to get astonishly good prices for drugs, and you dismiss that by suggesting a private company would be able to do better by virtue of simply being private? I'm inherently suspicious of Governments handing private companies monopolies (and in this case, in order to get anywhere near NICE levels, they'd need the buying power of all the NHS trusts), so I think you need to show your working a bit more here - can you explain how your funding method would work from year to year (seeing as how inflation and whatnot would mean that NICE prices wouldn't be a yardstick past the first year), and what might happen if the company being gifted with this monopoly went bankrupt?



Or, being better in that survey than Ireland, and better than Germany, which you previously used as a shining example of a health care system (and as in previous conversations, the German model does have its drawbacks, as Anonymous X used to explain). What that survey shows us is that we have a decent healthcare system, that yes, could use improvements, but isn't, to borrow a phrase, 'the sick man of Europe'.

Here's another survey from the Commonweath Fund that paints Britain in an even better light: [2] [3]

In this survey, we're about even with Switzerland in top place - scoring higher on some areas and low on others. Two different systems, but no overall winner. And of course, some quality beating up on Americans.

But going back to the survey you posted, look at #2. It's Denmark. And what does the Danish healthcare system look like? Well, it's a Beveridge-based system that looks quite similar to how the NHS operates. Not identical, no, but not an insurance based system either, and it's doing quite well for itself.

I'm not saying that insurance-based Bismarckian systems are inferior to Beveridge systems. But there's little in the evidence you've posted that *proves* that Bismarckian systems are the better system beyond all doubt. Given that, it seems madness to overhaul our healthcare to a system that may not end up delivering better care.

(and even more insane to move us to a model that seems to be wanting to bring in as much of the American system as the public will bear, but we're not arguing about the Coalition's reforms )

Finally, in regards to education - it's widely regarded from tests like PISA and TIMSS that the best schools in the world are in Finland. And they're comprehensive and egaliterian on a level that makes the 60s Labour reforms look tame in comparison. Which again tells us that the idea of tripartite being inherently superior to comprehensive schooling is a false one. Implementations, of course, may vary.

[1]: http://www.oecd.org/netherlands/Briefin ... DS2012.pdf
[2]: http://eprints.lse.ac.uk/42050/1/How_th ... ERO%29.pdf
[3]: http://www.commonwealthfund.org/~/media ... rtpack.pdf

I'm feeling another one of those "shite, I've been shot down in flames. Again." kind of moments coming on

Still, no matter. That's actually an entirely good thing, even for me personally. I'm here to learn. Peter, I'm on the iPhone now, but is there any way to easily determine the % GDP spend on healthcare (and education, come to that) of EU nations please? I don't want to sound cheeky but yknow, this is very much your area.

I just want to be clear in my mind as to the role of the method of delivery (if any, at this rate!) versus simply the amount of money, per capita, spent.

Healthcare GDP can be found here: http://www.oecd.org/unitedkingdom/Brief ... OM2012.pdf (we're slightly above the OECD average, but only just), and for education, I think you'll what to look at Sheet C_B2.1 here: http://www.oecd.org/edu/EAG2012_SL_B2.xls

(sorry, in a meeting right now, so links only )

Awesome! Many thanks Peter, don't know how you do it. I'll have a good firk around those spreadsheets later, but first glance interesting. For instance, UK spends more on education per capita than Finland does for one, not to mention a 25% rise in education funding in proportion to GDP terms between 1995 and 2009.

On health, Sweden's cost per capita in 2010 was $3758 as compared to the UK's $3433 (itself above average as you say), but it performed much better than we did. Finland's was even lower than ours at $3251 per head, yet did better than the NHS as well, so on the face of it, the data does not suggest that it's all simply down to how much money is thrown at the problem. However, I need more than 2 mins at the kitchen table to go through it in more detail.

(As regards your earlier point about the UK vs. Ireland though, they are virtually identical in performance terms in that link I gave earlier, to be fair)

Much of the investment in the NHS is only just seeing benefits realised. Where I work we only just now are able to afford to get rid of some prefab temporary buildings erected in the 1950s and replace them with something suitable. And to build a multi-storey car park for staff and visitors. This sort of thing is the legacy of all that underinvestment and it takes time to correct. It is utterly necessary but might not show instant benefits to health outcomes. Doesn't stop the Daily Mail type half-wits from concluding that every penny not paid to a nurse must have been stolen by greedy managers, though.

I think nurses should be paid more, but that's only because I'm married to one and I like money.

Ditto.

o/

(Oh, and because they get treated like shit by doctors, patients and Trusts a distressing amount of the time.)

And so am I, in fact my wife and now my sister are both nurses, my brother and sister in law are a GP and an A&E consultant and father in law is a pharmacist. From what my wife tells me some nurses should get paid a lot more, some a lot less and some hardly at all. Also some of them used to get promoted to what are essentially management roles, i.e. matrons, really through sheer persistence and often they are hopeless at it. But yeah some doctors are utter cockheads with other staff, usually it's the younger ones, they tend to gain a bit of humility as they get older. Or else they don't and become complete monsters but usually also the person you'd want there to help if you were all fucked up.

Hehe... pretty much exactly (apart from the other family stuff).

Maria has such stories about awesome nurses, but there are a load who are just terrible, and there's little-to-no pay differential as to whether you're super or shite.

I think nurses should definitely be paid more. Except the one last week who stuck an IV straight through one of my veins and out the other side, pumping 100ml of fluid just generally into my arm. She doesn't get any more.

This morning I received a package from the government containing a cyanide pill and directions to the ditch they'd like me to lie in.

That's a fucking disgrace. It should be a prescription for a pill and you should jolly well pay for it.

Mrs T used to work with a hospital receptionist who could hardly speak english and a dietician who had such a strong accent nobody could understand a word. The dietician used to complain about no-one ever coming back to the clinics she ran...

It's amusing, but seriously, how do these people get a job like that in the NHS in the first place? Especially the receptionist, surely being able to speak English is a prerequisite?
Actually I know how, the interviews are based on a fixed set of questions, with expected answers and points allocated aren't they? I'm guessing there wasn't a question "Can you understand them?", or if there was it wasn't rated high enough!

See now, I don't think stuff like this is helpful.

I passionately believe that the NHS could be seriously and systemically improved, which if so, would clearly benefit everyone, in fact normal people much moreso than the rich, who all have private medical healthcare anyway.

Since it's only me who seems to be suggesting NHS reform, I can only assume that these "I need to take a cyanide pill" Soylent Green type remarks are somehow directed towards me, as if somehow these are my sentiments - which I'm sorry is utter bullshit and actually quite offensive. I've ignored them thus far but I'm not going to keep on ignoring them as that's not me people are describing.

Personally I think this has been quite an informative, good-tempered debate so far. I certainly do not think I have all the answers or anything like, and as you can see am quite prepared to accept I could well be wrong, so stuff like this is neither helpful or appropriate anyway. I'm no tiresome, heartless Tory troll.

Woah there! I don't think that for a minute cavey, I don't think Dimrill does either. I know you don't agree with everything this government has done despite describing yourself as a Tory because you have said so. I took that comment as him voicing his opposition to the way that they are headed with things.

I'm quite sure they are not - there is a lot of useful debate in here so please try not to read too much into other parts of it

Ok, fair enough mate, thanks. I would truly hate it if anyone thought otherwise.

Hurtful. Yes. I am a sciving piece of scum who's claiming of benefits due to acute mental illness is a drain on the striving nation. I would be better off dead, and all the debates of what to do with me and my kind in the national press makes it so much easier to concentrate on recovery instead of more spiralling despair of my utter worthlessness. I look forward to my NHS treatment paid for by other taxpayers to get increasingly worse, making it easier to get better.

I really sorry Dimrill, if this kind of stuff/discussion upsets you I will withdraw immediately. Please believe me when I say that I did not intend any of this discussion to hurt you in any way.

I've suffered mental illness myself (and still have to have professional councilling every week) so, whilst I don't have to deal with what you do mate, at least I have half a clue as to what it's about.

Besides, never define anyone with what job they have or have not got, or how much money they do or don't have. You're ten or a hundred times the man of many people who I know who are minted, but absolute small-minded cockroaches without a gram of love in them between them.

I'm not pointing fingers at anyone here at all. You're remarkably levelled head (for a Tory! ). The newspaper and party politics that lead to demonisation of people in my predicament makes my voluntary imprisonment in these four walls seem like it will never, ever end. I would be better off dead.

Who would send me Warhammer eBooks?!

My life would be poorer with no Dimrill

Except the current Dutch system (which is basically an inexact copy of the fudged-together system that Switzerland has had since the early '90s) is as regressive as it gets. There is a flat-rate premium which you have to pay into private insurance schemes, on pain of government fines and losing healthcare coverage. Yes, you have to pay into private health insurance company, not statutory insurance or a mutual scheme. The compulsory 'basic' insurance package isn't risk adjusted, but add-on insurance schemes are. Add-on insurance covers what the basic insurance doesn't - but the basic scheme covers less and less over time, such as dentistry. Medicines mostly aren't covered by insurance, so there's no flat-rate or free prescriptions as the NHS has. There's a 'own risk' amount everyone regardless of their income has to pay (€350 from this year, up from €220) before the insurance pays for anything, let alone the monthly insurance premiums and co-payments running into hundreds or thousands of Euros. That's if the insurance company doesn't wriggle out of paying their share.

The Dutch health system is essentially takes a poll tax and gives it to private insurance companies, with all the problems of private insurance and relatively minimal safeguards. The only people who benefit from it compared to the pre-2006 system are the wealthy, who pay less per person than they did in the old system, and private insurers, who now have millions of citizens who are now compelled to buy their insurance.

I can't see why anyone would advocate Britain using such a system.

As long as those in power are not the very wealthy, or have strong connections to the financial sector then we will be fine.

Oh bugger...

Re: the point about insurance companies betting against the insured from a page or two back:

A lot of the stress behind insurance is the they won't pay out or you're not quite covered. So would you be willing to pay double or triple your premiums now with the knowledge that any claim you made wouldn't be fought against for technicalities?

On the plus side, we fortunately don't have a government, backed by rabid media, that's now spinning like crazy to foster an impression of the NHS with the general public of widespread incompetence and problems.

Oh bugger...

That's exactly why insurance based health systems are nowhere as universal as the NHS type model.

Indeed. And insurance companies have a lower premium for bring able to shaft you on technicalities. So would you pay more for a premium if you knew you wouldn't be shafted when it came to healthcare cover?

You should be asking Cavey that, not me.

Sorry guys, I'm out of this discussion since unbeknownst to me it was upsetting someone who's a good egg & the very last thing I would want to do.

I will very briefly say though that some very good counter-points (and evidence) have been made here, sufficient to make me have a major rethink on this (whatever that's worth lol), so thanks to all on that score.

Blogger claims to have been censored by Facecunts during yesterday's quiet privatisation of the NHS. via ScarySheep

Don't worry, nobody gives a shit about that sort of thing any more anyway.

I expect it was an auto antispam measure that was a bit overeager.

The exact same thing has happened before with censorship of online protests against ATOS and other government policies that have targeted disabled people, yet which have had zero media coverage.