Archive for the 'NHS' Category

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The main loser from the MidTerms looks set to be “Big Pharma”

Thursday, November 8th, 2018

One of the things we take for granted in the UK is the cost of our prescription medications. This is all part of the NHS and the majority of patients are too young/old or have chronic conditions which mean that they don’t pay.

Even those who don’t benefit from free prescriptions are not asked to pay the cost price of their medication but a fixed fee.

This means the NHS as almost a monopoly buyer is able to secure even the latest and most expensive medications at a pretty good prices.

How very different from the the US where public health programmes are barred by law from using their buying strength to negotiate big discounts for pharmaceuticals. This in one of the reasons why US health is so expensive.

To take an example. I an on a newish medication called Rivaroxaban which controls a genetic condition that causes me to have blood clots. The NHS pays about $2 per day for my pill which keeps me alive. The US price for exactly the same medication is just under $16 which many patients have to pay themselves.

Is it any wonder that the cost of pharmaceuticals is the biggest healthcare issue in US politics. The Democrats have promised to take action and Mr.Trump is also saying the same.

After Tuesday’s elections it clear that something will happen and big pharma is likely to be squeezed.

Mike Smithson




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Three Score and Ten? Has the NHS reached the end of its natural life?

Sunday, July 1st, 2018

On July 5th the NHS marks its 70th birthday, and the occasion will be marked by a significant financial injection as a means of life support by the Conservative government. This should keep it breathing for a while yet, but like any ageing process we should consider whether the condition is terminal, and what the objective of continued treatment is. Is the NHS a model of health care fit for the 2020’s or are there better ways of organising it in the modern world?

Why then was 1948 the moment of the birth of the NHS? And why has it taken up such a central place in Britain’s self-image? Other nations do not seem to fetishise their health care system to the same degree, or make it such a sacred cow. British politicians find this both a benefit and a curse, but as we saw with the £350 million per week Brexit Bus pledge, it is one that moves votes. The NHS was a central part of the first truly secure Socialist majority government in the UK, but also a product of its times.

In 1948 there had been substantial governmental involvement with management of hospitals for a decade, beginning in 1938 with planning for anticipated mass bombing casualties, health care staff had also spent a decade either in uniform, or in civilian government control. It was a unique moment in British history, when Attlee’s genteel Socialism and Blitz spirit of national unity came together as parents of the NHS. It was also the year of peak post war austerity.

The NHS was a sickly child from birth, with a vast legacy of untreated conditions, inadequate finance and staffing, and unsuitable legacy estate. Waiting lists were immediate, and the first co-payment charges shortly followed, precipitating Cabinet splits and resignations.

While waiting lists, central planning, and grey bureaucracy were acceptable, even state of the art, in 1948 they became increasingly grating to a population that had become more sophisticated and consumerist. Since then there has been a political desire to satisfy consumerist demands by both Conservative and New Labour governments, and also to introduce elements of competition. Largely this has been via the mechanism of internal market and contracting out of services to private providers, and one that continues today.

This element of privatisation has rarely met the desire for consumer choice, as the competition has been for contracts from the government. Operations and services are put up for bidding like cattle at auction, with the winner rarely being awarded the contract on the basis of clinical outcomes, but rather on the basis of price. This demonstrates that the customer is the government rather than the patient. We have arrived at a solution that meets some of the government’s aims, but at the expense of combining the worst of central planning, corporate profiteering, and lack of consumer responsiveness.

The  challenges to the future include medical inflation exceeding consumer inflation, rising expectations, failure to recruit and retain staff, the obesity crisis, and each of these deserve analysis. The biggest challenge is the demographic one, as summarised in this tweet:

Just as the solution to the pensions issue will be a combination of working longer, paying in more and getting less, the answer in health will be much the same. We will need to stay healthy longer, pay more (either in tax or privately) and get less, or a combination of the above. Staying healthy longer requires a public health approach such as that in the Marmot Report, and it seems increased rationing is on the way. The latter is likely to increase consumer dissatisfaction.

Funding remains the political football. Whether funded by a single government payer, or via compulsory insurance, universal healthcare is essentially redistributive. Those that gain are the elderly, the poor, the mentally infirm and the chronically sick, while the system is paid for by light users, who by and large are young healthy and relatively affluent. There will therefore always be tension between payers and recipient.

Any universal system has to be based on the greatest good for the greatest number, but should this be on the basis of need or of economic benefit? Should the system favour the working plumber over the retired one? The stockbroker with a breast cancer over the dinner lady with the same? I would argue that to do so would be politically suicide, and strike at the founding principle of the NHS. One parent of the NHS was that feeling of wartime national unity that defines postwar Britain, and is central in British psyche and in particular of social conservative voters.

As such, benefits have to be independent of economic utility, and defined on cost effectiveness for the whole nation. How then should we address the increasing restiveness and consumer demand for 24 hour access and rationed treatments? Well, the safety valve for this has historically been the private sector, but this is much smaller in the UK than in comparable OECD countries with universal access. To meet the demand, the UK private sector needs to grow, reform, to become more affordable, more transparent on price and outcomes, and to have robust clinical governance over rogue clinicians. If these were to happen then the consumer would find it more palatable to fund out of discretionary income.

This could be done via a combination of tax relief for private health insurance, vouchers for co-payment by the NHS to pay for an element of the private cost, and a Speedy Boarding co-payment for private wings at NHS hospitals. Private insurance has its merits, but insurance companies are rather prone to sell umbrellas on sunny days and take them back on rainy days, with nearly all policies excluding chronic conditions, mental illness, and pre-existing conditions.

Perhaps the answer for this is for individuals to be permitted to save for their own families health care in tax-deductible accounts analogous to private pensions, with the funds restricted to self funded health care. These could be preserved post retirement and include funding for approved social care. In many ways, such a system would be a return to the pre-NHS mix of workhouse hospitals, friendly societies and private provision, but better adapted to modern Britain.

Are there betting implications? Not really, other than that the NHS will become increasingly frail as it moves into its dottage, and post Brexit will return as a touchstone issue in British politics. It is also likely to remain fatal to political careers, whether in government or opposition. Health Ministers rarely get the top job. In the immortal words of John Reid, on being reshuffled into the job “Oh F***, not Health!”

Dr Foxy

Dr Foxy is a Hospital Specialist in NHS and Private Practice in Leicester. He also has worked and studied in the USA, Australia and New Zealand. He has an interest in statistics and public health planning, is an occasional political punter and longstanding contributor to PB.



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LAB continues to have double digit lead on the NHS but the gap is narrowing

Sunday, June 17th, 2018

Will TMay’s latest move make it even better for her?

A few weeks ago at PMQs Jeremy Corbyn reminded the PM that in the 1947/48 period when the NHS legislation was going through parliament it had been opposed by the Tories. That such a line can still resonate 70 years on is really quite remarkable and highlights the ongoing vulnerability that the Conservatives have on the National Health Service.

The National Health Service has always been a LAB issue and will always be raised whenever the pressure is placed upon them. In the recent Lewisham East by-election the main message from the successful Labour candidate was that they were the party of the NHS and that they would protect services better.

Quite what the Tories can do about this is hard to say. My general view in the past is that the best thing for the blue team is that they all is keep off the subject because it’s one on which they can never win.

The above polling table from YouGov shows how the firm’s best party on the NHS tracker has moved since the general election. The positive news for the Health Secretary, Jeremy Hunt, is that the gap is closing which is good for him and his party. In fact he is now the longest serving Health Secretary ever and I think that his manner has played a part in the Conservatives recovery on the matter. I like the fact that he does a simple things like always wears an NHS badge in his buttonhole whenever he appears in public.

Now we have got this morning’s announcement from Mrs May fleshing out the promise to put more money into the service and that might reinforce the trend the fact that it is going to be paid for buy resume, presumably, higher taxes is irrelevant period there seems to be a public attitude appetite4 more going out for better services.

The real problem, of course, is that the pressure gets so much greater as each year goes by because of the proportion of elderly in the population. So the 3.4% that Mrs May is now talking about will really only enable the NHS to stand still.

The most that the Tories can ever really hope for on the NHS is that it is not a big and negative for the party and political liability as it could be.

Mike Smithson




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New ComRes poll for the Daily Mirror shows 82% of voters, across all the main parties, would support a 1p rise in National Insurance contributions to fund NHS

Tuesday, June 5th, 2018

There’s a new ComRes poll out for The Daily Mirror on the NHS which shows really strong support for a 1p increase in National Insurance contributions to fund the NHS. The findings seems to reaffirm Lord Lawson’s view that “the NHS is the closest thing the English people have to a religion.”

ComRes say

The findings are revealed in the wake of yesterday’s dramatic intervention by Gordon Brown who warned that with mounting financial pressures and an ageing population, the NHS is in dire need of help and called for a repeat of his 1p rise in National Insurance to rescue it.

Tonight’s poll also shows the underlying political importance of the issue, with almost one in five people (18%) who say they would definitely be willing to change their vote at the next election in favour of a party which pledged additional NHS funding, and a further one in three (33%) who would probably be prepared to do so.  In a warning to the Government and Theresa May, more than four in ten Conservative voters (41%) say they would definitely or probably be prepared to switch vote as a result of the issue.

Importantly, the poll reveals the source of such strength of voter opinion.  When asked if the quality of service in the NHS has improved, stayed the same or declined since 2010, the year when the Conservative-led Coalition took power, 55% of voters answered negatively while just 9% said the quality of service in the NHS had improved.  There is significant variation in perceptions across the country, with fully three quarters of people living in the North East of England who say the quality has declined (75%), compared to 48% in Scotland and 45% in Wales.

You can see why Vote Leave made the NHS such an important part of the referendum just like NO2AV did in the AV referendum.

The question is if a party does propose this will there be a backlash like there was with the dementia tax?

TSE

Fieldwork note: ComRes interviewed 1,073 GB adults online on 5th June 2018. Data were weighted to be representative of all adults by region, gender and age.



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What makes people proud to be British by party and Brexit choice

Wednesday, February 7th, 2018

Why the NHS is so politically sensitive

The above YouGov polling sets out clearly how important the NHS and the memory of what Britain did during the war are central to national identity.

The party splits are not that large and underpin the approach of all parties with the exception of UKIP whose former leader, Mr Farage, made controversial comments about the NHS a few days ago that were picked up and Tweeted up by Trump.

Smart politicians shouldn’t attack what Brits are most proud of.

Mike Smithson




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The Tories need to move the agenda off the NHS if they’re to have any chance

Wednesday, January 24th, 2018

I had sort of stopped watching PMQs every week because it is just less interesting and less important. Corbyn is getting a bit better but both he and TMay are pedestrian compared with others that we’ve seen over the years.

My reduced interest is reflected in the fact that the Commons appears less full for the event compared with previous times.

Today, I did watch, and inevitably the Labour leader focused on the NHS and the Conservative leader used the standard replies of which we have heard so much. Whenever TMay is pressed on the NHS she always retorts about what’s happening in Labour’s Wales. This time Corbyn had an answer to that saying that this was because of the limited money that is allocated to the principality.

Assuming that the next election is in 2022 that will be three and a bit years on from Brexit and we can assume that that issue won’t be the dominant feature. Maybe we’ll still have the EU blame game but things will have moved on.

This inevitably means that we will be back with domestic issues like the NHS making running. With an aging population and more pressure on NHS services it will be hard for things to get better.

This is an issue where the Tories appear always to get beaten. They’re not seen as being as committed to the service as Labour as we see in just about every “best party on the NHS” polling.

At the very basic for TMay needs some better and newer lines on the NHS. She does come over as formulaic.

Mike Smithson




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New GE2017 study suggests that CON>LAB swing was larger in marginals facing NHS charges and A&E closures

Sunday, July 23rd, 2017

How true is the assertion that the NHS cost TMay her majority?

The I report notes that:

“The new analysis, by the specialist health consultancy Incisive Health and seen by i, reveals that the average 2017 swing from Conservatives to Labour in 105 marginal seats facing local A&E changes was 3.2 per cent. In seats not facing A&E changes the swing to Labour was half at 1.6 per cent. “The General Election was billed as the Brexit election, but changes to hospitals was a big issue on the doorstep.

Public concern about the future of an A&E can cut-through the noise of an election campaign like little else.” Kieran Lucia, Account Manager, Incisive Health If the swing in the 105 seats facing local A&E changes or closures is adjusted to match areas without, the Conservatives would have won 12 more seats – enough to have given Mrs May a majority in the House of Commons.

This on the face of it is interesting but I think we need to wait for the final BES study of what happened on June 8th before drawing too many conclusions. Clearly this study in the I report has been produced for a reason and that is to make a political point.

Correlation it should be remembered does not equate to causation.

Mike Smithson




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Take Care. The implications of the Conservative policy on social care

Saturday, May 20th, 2017

General elections aren’t usually about big ideas. They’re usually occasions for the parties to try to come up with visual representations of their opponents that sting, for frenetic arguments about trivial events and for their leaders to pose in unlikely photo-opportunities. Voters are expected to react, not to think.

So Conservative supporters have reacted with trepidation to the focus on their plans for long term care. This was not an afterthought but a flagship policy, mentioned in Theresa May’s foreword. This is terrain the Conservatives have consciously chosen to fight on. The manifesto proposes that:

“First, we will align the future basis for means-testing for domiciliary care with that for residential care, so that people are looked after in the place that is best for them. This will mean that the value of the family home will be taken into account along with other assets and income, whether care is provided at home, or in a residential or nursing care home.

Second, to ensure this is fair, we will introduce a single capital floor, set at £100,000, more than four times the current means test threshold. This will ensure that, no matter how large the cost of care turns out to be, people will always retain at least £100,000 of their savings and assets, including value in the family home.

Third, we will extend the current freedom to defer payments for residential care to those receiving care at home, so no-one will have to sell their home in their lifetime to pay for care.”

Cue much sound and fury about the possibility of an elderly person’s inheritance being eaten into. The opposition have been quick to label this a Dementia Tax. But what are the options?

Not everyone will need long term care. In fact, only something like one in six of us will. For those who need it, however, it can be very expensive indeed. The options are therefore: to offer long term care through the state (either with or without a contribution from the individual); to subsidise the cost of care; to set up an insurance market; or to get family members to undertake the care themselves. All these options have been tried and all have their drawbacks.

Whenever you hear about a risk that some but not all will trigger, you think of insurance as a possible model. Insurance companies have been looking at this area for years. But so far the public have not been interested in paying premiums well in advance, preferring to take their chances. This may be in part through a mistaken belief that the state would come to the rescue, but at least part of the problem is that none of us like the idea of thinking of ourselves as geriatric at any point in the future. It’s hard enough to get people to save for pensions, with the image they conjure up of being old and grey and creaky. Getting people voluntarily to provide for the possibility that they might be senile or incontinent is several steps harder.

In 2010 Labour proposed compulsory after-the-event insurance, levying £20,000 from every estate to pay for long term care. The Conservatives instantly labelled it a death tax (unfair but snappy monickers are not the sole preserve of the left). Whatever the benefits of compulsory insurance, levying money from people who demonstrably didn’t need it was always going to be a tough sell. After Labour’s defeat in 2010, the idea languished.

Labour’s proposal this time – also a flagship policy mentioned in Jeremy Corbyn’s foreword – is for a National Care Service, committing as follows:

“In its first years, our service will require an additional £3 billion of public funds every year, enough to place a maximum limit on lifetime personal contributions to care costs, raise the asset threshold below which people are entitled to state support, and provide free end of life care. There are different ways the necessary monies can be raised. We will seek consensus on a cross-party basis about how it should be funded, with options including wealth taxes, an employer care contribution or a new social care levy.”

So Labour is proposing to build a state system, funded initially at least in part by capped individual payments. Risks would be pooled not through insurance but through the state. Means testing is not mentioned, meaning that the rich who need care would have the bulk of their assets left untouched (though note that wealth taxes are a possible source of funds for this service).

The Conservatives’ proposal leaves care costs as primarily the individual’s responsibility, with a safety net that no one should be reduced below their last £100,000 of assets.

So who should bear the risk that you might need long term care in the future? It is undoubtedly bad luck to become so infirm. It is not immediately apparent why others should pay for that bad luck if you have the assets to do so yourself, at least at the level that the Conservatives are seeking to set as an asset floor. Paradoxically, Labour’s approach is on the face of it more sympathetic to the asset rich than the Conservatives’.

The IFS has criticised Conservative policy because it makes no attempt to deal with the fundamental challenge of social care funding, advocating an insurance model or a social insurance model. The IFS is wrong about this. It presupposes that the question is an insurance problem. But there is no evidence that the public wants the level of insurance that the IFS deems appropriate: as I’ve noted above, insurers haven’t found enough interest in this as an idea. We don’t make drivers buy comprehensive car insurance. Should we make people buy comprehensive care insurance?

What of the politics of all this? The following groups will be concerned about the Conservatives’ policy: the elderly with assets of considerably more than £100,000 who wish to leave their property to their children; the expectant children of the elderly with assets of considerably more than £100,000; and those who think that in due course they might be in one or other of the first two groups.

These are not small groups. Many in their 50s or above will fall into them, especially in southern England. Those with elderly relatives who live in and around London will be especially interested in this. It has to be noted that this is a group who carry particular clout in the media.

Meanwhile, however, what Leona Helmsley would have called the little people will be baffled at the fuss. Many of these are considering voting Conservative for the first time and may well regard this as a cue that Theresa May is drawing up policy for them rather than for the affluent. This group is more likely to be worried about the government messing around with winter fuel allowance.

It’s also worth noting that with its headline “At last, a PM not afraid to be honest with you” the Daily Mail has captured the mood of many in relation to this policy, including quite a few non-Conservatives. Those non-Conservatives probably won’t change their votes over this but not everyone is as mercenary about this as might be thought.

It is likely that as a result of this policy the Conservatives will see an appreciable drop in support among the wealthier, particularly in southern England. If, however, the grafters north of the Severn-Wash line are given a further tug in the direction of a Conservative vote, Theresa May will probably regard that as a reasonable trade-off. Some votes are worth more than others. Right now, working class votes in northern constituencies are gold dust.

Alastair Meeks