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Saturday, 15 August 2009

Daniel Hannan, the NHS, and Public Health

They started appearing on Twitter last week: emotive declarations of love for the National Health Service.

They appeared with the tag #welovethenhs accompanied with moving statements: "because it saved my life" and "because my mother is still alive" and so on.

One can hardly complain about such declarations and explanations of love.

In this largely wretched, hate-ridden, and generally uncaring world, any mass campaign of statements of love is surely a welcome phenomenon.

Indeed, we should perhaps do these love statements more often.

There could even be a new Twitter tag #welovejackofkent followed with explanations such as "because he writes in nice short paragraphs" or "because he writes in the form of Sun editorials".

If these statements of love for the NHS were just for some positive reason then all one should do is nod and perhaps even join in.

But I wonder if they were serving another purpose.

Perhaps wrongly, I formed the impression that they were attempts to close down a debate, opened up in part by the Conservative MEP Daniel Hannan. He has for sometime been critical of the NHS model of health provision and recently appeared on US television and explained why. The background to this is that the US are themselves in the midst of a political controversy about reforming their own provision (or lack of provision) of health services.


I can here declare two interests.

First, I am fond of the NHS.

I have no illusions about it. In many ways it is a racket: an expensive and inefficient mix of pharma profiteering, PFI profiteering, sloppy procurement, self-interested professionals, incompetent management, Luddite public sector unions, and woeful IT development. All this masked by the soppy but powerful sentimentality of the NHS brand, making it almost impossible for any politician to promote genuine reform.

All that said, however, the NHS does ensure treatment free at the point of use for the poorest in our society. Any other model seems to risk greater social exclusion. For me this is the most important test.

Also, in my view, placing public health provision on to an insurance policy basis does not remove the current complicated racket, but merely adds grasping insurance companies to the mix.

However, I could be wrong.

It may well be that there is actually a better model of health provision, including for the poor, than the NHS. It may even be that the NHS should be dismantled rather than reformed.

I rather doubt it, but it is an important debate, and one which should not really be closed down too readily.

And here I can declare a second interest.

I was at university with Daniel Hannan and knew him slightly. And although I have not spoken with him for some fifteen or so years, I have followed his political career with interest.

He is a rare political creature; not only is he sincere, his actions are actually connected to his stated beliefs. Moreover he has an independent mind, stocked with international comparisons and contrasts on many matters, not just health provision.

I do not agree with his views on many issues (now less than ever given my drift to the left), but it is always worth listening to him.

So it is useful to read what he has actually written on the subject, rather than creating a straw mman, for example here.

If he is right, and that other countries' models do have better public health outcomes, then this is an important contribution to the debate about health provision. And, if he is wrong, then this should be clearly set out.

But the wrong approach to his critique of the UK model of health care provision is, in my view, to rely on sentimentality of the #welovethenhs campaign.

It is not only discredited CAM practitioners with their misconceived legal claims that can effectively limit important debates on public health.

27 comments:

YorkshireLen said...

Just a quick observation.

"woeful IT development" - that's only really an argument that will hold water with people who believe private sector firms have efficient, well run, IT departments. Do such people exist? If so, they probably also believe NHS dentists could be replaced by the tooth fairy.

Regards,

Len

Matt Volatile said...

Jack,

For starters, it seems a little presumptuous to expect a reasonable response to Hannan's entirely unreasonable, mendacious statements. Just in that video in your post, he makes numerous claims that are outright falsehoods - a fact he must know, if he is as intelligent as you claim.

To wit:

"it has made people iller" - No, it hasn't. On almost all metrics, the NHS system outperforms the American system. We live longer, have better infant mortality etc. etc. Lie number 1.

"We spend a lot of money, and we get very bad results" - The US spends more in tax revenue than the British do to provide it's governmental healthcare programmes (Medicaid, Medicare, VA), that only a small percentage of the population can actually access. For it's equivalent or better outcomes, the NHS costs the taxpayer roughly half what the US system costs the American taxpayer. The NHS covers 100% of people paying into it. The US system does not. Another lie. (http://www.medicalnewstoday.com/articles/27348.php)

"We have very few doctors" - There are roughly the same number of physicians per head in the UK as the USA. (http://www.nationmaster.com/graph/hea_phy_per_1000_peo-physicians-per-1-000-people) Lie 3, in three consecutive sentences.

Secondly, note that Hannan's is not simply an excoriation of the NHS but a wholesale support of the broken, busted and bankrupt US healthcare status-quo. His rhetoric is standing between American and the healthcare system it deserves.

His is an ideologically-driven rant against "socialism", nothing more. Nearly everything he says is a distortion or outright falsehood.

Schroedinger99 said...

There are, as with most issues, several different things going on here - a state of affairs that is difficult do full justice to in Twitter memes.

Yes, there are debates to be had about the best way of continuing to providing universal health care that is free at the point of use (and of reintroducing this in the case of dental treatment) and sentimentality should not be allowed to close such debates down.

But many of the attacks from the US have been attacks on the very principle of providing universal health care. Since this is a principle that is widely subscribed to by the Brits, they feel, naturally enough, that many recent attack on the NHS represent attack on the values they hold dear.

[Note to US readers: Imagine how you would feel if we criticised the system in your country whereby you can buy a Kalashnikov in your local Walmart at age 12 and you only need a licence for a gun if it has wheels.]

[2nd Note to US readers: The above is what we call "a joke" – a bit like all the things you’ve been saying about the NHS, except you lot seem to take these things seriously.]

[3rd Note: I’m over-generalizing here obviously, because all the Americans I know think the stuff coming out of Fox is just as daft as I do.]

Anyway, there is also the problem of Nu Labour jumping on the bandwagon and trying to shift the debate to a Labour v Tory debate – which, historically, it has been of course; but I suspect there are lot of people Tweeting #welovetheNHS because they believe deeply in the principle of universal health care rather than because they are big fans of Gordon Brown.

Anyway, given all these caveats, I am Spartacus and I am happy to Tweet #welovetheNHS!

MatthewBowdish said...

Interesting post, but let me clear up a major misconception you guys seem to have about our health care system. The poorest Americans are already covered by Medicaid or a provision within Medicare...It is the lower middle class folks who work for small businesses that have the most difficult time affording insurance.

These folks account for about 12 million Americans. The rest of the "46 millions uninsured" are people who can afford to buy their own insurance but don't, people who do not know they are eligible for current govt medical coverage and illegal aliens/legal non-citizen immigrants.

Radically changing our system, which 80% of our folks are satisfied with, is a bad idea for many reasons, not the least of which would be a loss of innovation.

For example, you in the UK have much lower survival rates for various cancers and chronic medical conditions than we do.

That is well documented and due to the fact that your society has made that ethical argument (cover more for basic and not pay for modern care, or limit its access to really sick people). I am not sure Americans would settle for such a system.

Luckily, you also still have us to invent or use new medicines/technologies that will eventually trickle down to you once they become cheaper. I would also add that there are British pharma/tech companies that only make money because you sell your products here.

But if we in America spend less on expensive innovative care and more on primary care, we will all lose.

If you guys like or love the NHS, good for you. But I don't we deserve your ridicule for our brilliant but messy system.

Best, Matt

Jack of Kent said...

@Matt Volatile

Certainly not a lot of love in your post.

Matt Volatile said...

Jack - no, not much love at all! I don't extend love to opportunistic, mendacious ideologues like Hannan. I did, however, throw a few superfluous apostrophes his way.

Matthew Bowdish: This idea that the American healthcare system drives innovation is, frankly, nonsense. For starters, the HMOs do not fund healthcare research - not a single penny of your insurance premium is going to pay for medical innovation. Even if the USA were leading the world in healthcare innovation, this would be entirely separate from the issue of healthcare reform.

Nevertheless, the USA isn't (and my thanks to the JREF forums for these):

R&D 2008

non UHC country USA.

Pfizer = 7.945 Billion $
Johnson&Johnson = 7.6 Billion $

UHC Country Switzerland

Roche = ~8.25 Billion $
Novartis = ~7.2 Billion $

UHC Country UK

GlaxoSmithKline = ~6 Billion $
AstraZeneca = 5.179 Billion $

UHC Country France

Sanofi-Aventis = ~6.5 Billion $

Matt Volatile said...

Jack - no, not much love at all! I don't extend love to opportunistic, mendacious ideologues like Hannan. I did, however, throw a few superfluous apostrophes his way.

Matthew Bowdish: This idea that the American healthcare system drives innovation is, frankly, nonsense. For starters, the HMOs do not fund healthcare research - not a single penny of your insurance premium is going to pay for medical innovation. Even if the USA were leading the world in healthcare innovation, this would be entirely separate from the issue of healthcare reform.

Nevertheless, the USA isn't (and my thanks to the JREF forums for these - http://forums.randi.org/showthread.php?t=150486):

R&D 2008

non UHC country USA.

Pfizer = 7.945 Billion $
Johnson&Johnson = 7.6 Billion $

UHC Country Switzerland

Roche = ~8.25 Billion $
Novartis = ~7.2 Billion $

UHC Country UK

GlaxoSmithKline = ~6 Billion $
AstraZeneca = 5.179 Billion $

UHC Country France

Sanofi-Aventis = ~6.5 Billion $

Also: Universal healthcare would INCREASE the market for drugs - people who cannot currently afford the medications will be able to access them.

And as for your final point -
"But if we in America spend less on expensive innovative care and more on primary care, we will all lose". All, that is, except for those who need primary care but cannot currently access it. (http://www.telegraph.co.uk/news/worldnews/northamerica/usa/barackobama/6030211/Briton-providing-free-healthcare-to-thousands-of-Americans.html). And those whose businesses would benefit from a healthier staff. And those who have to pay higher insurance premiums to cover the cost of care for advanced illnesses of those who cannot pay. And... well, you get the idea.

Schroedinger99 said...

@ MatthewBowdish

This week it has been the USA ridiculing the British system rather than the other way around.

This is inappropriate not just because many of the statements being made about the NHS on channels like Fox are risible but because President Obama is not advocating an NHS style system. There are, after all, many different models to choose from – nearly every developed country in the world apart from the USA has some kind of universal provision.

On most indicators – life expectancy, infant mortality etc – Britain gets better outcomes than the USA for a fraction of the cost, so I’d be interested to see which particular statistics you are drawing on when you say "you in the UK have much lower survival rates for various cancers and chronic medical conditions than we do".

BTW When there are, occasionally, new treatments of unproven or limited efficacy that the NHS is not yet willing to fund, it is perfectly possible for people, who have the money, here in the UK to fund such payments from their own pockets. Also, people who can afford it can have as much private treatment as they desire here in the UK. So the NHS does not limit care in any way for rich people, it does, however provide treatment that is up there with the best in the world for the entire population – regardless of ability to pay.

Jack of Kent said...

@Matt Volatile

"...opportunistic, mendacious ideologues..."

Some people said the same of Bevan.

Matt Volatile said...

Jack - what has Hannan said that is worthy of serious consideration? What has he said - indeed, what did he say in the clip you posted - that you think we should take seriously?

It's perfectly clear that Hannan - an intelligent man, if you are to be believed - is willing to either lie about issues of serious importance for reasons of political self-aggrandisement, or, worse, present himself as an informed critic without bothering to check the facts about which he presents himself as an authority.

The people who slated Bevan were of the same cloth as Hannan - self-interested, grubby liars.

Chris Denton said...

I think what you have to bare in mind about the #welovethenhs campaign is that it was started to counter the absurd statements being made in some sections of the American press.

So, yeah, it's an over-the-top-love-in, but I don't think it can be seen as part of the UK debate on health care.

Alice said...

#welovejackofkent Because his blog is very cool, well-thought-out, informative, and knowledgeable about very important issues. I discovered Jack of Kent through the Simon Singh case and am glad I did :)

I also love the NHS because the patient is a fellow human being to help, not a customer to wrangle money from. They check your need, not your wallet.

Of course it has problems, but that does not affect the underlying principle. If someone makes a disgusting chocolate cake, that doesn't mean chocolate cake in general is bad. (Couldn't resist that one.)

I have American friends who cannot afford to pay health insurance - it's a choice of that or rent - or over half of whose salary goes to health insurance. And if Medicare was so good and available, could somebody please explain this? http://www.independent.co.uk/news/world/americas/the-brutal-truth-about-americarsquos-healthcare-1772580.html

Simon said...

#welovejackofkent Twitter group duly started. Please, other fellow readers, join in, else I may look slightly foolish.

msHedgehog said...

AFAI have heard this is mostly not a response to Daniel Hannan but a response to the stupendously wierd Investors Business Daily editorial that said Stephen Hawking would never have survived had he been British (Er ....). Apparently written by someone who thought not only that US health care reform was a secret plot to kill old people, but also that Stephen Hawking was American. That seems to have really got people's goat, which I suppose I can understand.

Neuroskeptic said...

I don't think the twittering is an attempt to avoid the debate.

Rather, it is an attempt to demonstrate that a lot of people who actually live under the NHS "regime", like it.

Because whether Hannan has good arguments or not, his appearance on American TV was hardly about arguments, rather it was about showing Americans a British guy who dislikes the NHS, "proving" that it must be wrong, because after all, he'd know.

slow urgency said...

Schroedinger99, one of the points where the NHS hasn't been particularly successful compared to the US has been in Treatment of certain specific cancers. the NHS is aware of this problem, and has been working to improve this, with survival rates rising at a much faster rate than any other comparable western health system. They've found the problem and are working on putting it right. One of the reasons why the NHS numbers are higher than the US is that these cancers tend to occur through diet and lifestyle more in the groups that the US system dosn't cover, so because theres no coverage, the yre not detected, so survival rates are not impacted.

gimpy said...

He is a rare political creature; not only is he sincere, his actions are actually connected to his stated beliefs. Moreover he has an independent mind, stocked with international comparisons and contrasts on many matters, not just health provision.

As has already been pointed out, what he said on Fox was factually inaccurate. So, assuming your statements of sincerity and intelligence are correct, this makes him ignorant. Which is quite understandable, he is a public school and Oxbridge educated, privileged member of the elite elected to represent constituents interests in Europe, not nationally - why should he be expected to have given the NHS some thought? It is not his major political concern and his background suggests it is not a personal concern either.
Or, the alternative, is that his politics are based on a self serving mendacious attitude to observed realities.

If anything it does suggest that if this is the best Fox could come up with to support their position then the NHS is under little political threat as a principle. However, it does not mean that Hannan has contributed anything worth discussing to the debate, other than as an illustration of ignorance/mendacity as a driver of political debate.

PS I am less than partial as regards Hannan. He is everything that, culturally, I was brought up to despise about the Conservative party. I suspect this is true of many contributors to this discussion on your blog.

Frank Wales said...

Here's a reference to a study, from the hardly-British Journal of the American Medical Association before the current brouhaha, indicating that some cancer treatments might be the only healthcare things that the US manages to do better than the UK.

Otherwise, Americans seem to be getting a grim deal (sic) for all the extra money they're spending, including the wealthiest.

Dr Aust said...

Jack wrote:

"Also, in my view, placing public health provision on to an insurance policy basis does not remove the current complicated racket, but merely adds grasping insurance companies to the mix."

If I may respond with a legal term, Jack:

"Res ipsa loquitur"

The mixed social insurance schemes in Europe (e.g. in Germany) work because the state mandates and underwrites universal insurance (which is compulsory) through non-profit insurance associations, and also regulates the private insurance market and the companies heavily.

Talking of a lot of the misinformed rubbish in the press, especially in the US: it is worth noting that a lot of the apparent longer survival for patients post-diagnosis with (e.g.) prostate cancer in the US compared to the UK is an illusion. My friend (and NHS consultant) Dr Grumble uses the analogy of US patients "getting on the same train but an at an earlier station" (i.e. they are diagnosed earlier, giving longer "survival time post diagnosis" but this does not necessarily equate to better outcomes).

Anonymous said...

I think #welovethenhs is a specific emotional reaction to a specific and foreign political attack; I don't think anyone contributing to it has confused it with a wider public debate on what the future of the NHS should be. Everyone has their legitimate criticisms of the way the health service is run.

I'd mention, though, that in all the discussions of health care and outcomes few mention medical fraud, which is also a big issue in designing a health care system. In the US now, one of the growing things is medical identity fraud. The typical scenario is a doctor bills for treatments that haven't been given, and the first the patient whose name is used knows of it is when his insurance company pulls his coverage or ups his premiums or he's denied credit or employment. Very, very nasty.

wg

kensington and chelsea said...

I think the debate is open but that people have passionate views on either side.

Croydon Bob said...

#welovejackofkent Despite him being a Brummy Tory Lawyer...

Ivan said...

The arguments people use to say they like the NHS are typical of the faulty arguments discussed in Jamie Whyte's enjoyable book "Bad Language".

Comparing British with US healthcare systems doesn't interest me very much. It is continental NW Europe (our "peers") that delivers better outcomes than UK and USA for lower expenditure than USA that interest me more. I expect that the social structures that exist in our peer countries, which their health services depend upon, are probably not replicable in Britain. One day some very clever person will work out what it is about those structures that is important, and how we can implement the important underlying features in Britain. Britain does have a relatively low number of doctors in comparison to our peer countries, but such comparisons are difficult because some places nurses do some things that in other places doctors do.

I read something in the Economist the other day that said that in most countries with good health services, the healthcare providers have some financial interest in the healthcare outcome they deliver, whereas in Britain that relationship is very weak.

Though no conservative voter, I tend to think that the previous (conservative) administration took a hard-to-take step in the right direction, whereby health providers had contracts with funding providers. The mechanism had its severe failings. But rather than being grateful that a hard-to-take step in the right direction had been made, and seeking to improve it, the present administration dismantled it, and has had little alternative to offer us.

Dr Aust said...

While the NW European insurance-based health systems offer an interesting "universal coverage" alternative to the NHS set-up, a few points are worth noting:

(i) these systems are a lot more expensive than the NHS, though not as expensive as the US;
(ii) they are expensive enough that there is a lot of worry in these countries over how sustainable the systems are;
(ii) Over-investigation (e.g. ordering up fancy scans that are not really needed) is a significant problem, and marginally useful but pricey treatments (like spinal surgery for back pain) ditto. These kind of things occur because doctors make money from them and generate "turnover" for their business.

I am not so sure that it is offering providers (whether institutions or individuals) a financial / contractual interest in "good healthcare outcomes" that is the key upside of the French and German systems. Speaking as the husband of a doctor I would say it is more the professional autonomy that the doctors and clinics are given.

One of the primary downsides that doctors express about the NHS is that they are frustrated and second-guessed by the bureaucracy and the Govt. You can see this most in General Practice. In GP-land the doctors are essentially running small businesses, and they have a clear contractual/financial interest in generating good outcomes through QOF. But they still feel micro-managed and bullied / beaten down by the Govt and its use of them as a political football, as you can easily find out by reading Dr Crippen's or the Jobbing Doctor's blogs.

A final model, or perhaps a model with a tweak, is universal single-provider plus selected point-of-access charges. The NHS is having difficulties partly because of a rising burden placed on it by people who don't really need healthcare, like all the pissed idiots who clog A&Es from Thursday-Sunday night inclusive. Some people reckon you could "re-balance" the system by charging £ 10-20 quid upfront for GP appointments, and pursuing costs back from people who end up having to be carted to A&E in an ambo and stomach-pumped after 30 jelly shots.

Quirk said...

I don't have enough time to pull all the figures together for you (although I spent enough time to know http://seer.cancer.gov/statistics/ will be helpful), but...

I would strongly urge people to compare the US and UK death statistics for various cancers, heart disease, etc. They do not make as rosy reading as we'd like to believe, as NHS fans.

"it is worth noting that a lot of the apparent longer survival for patients post-diagnosis with (e.g.) prostate cancer in the US compared to the UK is an illusion."
- while it is true that their aggressive early screening picks up a lot of benign cancers which would never have been a threat, the raw data on numbers of deaths from prostrate cancer IIRC favour the US over the UK, and it is important not to gloss over this.

Now, there may be various factors I'm unaware of affecting the counting of the deaths (a doctor friend of mine suggested the slightly higher smoking rate in the UK and the lack of post-mortems on the very poor in the US as possible issues), but the ratio between US and UK raw deaths from a number of major cancers and for heart disease is less than the raw population ratio (approx 5:1), and this does not seem to improve much from age-adjustment. This would suggest that the UK is not uniformly better at every major aspect of healthcare (cancer and heart disease being the largest causes of death in both the US and UK) and that it might be a little bit more complicated than that. And yes, of course, the US is spending a lot more money to achieve these results, but value for money is another argument entirely than simple efficacy.

davidp said...

#welovejackofkent because he covers interesting topics from a perspective not many others give, with expertise and fairness.

I love Australia's hybrid health system (I live in it). Everyone has cover for 100% public doctors, 85% cover for more pricy doctors, and can buy insurance for private hospitals at prices that don't cover the sales commissions on American policies. There's none of the coercion of the NHS (in NHS you must register with a single clinic, here you can chose each time).

For Pharmacuticals, most pay up to $AU 32, any higher cost being covered (plus an annual cap on this), the poor pay up to $AU 3.60, and we get any effective pharmacuticals from any pharmacy on this basis.

Outcomes are good.

Sadly we also have profiteering, sloppy procurement, self-interested professionals, incompetent management. Parts of the payment system are effectively an invitation to fraud that will not be caught, and no one does anything about this because Doctors are assumed to be trustworthy. (This is not doctor bashing - 10 of my close relatives are doctors, and I get on with them fine)

We also suffer from politicisation of health management, so much propaganda against our system came out of the national government in the last decade - surely such things only happen in a federation.


Try http://scienceblogs.com/denialism/2009/05/whats_health_care_like_in_aust.php and the subsequent posts for a discussion of various health care systems by an American trainee Doctor.

I do not know anything about the various N.W. European systems.

LeeT said...

The worst thing Hannan's interview was that he did not have a single positive thing to say about the NHS.