NHS Budgets - Junior Doctors

Money Talks - Bullsh** walks - as usual.

I'm back. After the summer break wherein readers were deprived of both my expertise and sterling wit, I renew my efforts with both humility and verve.

The Junior doctors are striking in a series of five-day walk-outs. Patient care will suffer as sure as eggs are eggs. What's it all about?

Firstly, it is essential to remember that no system of health care can possibly function without the consent and support of the health care professionals involved. That's the bottom line. The NHS could not have come into being were it not for many compromises made to keep the doctors on-board. ( Most serious was the opposition of doctors who disliked the idea of becoming employees of the state. Doctors were in an extremely powerful position, as without them the National Health Service (NHS) could not operate, and the government was forced to make a number of compromises. General Practitioner (GP) surgeries remained private businesses that could be bought and sold, and the NHS effectively gave these practices contracts to provide health care. Only the most senior doctors in hospitals (consultants) were allowed to continue private treatment. Similar compromises were worked out with dentists. Aneurin Bevan conceded these points in order to make the NHS work, but he was not happy with them. ) - The Cabinet Papers

Even today the NHS can not possibly function without the doctors being extensively involved.

For some reason, known only to the government and Jeremy Hunt, this fact has been conveniently forgotten. The government has imposed a new contract on the Junior doctors and they don't like some of the provisions. The government's goal of creating a seven day service cannot be done without the doctors and their good will. Somebody has forgotten to line up the ducks.

What are they up to? Why pick a fight you can't win? It's the old story, money talks and bulls**t walks.

The government knows very well that you can have any sort of NHS you are willing to pay for. They are just not willing to pay for it. So, they need to increase the work load of doctors and the new contract is the way they have chosen to accomplish it.

In response. the doctors are trying to occupy the moral high ground. They need to convince the public, whose support they still have, that this is nothing to do with money. This is, of course, nonsense but they keep pushing it. Their support among the public is slipping. If the planned 5 day strikes go ahead they will soon lose the support altogether.

Any light at the end of the tunnel? Well, not all doctors are quite so convinced that the new contract is the work of the devil. Cracks are appearing in the support of the various Royal Colleges to which the doctors belong. Time is running out.

Very soon, some people are going to die who might have lived. Where will the blame be apportioned? The Government? The BMA?

One thing is probably sure – the bean counters (the real culprits in the piece) will get off scot free. Money talks . . . .

Roof Roof

Brave New World

I can't get into the lifts at the Norfolk and Norwich without saying silently to myself, “Roof, Roof.”

Sometimes I say it aloud if there is no-one with me and the doors are closed.

I'm remembering the phrase in Huxley's Brave New World where the lift reaches the top and the Epsilon minus Sub Moron opens the door and says in awe, “Roof, Roof” and the last “Roof” is measured in ecstasy.

Now-a-days we have canned voices instead of Epsilon minus Sub Morons, but the effect is the same. When the metallic voice says, “Going up” it is mimicking Huxley and commenting, no matter how incapable of thought, on the futility of man and his machines. Huxley would surely approve.

Lifts, or elevators, can be funny things. At the N&N we have two lifts side by side just outside the ward. Strangely, they don't act the same, as you might expect from inanimate objects. They have, instead, minds of their own. The one on the right (as you face them) is much quicker than the other one. It even responds to the buttons on the control panel. You can get in, hit the door close button and the floor required, and it speeds off in the correct direction – without so much as a “Roof, Roof”.

The one on the left, by contrast does none of these things. You press the buttons and it just sits there as if it is saying, “Sod off, I ain't ready!” Eventually it goes, when it gets good and ready. It also makes mistakes. These can be quite disconcerting.

You get in. You press the button for floor three. It eventually goes, but (and I have heard and seen this, honest) when it gets to the third floor, the voices says, “Second Floor!”

Honest.

I didn't like the lifts at the Sears Tower in Chicago. They have an express lift that takes you to the 88th floor in about 30 seconds. And, there is no real sense of acceleration. I'm thinking Twilight Zone.

Oh, Brave New World!

NHS

I'd really like to stay out of this one. No, I really would.

When I turn on the TV and see my countrymen at Town Hall meetings almost coming to blows over heath care reform; when the news is full of half-truths, misconceptions and misleading statements about health care; and when the pundits all line up to have a pop at anything that smacks (in their view) of socialism – then I know we're in trouble and I'd dearly love to duck the issues!

How about some facts?

http://www.whitehouse.gov/issues/health_care/

http://www.whitehouse.gov/health-insurance-consumer-protections/

These web pages sum up the Obama healthcare plan. Is it perfect? No. Is it better than what we have already? Yes. Is it a British National Health Service in disguise? Absolutely not.

So, what is the British NHS and how does it work?

First of all it is not exactly what it was designed to be. The origin of the NHS was steeped in ideological tea and poured from a socialistic pot onto the public purse. It has never been either all-inclusive or all-encompassing. Americans might be flummoxed to learn that despite its name the NHS is not really national at all. Scotland and Wales have quite a different NHS than England and Northern Ireland.

They might be puzzled by the fact that there is a substantial, thriving private healthcare system running alongside the NHS. The might be amazed that it isn't really free at all – even disregarding the National Insurance contributions workers and employers pay to fund the system, large parts of the NHS are not free. Except for children, old people and a few others, prescriptions are paid for by the consumer. NHS dental treatment is very patchy. Most people pay for their dental treatment. Visitors from countries who do not have agreements with GB pay for their treatment. Many people have private health insurance which they or their employers fund as part of their pay structure. Many doctors who work for the NHS also have private patients at the same time.

Second, the “national” part is misleading. Folks in England think of the NHS as a local service. We have our local GP's We have four hospitals, James Paget in Yarmouth, Queen Elizabeth in King's Lynn and the Norfolk and Norwich (which includes Cromer Hospital) in Norwich. Serious cases are transferred to specialist hospitals like Addenbrook's (heart) in Cambridge or Great Ormond Street (children) in London. Key point: thereby services are not duplicated! Must be cheaper! So, despite the name, the NHS is for most people a local service.

Thirdly, the NHS is one of the few universally unifying structures in the UK. For 60 years no government or opposition has ever questioned the need for or the underlying rationale behind the NHS. To many people in the UK the NHS is the government. To borrow freely from the Constitution it is the one thing in Britain designed “to promote the general welfare, and secure the blessings of liberty to ourselves and our posterity”. Therefore it enjoys almost universal support. And, even though it is a national service people think of it as local. So, they speak about their GP and their hospitals.

What about the present US health care?

The WHO rates US heath care as 37th in the world – UK comes in at 18. How can this be? Surely as the richest nation on earth the US should enjoy the best healthcare. Maybe it's the money?

Nope.

Per capita spending: U.S. about £4000 per person UK about £1700
As % of GDP – U.S. about 16% - UK about 9%.

Number of nurses and doctors as a % of the populations?
Nope - Just about the same.

So, despite spending far more money both in real terms and as a percentage of national income, the US lags behind in providing healthcare for its citizens. How can this be?

This is the real question that the numpties who we see on TV screaming nonsense about healthcare are not dealing with. Any reasonable debate must focus on this issue. It is a national disgrace. Where does all the money go? I suspect it goes in the pockets of the doctors and the health insurance lobby – not to mention the drug companies.

The real tragedy is that we have been here before. With the Great Depression in full swing the incumbent President, Herbert Hoover, struggled manfully to attempt to get the economy moving again. Hoover made his name as a crusading humanitarian in WW I – providing relief for starving Belgians. Problem was he was ideologically opposed to the kind of government intervention that was needed and eventually was provided by Roosevelt's New Deal. He just could not come to terms with the kind of government intervention which eventually brought an end to the Great Depression.

In modern times when we see both the US and UK governments spending billions to kick start the economy and bail out the very crooks (sorry bankers) who got us into this mess, it is well to remember that the kind of government intervention/regulation which Roosevelt proposed in the New Deal was violently opposed as Un-American, Communistic and down right criminal by the forefathers of the present idiots who are so upset at the thought of decent health care for all citizens – not just those with money.

This argument will rumble on. Nothing affects people's lives so directly as health care. People who have legitimate concerns about the Obama plan need to have them answered and addressed. People who are just ideologically an philosophically opposed to any form of government health care need to listen the the arguments and stop shouting. You don't win any argument just because you can shout the loudest.
President Obama needs to make his plans clearer. Hesitation is just seen as weakness. This may be the only chance to reform US health care in a generation. It must not fail.

Moore Steaks Seared

Sicko Slams the NHS

Michael Moore is rarely out of the news. His particular brand of docu-drama has a following, not just in North America, but around the English-speaking world. He does what he does very well.

He has turned his own particular brand of hostile indignation on the American system of healthcare. His film is called Sicko and he has made more than a few this side of the pond feel a little sicko at his thesis. He contends that the European system of publicly-funded heathcare is so rosy and so superior no-one but a fool could stop himself from copying it. He may be right, but he also may be being economical with the truth.

Writing in the Sunday Times, columnist Minette Marrin is scathing about Moore's methods in painting such a gloriously white picture of the N.H.S. She rightly points out that there are big problems in the National Health and the tons of money thrown at it by Messrs Blair and Brown have hardly produced a system worthy of unreserved envy.

She's missed the point.

Michael Moore is not producing a critique of the NHS, he's proposing improvements in the American healthcare system. He is wondering why some system of publicly financed healthcare would not better than the shambolic, wasteful and expensive system Americans are saddled with at present. This is the criterion upon which his work should be judged – not whether the NHS is all-delightful, all-delicious, all-conquering and all-munificent. Obviously it is not. Equally it is manifestly better than what's on offer in most other countries.

It's not surprising that American politicians are not queueing up to adopt an NHS-type solution to America's healthcare problems. Assuming they speak to their UK counter-parts they must know that the real down-side to the NHS runs deeper than concerns about day-to-day running difficulties (GP's inflated salaries, wards infected with C. dificile and MRSA, nurses leaving faster than they can be trained, crazy bureaucratic decisions that compromise patient care – to mention just a few). No. The real problem with the NHS is that politicians are seen to be responsible for the healthcare of the nation.

Any American politician wanting to commit suicide, please form an orderly queue.

For; if the USA were to adopt any version of a national health service, the blame for every mistake, every short-coming, every poor clinical judgement would move miraculously from the doctors to the politicians. That's the NHS.

Michael Moore's particular talent is unashamedly finding those parts of American society that need improvement and ruthlessly exposing them. He's probably not the person to put in charge of fixing anything. He's not a very good analyst. He sometimes pretends to have all the answers when he doesn't.

That doesn't mean his ideas are dishonest or naïve. It just means that he is making documentaries and not policy.

Bean Counters

Crazy Finances

The Government is expected to announce today that the NHS has made a surplus of more than £500 million in the past financial year after an aggressive drive to reduce spending by health trusts. - The Times

On Sky News this morning:

Eamon, “Can you tell us, is the NHS a service or a business?

Patricia, “It's a service, but actually it must be business-like.”

Why can't we get a real debate about NHS finances? One that focuses on the real issues. One that tells the truth about how the service is financed. A debate that is not led by the bean-counters agenda.

Could someone tell us how the NHS can go from being in debt – to the tune of millions – to having a surplus – all in the space of a few weeks? It's just a nonsense.

The truth is no-one knows what the real financial situation of the NHS is because the bean-counters make the rules, change the rules and (seemingly) change the rules for changing the rules. Only the great British public could be flannelled by such a blatant misuse of power, language and logic.

So, when the media reports about a Primary Health Care Trust being “overspent”, what does that really mean? It means that they have exceeded their budget. Who made the budget? The government. What criteria have the government used to set the budget? No-one knows. Have they tried, as you and I would have to do, to match the income of the NHS to the expenditure? Who knows?

There is no meaningful measurement of NHS income. All the money from National Insurance contributions simply ends up at the Treasury. Only a proportion of this is for the NHS, some should go for unemployment, some for pensions, and so on. What is the exact sum allocated to the NHS in a year – on which a budget could sensibly be based? Who knows?

In the absence of an income statement, there is no NHS budget. Never has been. The NHS budget is simply what the government says it is. Unless the public can understand this the politicians can simply make up numbers. The result? In any one week you get stories about expensive new drugs bankrupting the NHS juxtaposed with the story about NHS budget surpluses.

I confidently predict that the bean-counters will continue to drive the debate. After all, it's in their interest, not ours, for the issues to be presented in budgetary terms. That's their business. They will continue to shift paper clips from one side of the desk to another and publish statistics.

It's sad that the government simply abdicates its responsibilities to the very people they should be holding responsible.