Monday, 23 November 2015

PoliticalSpeak: can we prevent neoliberals taking over the NHS?

Any ideas about how you want your NHS care to evolve? #MSBlog #PoliticalSpeak

"The NHS is never out of the news. We at the coalface can't keep-up with the politics nor can we keep up with demand from our patients and constituents. See the article below from the Economist that summarises the issues facing the NHS and the suggested solutions. Under the current model of MS care, we simply can't continue to deliver what we want; it is not sustainable without more resource, nor can we evolve without more investment, or at least the reallocation of resources to test new ideas and models of care. At the moment we are on the back foot. Either we give in and let standards slip, or we rethink how we deliver services in a new way that drives the necessary efficiency gains demanded by the government and still improve the lives of MSers and their families. The latter will require MSers taking more responsibility of their own care with less input from their healthcare professionals. Are you ready for change?"

"Some would argue that the Economist is a neoliberal right wing rag and it only supports the capitalist agenda and that any political solution proposed by the Economist is likely to be in the interests of the neoliberal movement and the market. You may be right, but the Economist is still able  to eloquently highlight the problems faced by the NHS. I think we need a rethink about what the NHS is and what it can realistically fund under the current model. NHS rationing, the gradual erosion of the NHS's founding principles and the low morale amongst us are beginning to take its toll on MS services. I think we need to have a debate on what we need to do to solve the crisis we currently find ourselves in otherwise the neoliberals will impose a market solution. Any thoughts?"


BAGEHOT. The case for ditching the NHS. The Economist Oct 23rd 2015.

If the taxpayer-funded model is not politically workable, Britain should adopt a social insurance system.
Excerpts


...... THE NHS is in a mess. Many studies suggest that it is worse than its European counterparts. Britain spends less on its health than do neighbouring countries with healthier populations. Even the one study regularly cited by the NHS’s defenders, that by the Commonwealth Fund last year, conceded that its main relative weakness was “its poor record of keeping people alive”. Some would argue that this specific particular matters quite a lot......

...... And things are getting worse. The government has kept spending on the health service flat as costs have spiralled upwards and spent less on related services like social care. As a result, £22 billion ($34 billion) of “efficiencies” (ie, savings) must be made just as the great Baby Boomer bulge of older, fatter Britons is beginning to get elderly and creaky in large numbers. One symptom of this is Jeremy Hunt’s battle with junior doctors over their new contract: both sides make some decent points, but their deadlock means the NHS is on track for a doctors’ strike in December or January, when a winter crisis is already expected......

..... These problems are often couched in clinical or structural terms. And it is true that the NHS could become yet more efficient (it is already among the rich world’s leaner health systems). But ultimately the matter comes down to politics. Britain is supposed to love its NHS. But it does not spend enough on it. And though polling on the matter is somewhat mixed, it generally suggests that few Britons are willing to pay more in taxes for their health service. The Conservatives certainly seem to think that is the case: they are increasing NHS spending relatively little compared with the rise in demand. They could easily find the money to plug they gap if they felt that the existing underfunding of the NHS were politically untenable.....

..... All of which begs the question: does Britain really love its NHS? I suspect that the reality is complicated: the various crises convulsing the health system with increasing regularity evince a deep shift in outlook among the British population. In the post-war years people felt united, common and responsible for each others’ well-being. Now that is much less the case. One can mourn the passing of that common feeling—as I do—but still acknowledge it as a fact. Instead politicians ignore it. Were they to face up to this reality, they would see that there are three main possible futures for the NHS......

..... The first one, the course on which the system is currently set, would see it gradually diminish: services deteriorating, waiting lists growing, wealthier patients bleeding off into the private sector and thus losing their interest in good, well-funded NHS services. This process could be slowed by structural reforms—shifting resources from cure to prevention, for example—but it would eventually occur nonetheless. Ultimately it would leave the NHS as a safety-net service used only by those who could not afford better......

..... The second one would see ministers confront voters with the harsh truth: the NHS needs more money if standards are not to fall. This might come in the form of a dedicated health tax, which polls suggest voters would prefer over a rise in other, generic taxes. It might come in the form of less-popular co-payments: charges for prescriptions, GP visits and so forth. These would, it is fair, curb unnecessary visits to hospitals and surgeries from people with nothing better to do. Yet doctors rightly fear that co-payments, or even measures to make users aware of the value of their treatment (they are already told how much their missed appointments cost the taxpayer), could dissuade those who most need to seek early medical attention—the old and frail—from doing so.....

...... The third one would be to move to a system that better reflects what Britons are willing to pay for and what they are not: the social insurance model used in Germany, the Netherlands, Austria and other countries close, in outlook and geography, to Britain. Under this system a private market of health care providers would operate under strict government regulation, each citizen obliged to buy health insurance and the state covering that of those unable to do so. Unlike in America, no-one would go without health care for lack of funds. Unlike in Britain, users would choose between providers, take more responsibility for their own coverage and see a direct connection between what they paid in and the security that they got out. The downside of this model would be that it is probably less efficient than the NHS one: consider the transaction costs of all the claims, reimbursements, risk-premium calculations and so forth. The upside would be that it responds to the reality of how people like to acquire services. On that basis sensible politicians like David Laws, the former Liberal Democrat minister, have already advocated such a shift. Ireland is currently moving from a British-style system to a Dutch-style one......

...... I am as fond as anyone of the NHS. As a child I had a life-saving operation on it. Two of my closest relatives work for it. When living in New York I was disgusted by the cost (to my insurers, luckily for me) of my treatment for a fractured ankle. But like most Britons, I want the health service to work as well as possible for those who need it. And there are big questions about whether the model under which the NHS currently operates—and, perhaps more importantly, the political and cultural climate in which it operates—makes that outcome more likely than the alternatives. Britain should never give up the principle of universal health care. But it should recognise that it is not the same as the tax-funded NHS......

32 comments:

  1. Interesting and thought provoking. If you prescribe lower cost drugs, for example rituximab and cladribine, and save on DMTs could you not simply allocate the money you save to invest in new MS services?

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    1. Re: "If you prescribe lower cost drugs, for example rituximab and cladribine, and save on DMTs could you not simply allocate the money you save to invest in new MS services?"

      Unfortunately not! The high-cost DMT budget is held by NHS England (specialist commissioning) and the services budget by local commissioners (CCGs). Saving money in one budget can't under the present system be allocated to another budget. In addition, we are not allowed to prescribe low cost drugs off-label if there are other drugs licensed and NICE approved for that indication. At present our off-label prescribing is for patients who can't access DMTs under current prescribing guidelines, for example patients with SPMS or PPMS with active scans (Gd-enhancing lesions).

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  2. I am a big fan of the Economist; they may be neoliberal but they usually identify what is important. Some of the most talented journalist work for the Economist, therefore, I wouldn't dismiss their proposed solutions for the NHS outright. The proposed solutions make a lot of sense. The question is the British public prepared for a change?

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    1. I can't see the British public ever accepting a health insurance-based model, the poorest will inevitably lose out. We keep getting told that the public will not accept any tax rise to fund the NHS properly, yet that's what Gordon Brown did in raising National Insurance in 2002 to pay for improvements to the NHS but, importantly that money needs to be ring-fenced for the NHS, which it wasn't under Labour. I am of the firm opinion that if the case was made the public would accept it but political cowardice and neoliberal ideology means the case is not being made.
      http://www.theguardian.com/society/2015/feb/17/labour-national-insurance-increase-save-nhs-mp-demands

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  3. The politics leaves me stone cold. All people with MS want are treatments which offer them the best chance of keeping their CNS as healthy as possible (maybe some repair in the future). I don't care if is the health care system which delivers this is left-wing, right-wing, Marxist, market-driven etc. My health outweigh any preferences I have regarding politics or economics. Just want some researchers to make some big breakthroughs on MS. Any news on the Charcot project - 2020?

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    1. Re: "Any news on the Charcot project - 2020?"

      Yes, we have our extended investigator meeting on the 1st December and will let you know our dissemination plan shortly after this.

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    2. Re: "My health outweigh any preferences I have regarding politics or economics. Just want some researchers to make some big breakthroughs on MS."

      I wish it was this simple. The NHS are implementing caps on high-cost prescribing which means we at the coalface will have to start rationing therapies, or get creative in how we use the treatments, both off- and on-label to maximise the benefits across the population of MSers we treat.

      Have you heard about the new NHS 70:30 policy? Our prescribing costs will be capped using last year's budget as the baseline. If we underspend on that budget we will get to keep 30% of the underspend to use locally local services etc. (yes they are allowing us access to cash). However, if we overspend compared to last year’s budget then our Trust will have find 30% of the cost of the drugs; NHS England or the specialist commissioners plan to penalise us for 'over-prescribing'. Is this really overprescribing? What is not worked into this equation is that the incidence of MS is increasing and once you are on a DMT you to tend to stay on it many years. What this policy is telling us that if we want to start anyone new on a DMT is that we will have to stop a DMT in another patient otherwise our Trust or Hospital will have to pay 30% of the bill. The economists will claim that this policy has both a carrot and a stick embedded within it; a carrot to incentivise to under prescribe, compared to last year or to stop treatments, and a stick to punish us if we over prescribe. Please note I don’t buy into that latter as the UK has one of the lowest DMT prescribing rates in the world.

      If you are a healthcare professional you can’t help getting into politics; you have to do it to fight for your patients. If we don’t advocate for them who will?

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    3. Meanwhile the cost of replacing Trident has gone up by 6 billion to 31 billion. Funny old world.

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    4. The NHS today is frighteningly close to the state it was in during the '80s and early '90s.
      When I was inundated with letters in 2010 telling me how David Cameron loves the NHS, I didn't believe it then and I don't believe it now. I've seen it all, it's not true that cancer patients are seen quickly, in some cases not even seeing a doctor for months.
      MS and DMTs have no chance. In 1997 Labour inherited a failing health service, with filthy wards, low morale and people dying on waiting lists. If we're chronically ill, we have to lobby our MPs and sit up and take notice.

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    5. 'Once you are on a DMT you tend to stay on it for many years'. Seems to me like a good economic reason, apart from the medical ones, for induction therapies

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  4. Dre where art thou? This post has clearly been designed to get Dr Dre to cast his pearls of wisdom.

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    1. I'm here, baby.

      Listen, I don't wanna respond to these kinds of posts anymore because one doesn't accept that the firmament of neurological policymaking is conducive to patients' needs. Don Giovannoni fires off DMT prescriptions like he's Yosemite Sam, assuming that being on some sort of drug is better than being without. Heck knows what the consequences of that will be in a generation... could be astounding... could be pernicious. What I know is that MS cannot be cured because no-one knows why it's even happening in the first place.

      I think I know why you're asking me to comment on this post specifically, so I'll give it a shot: The superstructure hates the NHS. The conservatives and liberals out there have undervalued the NHS throughout my lifetime, and, as a society, perhaps we now think that it's time to put it to bed. As Thatcher's children, we've been moulded to believe that self-preservation is tantamount, which means that the wellbeing of others is of great superfluity.

      This Wednesday will see the new budget announced which will usher in the biggest public spending cuts in living memory. The poorest, eldest, disabled and most vulnerable in the UK will be hit unconscionably hardest. Just wait and see how unforgivably cruel it will be. But that's what Britain voted for. The Tories have a mandate to do it and will be carrying it through. It is shameful to be British right now.

      I find it almost emotional that sentient and educated grown adults are more focussed on the release of a new Star Wars film than on issues that matter. It's coming to the point that I don't care what Britain decides to do. Do you?

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  5. "unnecessary visits to hospitals and surgeries from people with nothing better to do." Is there some statistics to sustain this claim? BTW I was shocked by the ad campaign "A&E are for emergencies only". How much did cost this necessary scare mongering ad campaign?

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    1. Re: "unnecessary visits to hospitals and surgeries from people with nothing better to do."

      I have no idea; just quoting a neoliberal journalist from the Economist.

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    2. You post made me laugh so thank you. But more seriously even neoliberals and leftists like me have a brain and this is an important matter. If such a study does not exist, it should be made. Don't you think? I know you are a Neuro but you might know people working in A&E. If such a study does exist, then it needs to be publicize. This can avoid stupid ads (this one was less stupid than the Heathrow against Gatwick thing) and also save life.

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  6. Here in Brazil we are facing the same problem, either with the Unified Health System (Portuguese acronym: SUS) or Social Security ... If I were a "political agent" try to include cheaper and more effective medications on the list of prescription SUS. You tried to make it there and did not work obviously the pressure of his own pharmaceutical industry; if they had achieved it would have been a landmark for Public Health Systems or cooparticipação worldwide. Also in Brazil to access the SUS you do not have to contribute anything (the charging Brazilian taxes is extremely high, only to feed a corrupt state machine), and the health services here in the UK are certainly better that here ... For me the big problem it's all about the high prices of medicines until States point and the population able to afford these exorbitant costs? I fully understand that Big Pharma invests "heavy" in research (in my humble opinion are the great minds in universities around) and innovation, but to what extent the system itself will be able to bear this burden? Here's one of the reasons of failure of health systems around the world ...

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  7. I don't accept that the NHS cannot be funded by taxation; if the necessary will was there to collect the corporation tax that is currently evaded and the personal taxation system was more fairly distributed so that the rich pay a higher share, much more money could be invested in the NHS. FYI our household income is taxed at the higher rate (I am unable to work or claim any benefits) and we would be willing to pay more tax to support the NHS.

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    1. I have a tiny income and am not working due to the MS. I have had such a awful time with the NHS making mistakes that I spend the little money I have on private healthcare. It's my back up option. It's too late now the damage is done to my body. If only I knew then what I know now, i've had to figure it all out myself. Some of my NHS medical staff are very good but this is not generally.
      I think the NHS is great but when referrals are wrong, examinations are wrong, lack of medical notes made and I keep having to chase the tails of NHS staff that should know better. I am doing part of their job. It's like I am studying for another degree this time in how the NHS works and neurology.
      Rant over but it has truly been an eye opener.

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  8. If only the man/wman on the street was better able to look after themselves then a lot of the problems would evaporate.

    Stop demnding antibiotics when you have a cold, take some execise every dayand eat properly is just the start.. Oh yes cut down on sugar and salt as well. In the 1970's there were almost no precooked meals. I'm sure everyone took more exercise and the doctors knew their patients properly.

    Somehow people have got to be more capable of looking after their own health and not expecting the state to pick up the tab.

    I don't want this to sound like right wing drivel (cos I'm not right wing) How many ptoblems can be put down to poor diet, lack of exercise and not looking after yourself. It ain't the magic wand but it must be a move in the right direction.

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    1. I wish that it would be that simple. To accuse the poor non-vegan lads. I am sorry to spoil this beautiful vision of the world. People who eat well and make sport everyday, they get old, they degenerate, and they die - like everybody. If you want to last the longest possible in good health good hospital and good NHS might help.

      BTW nothing sounds more right wing than "cos I'm not right wing" ;).

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    2. I'm sorry Xor Xor, Patrick is correct. If you follow a healthy lifestyle as mentioned in previous Prof G posts, you do stand a better chance of fighting disease.

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    3. If you look after your self and are aware of the consequences of unhealthy living then you tend to avoid it. Therefore the NHS has to spend less money looking after you. What does obesity cost the NHS. Too much salt, too much sugar in our diwt. These are changes to our diet in the last 30 years that eventually are a cost to the NHS. Healthy living is a simple thing that we can do ourselves and this reduces potential cost to the NHS

      Yes we will all eventually die, a cost to the NHS but meanwhile we remain healthy and therefore lower cost to the NHS

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    4. You might have misunderstood me. It is important to have an healthy diet and way of living. Just to feel better in everyday life. And thank for profG and all his team for the valuable advices.

      What I am saying is that a healthy lifestyle is a necessary but sadly no a sufficient condition. My brother fell in love with a girl, a lovely person, she was eating healthy. No smoking. No drinking. She even made my brother to eat veggies. One summer, she started to have strange bruises forming spontaneously. She was in her 20s. The bruises came from Leukaemia. She died 6 month later.

      I do not blame the health system for this horrible death (she died in France so no worry NHS). They did their best and I am not aware of any problem with the health system in this case. But having a healthy health system is really a game changer in these kind of (too fucking common) situation. The take home message here is simple: you should do anything to promote a good health system because this condition is very necessary.

      And about the dying stuff. Death is not the real cost. Degeneration is the real cost. You can eat as much kale as you want and jog everyday it does not prevent degeneration. Lets end on light note about this dying/degenerating thing. One way to save money for the society and NHS would be to heavily promote smoking. Indeed, smokers die fast (lung cancer kills quick) and often just at the end of their productive life. Therefore, no big health cost and no retirement to pay! Great, no?

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  9. Is the word neoliberals a right wing phrase that conservatives in Britain use to confuse people? Sort of like Fox News is Fair and Balanced.

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  10. On an unrelated news
    A judge in the UK ruled a woman with MS be given the right to die.
    She was described as being in a "minimally conscious state"
    https://www.mssociety.org.uk/ms-news/2015/11/judge-rules-woman-ms-allowed-have-life-support-withdrawn
    Would be interested to hear your opinion on this.

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    1. I saw this last week. l left this to see if profG wanted to comment, whilst i support the right to choose i do not want to debate this. I am sure you all have opinions one way or another.

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  11. watching the Wilko Johnson documentary last night on the BBC. His parting statement was something like We love the NHS we have to keep it. Wilko is a guitarist with doctor feelgood would got cancer and has been given more time by the NHS.

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    1. That was a Feelgood documentary.
      Boom tish..............;-)

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    2. i only saw the end, wasnt that norman whatroy on bass?.

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    3. Indeed it was. Also saved by the NHS after he had a brain haemorrhage.

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  12. Are DMTs for MS not much more readily prescribed in Germany than in the UK, and is that not a good thing/sign? My experience of medical care in Germany, albeit prior to onset of PPMS, was that it was incredibly professional and polished. In my humble opinion, I don't think the UK need look to the US for an example. I think much more could be learned from Germany's system.

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    1. Yes Germany are usually early adopters of new treatments and the UK is second to the worst in Europe

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