Sunday, 28 March 2010

Why the NHS can never work

Whenever I hear debates about the NHS I am struck by something that is usually not said far more than by anything that is. The point rarely made is that you can fund health care through taxation without the delivery of the service being run by the State. In fact taxation funds all sorts of activities without having a direct hand in their provision, for example the payment of benefits allows people to buy food from supermarkets not from a State shop. The problem with the NHS, and the reason it is riddled with inefficiency and bureaucracy, is nothing to do with being funded out of taxation it is directly and necessarily a consequence of being under the political control of government.

One noticeable feature of the public sector is that dismissal for failing to do a job properly is reserved almost exclusively for the lowliest employees. There are notable exception such as the dreadful old bint who was squeezed out of her job at the head of a council's social services department as a result of the failings in the Baby P case, but her resignation/dismissal was more the consequence of public outcry than the imposition of a sanction by her employers. This, I am sure, is a consequence of the people at the top - the government ministers - being practically immune from sanction no matter what failings occur in their departments.

In the private sector there are consequences for not delivering a proper service and for wasting money on unnecessary fripperies. The directors of a company are accountable to the shareholders, the managers to the directors and the shop floor workers to the managers; the role of each is spelled out by their contracts of employment and failure to honour those terms can lead, ultimately, to dismissal. No NHS hospital manager seems to lose their job when wards are beset by MRSA and patients are left in their own soil. Were such things to occur in a private hospital heads would roll.

Tellingly, "superbug" infections are virtually unknown in private hospitals. In part this can be explained by the risk to managers' jobs were they to allow such conditions to prevail, but it is also the result of two other factors. First, the continued existence of the hospital depends on being able to attract customers. This means that hospital acquired infections not only put individual managers at risk they put the whole business at risk. Against that background it is no more surprising to find private hospitals to be clean than it is to find clean glasses being put in front of diners in a restaurant before their wine is served. Secondly, the business of a private hospital is built from the bottom up not the top down. Providing what the customer demands is a prerequisite not just to the business continuing but to it getting off the ground in the first place. This creates an ethos of offering a proper service first and restricting your administrative structure to the minimum necessary to run that service.

In all this, the till is the measure of whether an adequate service is being provided. Customers only pay if they get what they want at a price they can afford. If they do receive that, they pay and the bell on the till goes ding. Money is just the measurement used, however, it is not the judge of whether the hospital is doing things properly. The judge is the customer. What happens to his money is the evidence of his judgment. It might go into the till of hospital A or hospital B or hospital C, just as it might go into the till of Tesco or Sainsburys or Morrisons or some other supermarket. These supermarket giants succeed in business because they react to what the customers want and offer the best produce they can at the lowest price they can manage. The directors of these companies run their businesses by looking only at what is good for the businesses themselves and that is determined by what is best for the customers. There is no such thing as what is best for the directors there is only what is best for the customers, the directors might receive tasty bonuses when profits are made but that can happen only as a consequence of the customers' decision to shop at one rather than the other.

This fundamental difference between the public and private sector is only part of the reason why the provision of medical services cannot function efficiently as a top-down operation. The other important factor is that politicians will always see the NHS as something that can be used to their political advantage as well as being a means of providing medical services. The service can be brilliant but that will garner no extra votes unless the little people share the view that it is brilliant. More relevantly, the service can get worse or stay the same or improve only a tiny bit yet votes will flow from the little people believing it is better than it is.

There have been countless instances over the last thirteen years of the government launching expensive NHS initiatives and telling us they have been a massive success. It started with waiting times for treatment. Some treatments were provided instantly, others took time. Of course no one wants to wait if they need medical treatment but some waiting is inevitable because there are not endless resources. The result was diktats from above about waiting times with the continued funding of hospital departments being dependent on meeting the waiting time targets. The consequences were obvious. Waiting times in the problem fields fell by a combination of: (i) taking resources from a field in which people were not having to wait (so that they then did have to wait) and pumping them into the problem area and (ii) cheating by having doctors and nurses say hello to someone as they were approaching the maximum waiting time just so that it could be said they had been seen by a medical professional before the deadline.

There was another result, one just as obvious but much more expensive. In order to know whether the waiting time targets were met a whole new layer of bureaucracy had to be created and paid for. That layer exists purely for the benefit of the government. It exists so that statistics can be gathered, edited, massaged and falsified to provide the pre-determined result: "the government has improved health care". In fact it also creates a second unnecessary and expensive layer of bureaucracy at hospital level. Not only do they have to collect statistics for the government's number-crunchers to play with, they have to crunch their own numbers in order to preserve their funding for the following year. Bureaucracy costs money, money that could otherwise have been used to provide more hospital beds and more equipment. Remember, though, there are no votes in more beds and equipment, votes come only from the perceptions of potential voters. The process is an ever-more expensive spiral of unnecessary costs because you cannot stop after one initiative, the voter is a fickle being and requires constant persuasion.

Because politicians see the NHS as a way of gaining votes they cannot stop interfering, new initiatives are brought into effect before it has been possible to assess whether the previous initiative has been beneficial. The injection of additional funds is also accompanied by the need for additional statistics to show this new money has produced an improvement - not to measure whether there has been improvement but to show improvement. For the politicians it is utterly irrelevant whether an earlier change has improved the service provided to patients, what matters is whether it is beneficial to them, so they can abandon the last change at will or retain it and introduce another simply to get votes.

For so long as the NHS is under political control we will see the same thing happening. Every year it will become more expensive as more vote-seeking initiatives are added to the list and more pen-pushers are needed to keep track of what is happening. The provision of medical services will be guided to an ever greater extent by what the politicians think might be good for them with twisted statistics justifying their every move. And still superbugs will kill in NHS hospitals and be virtually unknown in the private sector.


Anonymous said...

Getting away from the current state monopoly on public health spending is a political obstacle, and not one easily overcome.
I think you have made the assumption that where there's a state health service there cannot be fair competition, but in theory a state health system could be chopped up into enterprises in competition with each other for that health Pound, while each and every enterprise remained state owned. Not as economically desirable, (the sum would still be subject to political manipulation) but possibly a more politically feasibly idea than complete privatization.

Andrew W

Brian, follower of Deornoth said...

"some waiting is inevitable because there are not endless resources"

I don't have to join a waiting list to buy a pineapple or a motor car, despite there being only finite resources available. Thinking about why not is very instructive.

Norman said...

I couldn't agree more with this post.

David Cameron has some hare brained ideas (anything involving the words 'Green' or 'energy' for a start) but his obsession with trying to show us that he'll outspend Labour on the NHS is alienating me more than other policy.

I could write an essay on all the reasons why this is lunacy and a massive vote loser but my blood pressure won't allow it.

Stan said...

I've been saying the same thing myself for years, FB - as long as health care is free at the point of delivery then why should it matter if it is provided by the private sector?

It shouldn't - but for some reason we treat the NHS as some sort of sacred cow. And, of course, to the NHS an operation is a "cost" so, when money is tight, they cut operations to cut costs. In the private sector an operation is income so operations are rarely cut.

The NHS costs every man, woman and child £1300 a year - over £5K for the average family of four - and this does not include the huge "social care" costs which aren't included in the NHS budget.

Mark Wadsworth said...

"The point rarely made is that you can fund health care through taxation without the delivery of the service being run by the State."

I say it, Stan says it, UKIP says it, in fact most other European countries say it (and GPs in the UK say it). Taxpayer-funding up to a certain minimum level; private provision. Problem solved; or at least, problem minimised.

TheFatBigot said...

Mr Andrew, attempts have been made to do exactly what you suggest. They achieved some success but were still subject to constant political interference.

Mr Brian, I think you are quite wrong. If a pineapple costs £1.50 and you only have £1 spare a week you do have to wait. You also have to wait for the shop to re-stock if all the pineapples have been sold despite you having £1.50 in your sweaty palm. No one puts you on a list but you have to wait. There are waiting lists for many cars. Not, usually, for the run-of-the-mill mass-produced ones but for the really fancy items.

Brian, follower of Deornoth said...

Not quite, Mr FB. If a pineapple costs £1.50 and I only have £1, I have to earn, not wait.

sobers said...

I have a puppy. A few weeks ago he was ill, dicky stomach, blood in his stools. I was worried he'd eaten something he shouldn't have (he is terrible for trying to eat anything and everything). This was a Sunday morning. I rang my vet's practice and explained the situation, it was about midday. I was given an appointment for 1:30pm. I took him in, he was examined by the vet (the practice was open and staffed on a Sunday). Fortunately he wasn't seriously ill, I was given various powders and special foods for him, and instructions as to what to do. All this cost me £75. Which I paid. I do have insurance, but the excess is £75 so I'd have to cough up anyway.

There are millions of pet owners all across the country who do this - pay personally for their pets illnesses, often hundreds if not thousands of pounds. There is no National Vet Service. Why is it considered so 'out there' politically to suggest that people do the same for themselves? Especially given we pay the money for the NHS anyway in our taxes, which could be returned to us for us to spend as we saw fit.

I suggest that everyone be forced to have critical illness insurance cover, for the really expensive conditions (cancer etc). The State could pay the premia for those too poor to pay. Everything else would be down to the individual to fund, either by getting insurance, or paying as you go. All the taxation currently levied on us that goes to the NHS would be returned.

Oh, and regarding pineapples, the price is the waiting list. Thats what prices are. They separate those who want something from those want it AND can pay for it. If anything of value is free there will be infinite demand and limited supply. Hence waiting lists. Solution - introduce prices for healthcare.