Britain’s National Health Service is becoming less Centralized to Improve Quality

Posted by PITHOCRATES - March 31st, 2013

Week in Review

The answer in fixing the American health care system, according to Obamacare, is for more top-down management.  A centralization of the health care system.  Having distant bureaucrats make treatment decisions for patients.  Why?  According to President Obama, doctors were ordering needless tests and procedures just to maximize their billings.  The president even said they were amputating limbs unnecessarily.  Again, to maximize their billings.  And the only way to stop that was with the heavy hand of government.  Just like they do in Britain (see Hospitals that fail patients will be fined, says NHS chief by Denis Campbell posted 3/29/2013 on the guardian).

Hospitals will face financial penalties if they fail to give patients with problems such as a stroke or heart attack the best possible care, under controversial plans spelled out by the NHS’s top doctor.

Professor Sir Bruce Keogh, speaking to the Guardian, said the new GP-led clinical commissioning groups (CCGs) that will take control of £65bn of health spending on Monday will hold back from a hospital part of the fees for an operation if the patient has not been treated to the highest possible standards. “The idea is that the CCG would say: ‘We will withhold a certain amount of payment from you until you can demonstrate that you’ve met these standards.’ So it’s a bit like the building industry – you pay 90% of the [cost of] the building upfront, and then the final payments comes a bit later, when you’re sure everything is OK,” Keogh said in his only interview before the new NHS system starts in England on 1 April.

Such differential payments – it is hoped – will compel hospitals to provide high-quality care and force units that do not embrace the latest medical thinking in their specialism to overhaul what they do. Medical teams that do not implement the latest clinical guidance – called quality standards – on how to manage those with a particular condition will forfeit an as yet to be agreed part of the payment…

His tough message to hospitals on quality of care was reinforced by the decision late on Thursday to suspend children’s heart surgery in Leeds General Infirmary following concerns about the quality of lifesaving procedures offered there and the number of its patients who died. An inquiry into practice at LGI has begun…

The NHS Confederation, which represents hospitals, voiced unease at the plan. It would be better to give high-performing hospitals small bonuses over and above the full tariff rather than use penalties against the weaker ones, said Mike Farrar, its chief executive and a former boss of the NHS’s north-west region.

“Bruce is right that commissioners [CCGs] need to use levers. But the downside of penalties is that if hospitals don’t reach the standards set, then they don’t get the rest of the tariff fee and the risk is of a downward spiral in which they have less resources next year in which to try and meet the standards,” Farrar said.

In the Guardian interview Keogh urged the NHS to help stick to its tight spending limits by cracking down on patients receiving unnecessary tests and procedures – known as “overtreatment”.

He voiced concern that the NHS is conducting too many x-rays and blood tests without a good medical reason, subjecting some patients to operations they do not need, and prescribing too many antibiotics.

Odd.  The very things a more top-down approach was supposed to eliminate are now being eliminated by moving away from that top-down approach.  And moving towards a more local approach.  Having people closer to the patients making treatment decisions.  Holding caregivers accountable before they authorize final payment for their services.  And making sure patients and their families are satisfied with the care they received.

Almost sounds like a step back to that intimate doctor-patient relationship.  That served patients so well.  And doctors.  For the only way for doctors to get rich was by taking care of their patients as if they were family.  So they wouldn’t go to another doctor.  And form an intimate doctor-patient relationship there.  Providing a strong incentive to give patients the best care possible.  Because there was accountability.  Not a cold, faceless bureaucracy.

Those on the left have long pointed to Britain’s National Health Service (NHS) as the proper way to do health care.  And here they are.  Moving towards the way things were in America.  Before Obamacare.  Basically a tantamount admission by someone in the business of national health care that it doesn’t work.  And yet here we are in the United States.  Moving towards something with a proven track record of failure.  Something that will benefit the politicians.  At the expense of the patient.

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Market Forces and Health Care

Posted by PITHOCRATES - March 4th, 2013

Economics 101

Keynesians try to reduce Human Behavior down to Complex and Confusing Math

We hear a lot about introducing market forces into health care.  But what does that mean?  What exactly are market forces?  Are they like magnetic forces?  Electric forces?  Hydraulic forces?  No.  Market forces are not forces that conform to the laws of science.  Rather, they belong in the realm of the social sciences.  That are less science.  And more opinion.  Where there are a lot of theories.  And politicians massage the data to fit their theory.  As Mark Twain said, facts don’t lie but liars figure.  And politicians figure.  A lot.

So there are no hard rules when it comes to the social sciences.  Just a lot of theorizing.  And a lot of drawing conclusions.  Based on the data.  And how some massage the data.  Something to keep in mind whenever anyone discusses economic numbers.  For the accepted school of economics most politicians adhere to is the Keynesian school.  The dirty little whore of economics.  For there is a whole lot of massaging going on with Keynesians.  With the data.  Not each other.  Politicians love Keynesian economics because this school of economic thought calls for governments to tax, borrow, print and spend.  Empowering government.  Making government grow.  And become more intrusive in our personal lives.  All things politicians love.  Which is why they massage the economic data.  They have to.  Because this school of economic thought doesn’t work.

Keynesians make economics very complex.  Open a text book and you will find a lot of graphs and formulas.  Where they try to reduce human behavior down to math.  Very complex and confusing math.  And you can’t do that.  Humans have free will.  They make decisions based on any number of things.  One influencing factor more or less could change the way they decide.  And there’s no way we can quantify all the variables in our lives.  Therefore, there’s no way to reduce human decision-making down to math.  Which is what drives market forces.  Our decision-making process.  That point in time that triggers the free exchange of money for goods and/or services.

When it comes to the All-You-Can-Eat Buffet Customers think more in Terms of Quantity than Quality

Consider an all-you-can-eat buffet.  And how it changes your decision-making process.  But first let’s look at some typical behavior at a normal restaurant.  Where you may spend $15 for a 4-course meal and drink.  Soup, salad, entrée and dessert.  Which you enjoy with a friend.  You have pleasant conversation as you enjoy each of your 4 courses.  Taking your time.  Enjoying each course.  Slowly getting full.  And satisfied.  The portion sizes are just right.  Leaving just enough room for dessert.  You’re full.  But not too full.  Comfortable.  You’re able to go for an after-dinner walk.  Even take in a movie.

Now let’s consider the all-you-can-eat buffet.  Where you may pay $20 for unlimited access to the buffet.  You’re paying more than for a sit-down service.  Why?  Because you plan to eat more.  You will maximize the value you get for your $20.  Which means you’ll probably skip the soup and salad.  And start loading your plate with the expensive entrées.  You’ll probably go back once or twice.  Making sure you get a taste of everything.  And a lot of anything that is expensive.  Again, to maximize your value.  In fact you maximize so much that you become uncomfortably full.  Too full to sit through a movie without nodding off.  And too full for a walk.  All you want to do is go home and nap.

The restaurant sees this from a slightly different perspective.  The all-you-can-eat buffet is simple to serve.  You mass produce food to load up the buffet so it’s ready at the beginning of the buffet hours.  You replace the items people eat most.  While the less popular items sit longer in the buffet.  Becoming less fresh.  Also, the buffet is a good way to get rid of things approaching their ‘serve by’ dates.  Saving the freshest food for the made-to-order sit-down service.  And putting the older food in the buffet.  Because when it comes to the buffet you know customers are thinking more in terms of quantity than quality.  The food is good in the buffet.  But not as good as the food for the sit-down clientele.

If you Pay Cash at the Pharmacy you are more likely to Ask for the Less Expensive Generic Drugs

These are market forces.  People have come together to make voluntary exchanges.  The quantity of food available makes some people opt for the more expensive all-you-can-eat buffet.  Others may opt for the less expensive but higher quality made-to-order sit down service.  For the person who places the greatest value on eating mass quantities of food will choose the buffet.  The person who places the greatest value on the dining experience (quality of food, made-to-order, conversation, after-dinner walk or movie, etc.) will choose the sit-down service.  If more people are choosing the buffet the owner may extend the buffet hours.  If fewer people are choosing the buffet and leave a lot a food to throw away the owner may end the buffet service.  These are market forces.  Buyer and sellers coming together in the marketplace.  Seeing what each has to offer.  If they come to a mutual agreement they make an economic exchange.  The buyer willingly exchanges his or her money for goods and/or services.  The seller willingly accepts an amount of money in exchange for his or her goods and/or services.

The private economy works because it is buyers and sellers meeting and making exchanges they both freely agree to.  This is the key of market forces.  It’s what makes people with money go to the marketplace.  And it’s what makes people bring goods and/or services to the marketplace.  Because they will seek each other out and make these exchanges.  After which both buyer and seller will come away with something they value more.  This is what is missing in health care.  Buyer and sellers aren’t meeting to make exchanges.  In fact, the buyer and seller do not even meet.  Patients never ask for any prices.  Because they aren’t paying for anything.  Their insurer is.  And the medical provider will always provide the most expensive treatment billing guidelines will allow.  For that’s who they must please.  The people paying them.  Not the patient.  And they have to charge as much as they can to cover all the things they won’t get paid for.  People they treat without insurance who can’t pay.  And for the billings the insurers deny.

So this changes the decision making process.  For everyone.  Introducing a third party into the equation removes market forces.  If you pay cash at the pharmacy you are more likely to ask for the less expensive generic drugs.  If you get free prescription coverage you will ask for the most expensive name-brand medicine they have.  For when you’re not paying price is no object.  But when you are paying price is a very important object.  Because when it’s our money getting value for our money is very important.  So we’ll ask if the name-brand has any more value than the generic.  For who would spend more for something that doesn’t give you any more value than something you can get for less?

When it comes to medical tests and procedures patients aren’t going to ask for more than they absolutely need.  And doctors aren’t going to prescribe any more than a patient needs.  Because they aren’t billing a faceless bureaucrat.  They’re billing someone they have a close and personal relationship with.  And they sure aren’t going to try and bill someone they have a close and personal relationship with for someone else’s unpaid bill.  Not if they want to keep them as a patient.  Because a doctor-patient relationship is a long-term relationship.  A doctor could lose a lot of business by mistreating a patient to make an extra buck.  These are market forces.  Which makes the private sector work so well.  And why their absence makes the health care system not work so well.  Transforming our health care from a moderately priced, high quality, custom, sit-down service to a higher priced, mass-produced, lower quality, all-you-can-eat buffet.

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Government Bureaucrats are bad for your Health in the UK and in the US

Posted by PITHOCRATES - March 2nd, 2011

 To be Great be like Margaret Thatcher and Ronald Reagan

People have said that the British and the Americans are one people separated by a common language.  We’re very similar.  Even if we speak the Queen’s English a bit differently.  It turns out that’s not the only thing we share.  We also bend over backwards to compare ourselves with great conservatives from our past (see Look at what the Conservatives are achieving by Michael Fallon, MP for Sevenoaks and deputy chairman of the Conservative Party, posted 3/2/2011 on the UK’s Telegraph).

Yes, Thatcher abolished the dock labour scheme – 10 years after she was elected. Yes, she tackled trade union power: they finally lost their closed shop in 1988, nine years after she started. Yes, she set up grant-maintained schools, independent of local authorities. But when we left office, they comprised less than 5 per cent of the country’s total.

David Cameron’s Government has moved further and faster. Take the public finances: public borrowing, cyclically adjusted, will be 0.3 per cent of GDP by 2015, well below the 2.6 per cent it was in 1990, and the budget will be back in surplus. Corporation tax was 34 per cent when Thatcher left office; by 2015 it will be 24 per cent. Small business tax, 25 per cent in1990, will have fallen to 20 per cent.

Not only is David Cameron Thatcher-like, he’s even out ‘Thatchered’ her.  This speaks volumes about the greatness of Margaret Thatcher.  In America, it’s the other half of that dynamic duo.  Ronald Reagan.  Come election time, every candidate is trying to show how Ronald Reagan he or she is.  Even the Democrats.  Even Barak Obama as his poll numbers plunge.

For a first-term prime minister leading an entirely novel coalition, the essential tasks might be enough: growing the economy; weaning it off its over-reliance on public spending, financial services and an unsustainable property boom; and pulling our finances back from the brink over which Greece and Ireland plunged.

Yet far more significant is the quiet revolution that is turning government inside out – away from Whitehall and targets and regional authorities and back to councils, GPs, head teachers, police commanders, community groups and charities. Ending the state monopoly in almost all public services, encouraging new providers, ensuring competition and choice – these are the most radical reforms since the Attlee government.

And Obama couldn’t be any more un-Ronald Reagan-like if he tried.  He’s trying to take America in the opposite direction that David Cameron is trying to take the UK.  Cameron is trying to decentralize while Obama is trying to centralize.  Especially health care.

Poor Quality, High Cost and Rationing in the National Health Service

The National Health Service in the UK has high costs and quality concerns.  The costs have been addressed in the past by rationing services.  The quality concerns have been addressed by layers of bureaucracy that have often been the original cause of the quality concern.

The problem with the NHS is size.  It’s a behemoth.  And because of that, it has layers of bureaucracy.  Which results in bureaucrats making decisions for patients instead of doctors.  They’re trying to change all this by grouping together and empowering local general practitioners (GPs) into consortia (see Hospitals shake-up essential, says King’s Fund by Nick Triggle posted 3/2/2011 on the UK’s BBC).

The government has protected the NHS budget by giving it small above-inflation budget rises over the next four years.

But the report said it was still entering a “cold climate” because demands and costs were outstripping the settlement.

It said without change there could be a “downward” spiral of falling income, growing deficit and declining quality.

Will this fix all the woes of the NHS?

Scandals such as Mid Staffordshire, where an official report found hundreds of patients died needlessly because of poor care, could not be ruled out.

Probably not.  But it’s a step in the right direction.  For the patients, at least.

A Department of Health spokesman said GP consortia would strengthen the ability of the NHS to make the right decisions.

“We urgently need to modernise the NHS – that is why our plans include many measures to make services more responsive to patients and to consistently drive up quality.”

The key to good health care has always been the doctor patient relationship.  The more people that get in between the doctor and the patient the poorer the health care gets.  Because the focus shifts from quality to cost efficiency.

This is a step in the right direction, but it’s still a heavy bureaucracy.  There is another way to ensure quality, though.  Competition.  When my dad had his first heart attack the paramedics gave us a choice of two hospitals they could take him to.  One had a bad reputation.  The other didn’t.  We chose the one with the good reputation. 

That other hospital continued to do poorly for years and eventually had financial troubles.  Then a big hospital bought it and brought it up to their standards.  And many years later, both of these hospitals are now providing quality care.  You see, competition makes everything better.  Even health care.

Using High-Fructose Corn Syrup instead of Sugar making us Obese?

The British and Americans have something else in common.  We like our sweets.  While one of us loses their teeth to this indulgence, the other has gotten obese (see The Fight Over High-Fructose Corn Syrup by Sharon Begley posted 2/28/2011 on The Daily Beast).

Now a stream of studies shows that sugar and corn sweeteners differ in important ways, including how they affect the appetite-control centers in the brain. That suggests that [High-Fructose Corn Syrup] HFCS may be partly responsible for the obesity epidemic…

The new study is too small to decide the question—it included only nine people—but it fits with other research on both humans and lab animals.  Scientists led by Jonathan Purnell of Oregon Health & Science University gave fructose, glucose, or salt water to volunteers and then measured brain activity with functional MRI scans. Over several regions of the cortex, activity increased in people given glucose but decreased in those given fructose, the scientists will report in Diabetes, Obesity and Metabolism. Cortical regions that responded differently included the orbital prefrontal, a key player in the reward circuit, and regions that process the pleasurable effects of food. “It’s evidence that fructose and glucose elicit opposite responses in the human brain,” says Purnell…

Rats eating equal calories from the two gained significantly more weight on HFCS than on table sugar, scientists led by Bart Hoebel of Princeton reported in 2010. The HFCS-fed animals also had increases in abdominal fat and triglycerides. And in a 2010 review, scientists at the University of California, Davis, noted that, in people, fructose added to abdominal fat and other measures “associated with increased risk for cardiovascular disease and type 2 diabetes.” HFCS is not the sole culprit in obesity. But the body and brain don’t seem to treat it as an innocent bystander, either.

Great Britain’s early Caribbean colonial possessions sent shiploads of cane sugar back to England for their tea.  And to make their chocolates.  They so liked their sweets.  And, as a consequence of this sugary indulgence, their bad teeth are legendary in the world of dental hygiene.  George Harrison even wrote a song about a fellow Brit with a chocolate addiction.  Eric Clapton.  Who he warned that he’ll have to have all his teeth pulled out after the Savoy Truffle (a song on the BeatlesWhite Album).

So the British are the butt of many a dental hygiene joke.  But they aren’t obese.  Like the Americans are.  Who also have a sweet tooth.  But we don’t eat sugar.  We eat HFCS.  Why?  Not because we prefer it.  But because of our government.  Big Corn lobbies Congress for sugar tariffs.  And Congress delivers.  Which makes imported sugar more expensive than HFCS.  So we eat HFCS not by choice.  But by government fiat.  And it now appears it may be part of the cause for the explosion in obesity and diabetes in America.  How about that? 

Yet another reason to keep government bureaucrats out of our health care system.

Conservatism Works every time it’s Tried

Bureaucrats are good at shuffling paper.  They aren’t good research scientists.  Or doctors.  So it’s best to keep them shuffling paper.  And let the professionals determine what we should eat.  What we probably shouldn’t eat.  And take care of us when we get sick.  I’m sure we’d all live a longer and healthier life if we do.

The dynamic duo of Margaret Thatcher and Ronald Reagan knew this.  Their conservatism worked.  It made the UK and the US great again.  And this is why everyone bends over backwards to show how much they are like these great conservatives from our past.  Even those who couldn’t be more opposed to their philosophy.  Because they know that conservatism works and has worked every time it’s been tried.  And they’re willing to admit that (a little) at election time.  Even if they’re lying through their teeth.  That is, if they haven’t been pulled out yet after the Savoy Truffle.

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