Sunday, September 09, 2007

Another bad hair day for the NHS

One task this blog has undertaken is to challenge the illusions and myths of nationalized health care. Which is not to argue that the US system is the ideal alternative. That is a different issue. The main myth we try to address is the idea that there is universal health coverage under socialized medicine. Much like we know that socialism doesn’t feed everyone—witness the politically induced famines in the Ukraine in the Thirties and in China in the 50s — we know it doesn’t give medical care to all either.

Socialism has always relied upon the political allocation of scarce goods, meaning that some groups or classes of people are intentionally denied access. And since socialism has proven itself very poor at the creation of those goods and services, its allocations are, by necessity, made from a smaller pool. There is no “universal” coverage under “universal health insurance”.

It may be that everyone can get an aspirin if they want it, or a doctor’s appointment if they can wait long enough. But the serious medical requirements, the ones most people worry about, are not available to everyone by any stretch of the imagination. They are often denied in a calculated manner to bolster the second main claim of socialized health care -- that it is cheaper. Obviously if you refuse to give people care that is costly, you can have cheaper care. Deny all care and the cost is zero. “Cheaper” can be obtained in any system if you limit consumption intentionally. That is not necessarily a good thing.

To illustrate this point we take a snapshot look at the much praised (by the nationalizers) National Health Service in the United Kingdom. This service is often held up as a model for the world to emulate. The argument given by some is that it provides more service, better service and cheaper service. Nationalized care gives more of one kind of service, over small things, and lots less of other services for serious illnesses. Add it all together and there is a lot less health care. The service is better if you are worried about small issues but worse if you are concerned about serious ones. So “better” is determined by whether there is a minor problem with your health or something major. Cheaper it is, but the lower cost is induced by the denial of care on a routine basis for more costly problems.

What is wrong with a snapshot, using British news reports on the NHS over a few days, is that perhaps the NHS was having “a bad hair day”. There are just some days when even the super models look pretty awful. So regular snapshots are needed. In fact, a portfolio of photos is usually required to make a decent judgment.

Here are a few other snapshots taken from British news sources for the last few days. We are not accumulating random incidents over a long period of time, but numerous incidents over a very short period of time. These are in no particular order to this issues.

The National Health Service says that they will have a 983 million pound surplus (almost 2 billion dollars) this year. That is after a 547 million deficit last year. Twenty-two of the local trusts, which provide the actual care, are in debt and for 13 of them the debt is growing rapidly. This is not as bad as last year but still serious. Sounds good. Of course one way to get rid of a deficit, or lower it, is to spend less which in this case means to cut health care.

The general secretary of the Royal College of Nursing, Dr. Peter Carter, raised that issue. “We have to ask at what cost this has been achieved.” Carter says one way this was done was to increase workloads of doctors and nurses even more. The Telegraph for August 30 reports:
... Hamish Meldrum, chairman of the BMA GPs' committee, said the cuts were "thinly disguised forms of rationing" patient care. "At the end of last year we saw services to patients being cut, with operations delayed, outpatient clinics cancelled, and referral management schemes," he said. "There are still hospitals that are threatening to lay off hundreds of staff in order to break even." Only last week, plans to downgrade A & E services and maternity services in Greater Manchester sparked protests from the Tories. Maternity services will shut at four hospitals, the A & E at one hospital will be downgraded and intensive care for premature babies will move from another.

Liberal Democrat health spokesman, Norman Lamb, said “this year’s surplus” was created by “dreadful cuts in key services” last year. One such cost savings has been in the way junior doctors have been treated. Many are simply left unemployed as the NHS trusts try to cut costs by reducing the number of physicians they have to pay.

For instance, Dr. Kapil Lad was working at one hospital which blocks access to personal email during work hours. When he got home that evening he found an email which said he had a few hours to respond as to whether he wanted to take a one month job. Non-response during that time was considered a rejection. Yet the time limit had passed because he was actually in the hospital caring for patients. Now he finds himself unemployed as a physician. He is now considering employment options outside the UK and says that he feels that if takes a foreign job it is unlikely he’ll return to the UK.

Trainee doctors are easy for the NHS to dismiss or ignore so they have. The country has 33,000 of them but is offering only 22,000 training posts. The rest are left out in the cold. With about a third of all junior doctors getting screwed over it is no surprise that many of them took to the streets to protest as the accompanying photo shows.

Hip replacements under the NHS are notoriously slow. But 79-year-old Thembi Nobadula finally received the replacement she needed and then was sent home without the follow up care required. She ends up sleeping sitting up in a chair and has been unable to take a bath for months. All she needed was one piece of equipment that would allow her to get in and out of the tub but NHS wasn’t listening. Her condition was considered bad enough that the NHS sent her to hospital appointments by ambulance but no one would listen to her needs. Only after the local Islington newspaper got involved did they suddenly listen and promise she would get the equipment she needed in about a week’s time.

Thelma Nixon has a serious eye condition that will lead to blindness unless treated -- wet macular degeneration. Injections of Lucentis into the eye are needed. But the NHS told her she can’t have them. They were more expensive than guidelines allowed. Thelma remortgaged her home to cover the cost of injections herself through private care. The York Press campaigned on her behalf and so did the Royal National Institute for the Blind -- without the publicity it is unlikely she would have received the NHS treatment.

A local businessman funded some of her injections and two other readers of the original newspaper article also were donating funds toward further injections. But with the bad publicity in this case the local NHS trust relented. But Thelma was warned that if she sought any further private treatment it would jeopardize the funding she would received.

William Foreman, 66, of Suffolk, needed a hip replacement. The NHS told him he would have to wait. And when it comes to hip replacements the elderly wait, and wait, and wait. Foreman didn’t wait. He took 6,400 of his savings and flew to Poland. That covered his flight, the hip replacement, and three weeks or rehabilitation. From the time he was told he needed the hip replacement to the surgery itself was a total of two weeks. For this price he got a private room and twice daily sessions with a physiotherapist.

Foreman is just one of thousands of people from the UK who become “medical tourists”. Medical tourism is a booming business that helps individuals who can’t get timely treatment, or treatment at all, from the NHS obtain the same treatment overseas. One study indicates that 50,000 people leave the UK every year for medical treatment elsewhere. If they didn't the waiting lists would be even longer. And the money these people spend to get the care they aren't receiving from the NHS is not counted toward health care costs for the NHS.

Russ Jones needs the drug Sutent because he has a gastrointestinal stromal tumor. The NHS has refused to supply it because it is too costly and they question whether it is effective. Jones is now depleting his savings to pay for the drugs himself. The problem Jones has is very rare which is why there is little research on the drug which would prove whether it is effective or not. But in some parts of the UK Sutent is available while in others it is routinely denied. This has lead to what some are calling a “postcode lottery”. People who live in certain favored areas receive treatment that is routinely denied to everyone else.

Cancer patients in Northern Ireland, part of the UK and under the NHS, are unhappy. Those suffering from asbestos cancer have been told they will have to wait until 2009 at the earliest before they can receive the drug Alimta. This form of lung cancer is incurable and Belfast is one of the UK hotspots for the disease. While Alimta does not cure the disease it relieves symptoms and increases life expectancy. Waiting two years for treatment is a death sentence since most patients with the disease die within one year. The drug is available in other parts of the UK by the NHS just not to people in the “hotspot” of Northern Ireland.

Brigitte Stankovic has worked her entire life as a hair dresser. Now 42 she runs a busy hair salon. She has kidney problems and high blood pressure and needs regular medical attention. But to seek that treatment means taking hours off of work at a loss of personal income -- and lost income is not counted in health care costs. Brigitte explained her problem:
With the NHS I just couldn’t get an appointment to suit me or the phone was constantly engaged and when I did get an appointment you would be sitting for ages in cramped conditions and then rarely see the same doctor. I have worked all my life, since I was 15-years-old and running a hairdressing salon is a job where time is money and I couldn’t afford to go on like that.

She said that with the NHS it was impossible to get treatment without losing work time and income. Brigitte now uses the first private GP practice to open in Wales. Dr. Jo Longstaffe sent up Independent General Practice three years ago and now has three offices with a fourth opening shortly. She has six doctors working for her and three more on the way.

Our final snapshot of the NHS for the last few days covers the phenomenon of “hidden” waiting lists. It is widely known that socialized health care often results in very long waiting lists. These lists prove a constant embarrassment to the advocates of the system. One way of addressing the problem is to cut the lists. This doesn’t mean that people receive treatment. It just means they are removed from the official waiting list and put on a waiting list for the waiting list. This means they no longer have “guaranteed” treatment within a specific period of time.

The Scotsman reports that “5000 Lothian patients have been switched from main waiting lists on to the ‘availability status code’ list” instead. And while these secondary waiting lists had seen some reductions in recent years they are growing once again. The reason for the growth is that fewer surgeries than needed are provided.
Separately, NHS Lothian was also unable to secure all the surgery time it wanted for patients with coronary heart disease - one of the biggest killers in the region. Local health chiefs asked the Golden Jubilee for four weekly sessions, but were only granted two, later increased to three. Another issue in tackling the level of ASC codes in the Lothians is the need to provide more orthopaedic surgery, such as hip and knee operations. More than 300 plastic surgery and orthopaedic patients have now been sent to the private Murrayfield Hospital instead.

In Scotland alone the “hidden” waiting list has 25,000 people on it who are merely waiting to be moved to the official waiting list. Public Health Minister Shona Robison promises that no one will wait “more than 16 weeks for treatment” and that they will get “rid of hidden waiting lists” -- next year. Apparently it’s another bad hair day for the NHS.


Wealthy could get health benefits under Democrat plan

Thousands of families who earn enough to pay a tax designed for wealthy Americans also would be eligible for government-subsidized health care for low-income children if proposals in the Democrat-controlled Congress become law. In New York, almost 15,000 families who pay the alternative minimum tax would be covered under the healthcare program if the state's plan to increase eligibility to those earning four times the poverty level - $83,000 for a family of four - is approved, according to an analysis by the Heritage Foundation, a conservative think tank. "Only in Washington would you consider a family both rich and poor at the same time," said Greg D'Angelo, a research assistant with the Heritage Foundation. "It's the only place where one could be that creative."

If every state raised its eligibility cap for the program to New York's standard, then about 70,000 families nationwide who pay the tax - which applies to millions of households that make heavy use of certain tax breaks such as tax-exempt bonds and child credits - would be eligible. The House and Senate last month passed bills to expand the State Children's Health Insurance Plan, or SCHIP, to families earning several times the national poverty level. A conference to hammer out differences in the two versions is expected to begin this week.

The White House has threatened to veto both bills because of their hefty costs. The Senate bill would expand eligibility in the program to families earning up to three times the national poverty level - about $62,000 annually for a family of four. About 1.7 million children and a handful of adults enrolled in private health insurance plans would receive SCHIP coverage by 2012 under the bill, according to analysis of the program by the Congressional Budget Office. "This bill essentially extends a welfare benefit to middle-class households," stated a policy paper issued by the White House Office of Management and Budget.

The House bill would give SCHIP coverage to 1.5 million Americans who currently have insurance, the Congressional Budget Office says. Both bills would allow states to seek waivers to exceed the eligibility caps in the legislation, provided that the states meet certain benchmarks ensuring that their poorest children are covered by the program. Many states are expected to seek waivers for families earning three times or more above the national poverty level, thus extending SCHIP coverage to millions of middle-class Americans. "If we just want to go to a government-run, socialized medicine, fine - this is it," said Senate Minority Whip Trent Lott, Mississippi Republican, on the Senate floor last month. "I'll be back in years to come and say: 'I warned ya.' This thing is going to continue to grow."

The Bush administration last month announced new rules that will make it more difficult for states to seek waivers. The policy includes a requirement that 95 percent of all children from families earning less than twice poverty level must first be enrolled in SCHIP or Medicaid before a waiver is granted.

Democrats have accused the president of obstructing the program, saying that locating and enrolling 95 percent of a state's poorest families is almost a logistic impossibility. State health officials in high-tax states such as New Jersey, which currently has the nation's highest SCHIP income eligibility cap at 350 percent, or $72,275 for a family of four, say waivers are needed to keep pace with their state's high cost of living.

More than 75 percent of the 122,525 New Jersey children receiving SCHIP assistance live in families earning no more than twice the federal poverty level - $41,300 for a family of four. The median family income in New Jersey for a family of four is $90,261 - about $30,000 higher than the national median, according to the U.S. Census Bureau. "Living in New Jersey, it's a huge expenditure for a low-income family to have medical stability," said Suzanne Esterman, a spokeswoman with the New Jersey Department of Human Resources. "This is a vital program in New Jersey."

And SCHIP coverage isn't free for everyone. In New Jersey, only families at the lowest income levels escape paying monthly premiums and co-payments for doctor visits. Families earning 350 percent about the poverty level pay a $125 monthly premium, while families at the 300 percent level pay $74.50.

The House bill proposes a $50 billion spending increase for the program over five years, for a total of about $75 billion. The plan would add an estimated 5 million children to the 6 million already enrolled in the program, which expires Sept. 30. The Senate version would spend an additional $35 billion over five years and would cover about 3 million children not currently enrolled. To pay for the plans, House Democrats proposed a 45-cent-per-pack increase in the cigarette tax and cuts to the Medicare Advantage program. The Senate version calls for a 61-cent-per-pack increase in the cigarette tax but no cuts to Medicare Advantage.


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