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Why is the National Health Service in crisis?

This post was written by my regular correspondent “ARC”, who has several family members working in the NHS. – NS

I’ve been discussing the NHS A&E issue that’s been in the news of late with the medically knowledgeable and NHS-aware members of my family and thought you might be interested in their background information, so have written it up while the conversations are still fairly fresh in my mind. I summarise, then give my own thoughts at the end.

The immediate cause of the NHS A&E issue being such a story in the media at this time (other than the upcoming election, of course) is simply that at Christmas a great many staff take holidays. The resulting shortfall exposes long-term trends in an area under pressure. There is no other immediate cause, as distinct from long-term trends: these problems have been growing for 15 years and more as follows.

1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort – delaying release and also using up time of staff in non-health work – and costs money.

This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years – “If the NHS were a patient, she’d be on the critical list” – was caused by this and the resultant bed-blocking more than any other one cause.

A more recent context is over-regulation of local councils’ social services leading to declining throughput, unrealistic expectations for their visit times, etc., and there have also been some social services cuts by said councils. These also have an impact on a hospital’s ability to get people out of the back-end to free up beds for A&E incomers.

2) The new 111 service is sending many more patients to A&E.

2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.

2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).

3) Regulation prevents fixing the problem as well as causing it. A Birmingham hospital (Queen Elizabeth in Edgebaston IIRC), said to be very efficient as such things go, tried to create a low-level care unit precisely to solve the problem. Because of the regulations, the attempt had to be abandoned – they just could not tick all the boxes.

4) Back in the early-80s, when my sister (a doctor) did her elective in A&E, she loved it. Now, doctors are avoiding A&E as a speciality because they know how brutal is the pressure there. So the problem is beginning to compound itself.

There is a great deal more one could say, but the above are what my informed relations see as the key immediately-relevant causes. So far my summary. Now some thoughts of my own.

What I observe has most changed in the last two decades in these either left-leaning or were-left-leaning people is firstly their belief that “No party can fix it”. (This I heard from a previously definitely-left individual who would probably still cut her hand off before it voted Tory and whose heart wavered between Labour and [Scots] Nats although her head despises Nats ideas and despairs of Labour.) There is an expectation that no likely government will do anything other than talk of reform while actually causing yet more regulation. Some of this in some of them might be a reluctance to think that the side of politics they’ve loved to hate in the past might be the place to look for an answer (I am reminded of Gore Vidal in 1979, “I feel the despair of coming to think that the Soviet Union may be as despicable as the U.S.” – quoted from memory) but it also reflects their opinion that the Tory-led coalition has failed to reverse any of the above trends, and this opinion I fear is not mere prejudice but has a basis in their experience of the last three years, just as much of the above reflects their experience of the last 15 years.

Secondly, they report a widespread belief within the health service that this time “a bit of money can’t fix it”. There is no expectation of an ocean of money (and – I sense – awareness that the NHS already consumes an ocean of money, so can hardly demand another ocean of money even as a righteous goal, however impossible to arrange).

Lastly, I know that behind all this inefficiency of regulation, there lurks a compounding problem of looming social trends. The number of patients who have no family ready to help is rising. The promise that the state will look after all has led more people to lead lives that make no other arrangements. But these long-term trends are not the reason the NHS operates much worse now than two or three decades ago.

NHS Kremlinology

Back in the bad old days, Kremlinologists used to try to figure out what was going on in the leadership of the USSR by observing signs and portents.

During the Cold War, lack of reliable information about the country forced Western analysts to “read between the lines” and to use the tiniest tidbits, such as the removal of portraits, the rearranging of chairs, positions at the reviewing stand for parades in Red Square, the choice of capital or small initial letters in phrases such as “First Secretary”, the arrangement of articles on the pages of the party newspaper “Pravda” and other indirect signs to try to understand what was happening in internal Soviet politics.

To study the relations between Communist fraternal states, Kremlinologists compare the statements issued by the respective national Communist parties, looking for omissions and discrepancies in the ordering of objectives. The description of state visits in the Communist press are also scrutinized, as well as the degree of hospitality leant to dignitaries. Kremlinology also emphasizes ritual, in that it notices and ascribes meaning to the unusual absence of a policy statement on a certain anniversary or holiday.

Brian Micklethwait has often written of the “sovietisation” of various parts of the British State such as state schools and the NHS. To illustrate this process, take a look at the way a “major incident” at Colchester Hospital has been reported.

What major incident you ask? My point exactly: you ask, they don’t answer. Likewise “safeguarding” is repeatedly mentioned. Something needs to be safeguarded.

Late last night or early this morning there were oracular bulletins from the Telegraph and Times, all chock-full of unspecified “incident”. From the Times:

On Wednesday, the Care Quality Commission (CQC) inspected Colchester Hospital’s accident and emergency department and emergency assessment unit and told trust it had concerns over “safeguarding” there.

The major incident is likely to last for a week, and the trust has reminded members of the public to only visit A&E if they have a “serious or life-threatening condition”.

A spokesman for the hospital said the inspection was not the sole reason for the major incident being declared, although it played a role.

All clear now? There was a similarly opaque article on the AOL homepage. It has been updated since, as has the Telegraph one, I think, but the Times, like a good horror movie, is delaying the big reveal.

The BBC followed suit: “Colchester Hospital declares major incident.” The BBC did tell us what sort of general thing might constitute a “major incident” but not about this major incident. As a result everyone thinks it’s ebola and as I write this it’s the most looked-at article on the BBC website.

Stand down. It’s not ebola. The Guardian was slow to get the story but does actually tell it:

A major incident has been declared at Colchester hospital after a surprise inspection this week found patients being inappropriately restrained and sedated without consent and “do not resuscitate” notices being disregarded.

The ward concerned has been closed to new admissions, an emergency control centre has been put in place to address capacity problems, and patients are being urged to go to A&E only if they have a serious or life-threatening condition.

Inspectors from the Care Quality Commission (CQC) found that the Essex hospital is struggling with “unprecedented demand”, but the Guardian understands concerns were also raised about safeguarding issues relating to inappropriate restraint, resuscitation and sedation of elderly people, some with dementia.

Oh dear, what a let down. Just as it used to in the days of Pravda and Izvestia the secrecy concealed mundanity. It’s just the NHS in crisis again. Can’t they do anything right? The zombies they make aren’t even dead yet.

Call that an epidemic? This is an epidemic.

This is how in 1918 Times readers first found out about Spanish flu:

The Times 3 June 1918 p5

The Times 3 June 1918 p5


You can say that again. It ended up killing 40 million people.

Incidentally the Wikipedia page on the subject is an appalling mess. At one point it claims that it began on the Allied side of the front, at another that it began on the Central Powers’ side. At one point it claims that it was particularly lethal to those with strong immune systems and at another to those with weak immune systems.

Having said that I love the suggestion that it was called Spanish flu because that was the origin of the first reports of the disease. It was the origin of the reports not because it was the first place to get the disease but because wartime censors did not want to encourage the enemy by admitting its presence.

So, it’s possible that this was not how Times readers first found out about it.

A tale of two paradigms

Here is an interesting observation by Jo Nova of two sets of reactions in an article titled Company stops Ebola, Bureaucracy puts it on a plane:

The rubber plantation has 8,000 workers with 71,000 dependents. It is an hour north-east of Monrovia, surrounded by Ebola outbreaks. The virus arrived on the plantation in March. Knowing that the UN and the Liberian government were not going to save them, the managers sat around a rubber tree and googled “Ebola” and learned on the run instead. They turned shipping containers into isolation units, trucks into ambulances, and chemical cleaning suits into “haz-mat” gear. They trained cleaners, and teachers, they blocked visitors, and over the next five months dealt with 71 infections, but by early October were clear of the virus. There were only 17 survivors (the same 70% mortality rate as elsewhere). But without good management, there could have been so many more deaths.

In contrast, the nanny-state takes a good brain and stops it thinking. In Texas, trained health professionals were caught unprepared, following inadequate protocols they assumed were good enough, and even risking their own lives. A nurse who cared for a dying Ebola patient — and knew how bad Ebola could be — still needed to phone someone to ask if it was OK to board a plane with a slightly raised temperature (99.5F or 37.5C). The official she spoke to “didn’t Google”, they just said yes because her temperature was lower than the official threshold of 100.4F.

Read the whole thing.

A bet on Ebola

Bryan Caplan, over at the EconLog blog, has issued a sort of challenge to folk in the US getting worried about Ebola:

Mainstream scientists assure us that Ebola poses very little threat to Americans; unless you’re a health worker who cares for the infected, Ebola is almost impossible to catch in a rich, modern society.  Yet many populists and borderline conspiracy theorists are convinced that the experts are seriously understating the danger.  In their contrarian opinion, we desperately need to close the border now. Fortunately, this is an easy argument to put to a bet. My tentative offer: $100 says that less than 300 people will die of Ebola within the fifty United States by January 1, 2018.  I’m willing to switch to “Unless the U.S. changes its Ebola-related policies, $100 says that less than 300 people will die of Ebola within the fifty United States by January 1, 2018,” but then we’d have to carefully define what policy changes count.

Leaving aside what you think about the specifics of the Ebola case, this idea of economists and other commentators making hard financial bets on specific claims has the merit of injecting a certain edge to proceedings. There is nothing quite so much like a bet to make people prove they are convinced of something. And as the late Julian L Simon proved when he bet against a neo-Malthusian about commodity price trends, there is nothing more satisfying than being proven right.  (Paul Ehrlich, who lost the bet to Simon, was invited to have another go and declined the offer, despite responding to Simon with singular ill grace.)

Direct health care: register your interest

Recently I wrote about Simon Gibbs’ idea to find doctors willing to offer direct health care, providing better care at good value to customers and making a profit at it. Now his site Libertarian Home is gathering a list of people in the UK interested in such a service.

Register to express your interest in purchasing, for your own needs, a monthly subscription for GP services such as check-ups, disease management, minor treatments, obstetrics, and advice.

Simon explained to me that he wants to find a cluster of people who make a potentially viable business for someone, and put them in touch. You will be signing up to be notified of opportunities.

I hope he can help make this work. For the right price I would welcome such a service: it would be valuable to just have access to a doctor who I could chat with at leisure for general advice and not feel like I was being a nuisance.

The Ashya King story: am I missing something here?

This seems like a very odd story. Some parents remove their child from a UK hospital after they determine the NHS will not provide what they conclude is the most appropriate treatment for a brain tumour. They then go overseas where they hope to find somewhere such treatment is available. And this triggers a Europe-wide manhunt?

Is there more to this than meets the eye? Because if not, what possible justification is there for state involvement at all, let alone hunting the parents down in Spain.

Health and safety law in action

All eggs that are sold in the United States would be illegal according to European health regulations.

Also, all eggs that are sold in Europe would be illegal according to US health regulations.

Simon Gibbs on direct health care

Last Friday Simon Gibbs spoke at Brian Micklethwait’s. He explained that libertarians are very good at talking, which is important and useful, but that he wanted to see them doing more, and that inspiring such action is what his Libertarian Home project is really about.

He had many ideas of things that libertarians could do. Some were simple and obvious, such as attending demonstrations so that the media is forced to explain who this strange new breed of demonstrator is, or handing out leaflets at events such as Occupy demonstrations where some of the attendees might not be fully sold on all of the ideas of their movement and might be amenable to persuasion. But what he really wants to see is demonstrations of things that would be everyday in a libertarian society actually working.

An example of this is direct health care. In the USA, Dr Josh Umbehr runs AtlasMD. You pay $50 per month for access to a general practitioner. You get better service, email and phone advice, and out of hours appointments. And someone who sees you as a customer rather than a nuisance, and spends time with you and helps you to find the right consultant or to try different medicines instead of rushing you out in time for the next appointment. Simon found one doctor in the UK who offers such a service for £125 per month for a couple.

I would like to see more of this. Simon explains:

It would not need to be the dominant form of healthcare, but merely to be available for about the price of a gym membership to 10% of the population. We can then start to use this kind of care as a counter example to the sainted NHS. To get there, we need to stimulate demand. We need to talk about this idea with friends and talk about the various ways in which this would be more pleasant and more convenient than the GP service we get from the NHS. We would then be able to talk about the NHS as something like a safety net for very serious medical catastrophes, not something we rely on every day for every kind of medical assistance.

The British Medical Association – auf den Tag!

Teresa May, I could learn to like even you. Just deal with the BMA as you have dealt with the Police Federation.

Soon, soon, oh let the day be soon!

Doctors vote for ban on UK cigarette sales to those born after 2000.

Samizdata quote of the day

The only serious black mark against the NHS was its poor record on keeping people alive

– This was written in all seriousness in a Guardian (No! Really?) article praising the NHS. Seriously. Not joking.

Speaking of Krugman misspeaking…

In the United States, we’re in the midst of a giant scandal about just how bad the Veterans Administration hospital system is.

For those unfamiliar with it, the US maintains a mini-NHS just for former soldiers, and it appears that it has both been undergoing a systematic meltdown and systematically falsifying records that would have allowed outsiders to learn of the situation.

As it happens, Paul Krugman, everyone’s favorite economist, effusively praised the VA hospital network as a model for future American health care in 2006, claiming it demonstrated that state operation of the health system was to be wished for rather than feared. Quoting his New York Times Column:

I know about a health care system that has been highly successful in containing costs, yet provides excellent care. And the story of this system’s success provides a helpful corrective to anti-government ideology. For the government doesn’t just pay the bills in this system–it runs the hospitals and clinics.

No, I’m not talking about some faraway country. The system in question is our very own Veterans Health Administration, whose success story is one of the best-kept secrets in the American policy debate.

The discovery of a column or speech by Professor Krugman that seems embarrassing in the light of later discoveries has become quite routine. (see, for example, his effusive praise for the quality of Thomas Piketty’s data and the inability of opponents to refute it at a point where “Capital in the 21st Century” had been in public hands for mere days. There are numerous other examples to be had.)

What is not routine, sadly, is for Professor Krugman to ever acknowledge such a mistake. I am unaware of an instance of his admitting to an error.