We are developing the social individualist meta-context for the future. From the very serious to the extremely frivolous... lets see what is on the mind of the Samizdata people.

Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]


Healthy life expectancy is shorter in the UK than abroad

People in the UK enjoy fewer years of good health before they die than the citizens of most comparable European countries as well as Australia and Canada, a major report shows.

The health secretary, Jeremy Hunt, said Britain’s performance was “shocking” compared with that of other countries, and called for action to turn it around by local health commissioners, who are about to take up their new responsibilities.

The UK ranked 12th out of 19 countries of similar affluence in 2010 in terms of healthy life expectancy at birth, according to a detailed analysis from the Global Burden of Disease data collected by the Institute for Health Metrics and Evaluation (IHME) in Seattle.

Despite big increases in funding for the NHS in recent years and many reform initiatives, the UK was in exactly the same place as in the league table for 1990, according to the IHME report, published in the Lancet medical journal.

Emphasis added. The report’s authors, and the Guardian article from which I quote, are at pains to say that

the problem is only in part to do with hospital care – much of it is about the way we live. Our diet, our drinking and continuing smoking habits all play a part

In other words, Britain’s relatively poor average life expectancy partly is to do with NHS hospital care, but they would rather not say so. As for the remainder of the problem that is not caused directly by the failings of the NHS, I wonder if the report’s authors have considered the possibility that the “despite” might be a “because”? Why do the British do worse than other nationalities of similar wealth when it comes to living an unhealthy lifestyle? It is no answer to just say “culture”; why is our culture as it is? Have we always been thus? We have a long tradition of getting drunk, I grant you, but my impression is that the British were not considered any fatter or any more drug-addled than comparable nations a few decades ago… before 1947, let us say for the purposes of discussion.

It is often said that one of the great blessings of the NHS is that it has lessened the fear of illness. The fact that they do not have additional worries about costs or insurance does come to those already worried about illness as a huge relief, and NHS-sceptics like me have to engage with that, sometimes in our own lives. So let us do so. I submit the hypothesis that a certain amount of fear of getting ill is salutary – both in the general sense of producing a beneficial effect and in the more specific, and original, sense of promoting health.

Naturally, I speak here of averages over a large population. Many illnesses cannot be avoided by human action; that is what insurance is for. When considering any one individual, I doubt that when making the many small bad decisions that have the cumulative effect of making him or her unhealthy, “hey, I don’t have to worry about paying for healthcare” often comes consciously to mind. But, like the proverbial mills of God, the mills of incentives grind slow but they grind exceeding small. In some countries those many small decisions take place under the shadow of “I might end up with a bill for this”. In Britain they do not. My hypothesis might go some way to explaining Britain’s anomalously poor average health. Something must explain it.

By the way, I shall take it as read that every human being has a perfect right to eat, drink, smoke and inject as he or she pleases. I shall also take it as read that the authors of the report and 95% of its readers wish to deny others that right. If the hypothesis above is correct, Britain has set up a system that, besides the inherent wrong of being based on coercion, removes one of the incentives for people to take care of their own health. How to solve that? More coercion, of course.

18 comments to Despite?

  • Paul Marks

    Natalie – most people in Britain (the sort that listen briefly to the radio news, and nod, or listen the “entainment” programmes) blame “privatisation” for the mass death in the NHS.

    “But what about the intelligent educated people” – would that be the Radio Four listeners? Such the “P.M.” programme yesterday which ran a follow up story to the mass slaughter in “Mid Staffs” – covering the testimony of the top NHS manager to Parliament. Mr Cameron was reported by the programme as giving his “full support” to the sleazy manager – and (by “coincidence”) the next item on the programme was how the Cameron government had withdrawn its new regulations as these were badly drawn and might lead to (boo-hiss) to evem more competitition in the NHS – the listener was left the impression that…..

    Government spending continues to increase (whilst the lying establishment, Mr Osbourne, the Economist magazine and so on – talk how it has been “cut”). And the services the government runs are organised in the LEAST effective way. Mass death in the health service blamed on “commericialisation” (or whatever), the failure of the schools on “obsession with market forces – market fundementalism”…….

    And on and on.

    If there is any hope in the United Kingdom I can not see it.

    Hopefully other people will show me how I am in error.

  • John B

    It is quite simple really. There is a significant factor why the NHS is primarily, not partly, the cause.

    To the NHS a patient is a cost. In other for-profit health systems, a patient is a revenue generator.

    In these systems elderly patients require more diagnostic procedures and intervention so are welcome customers, and it is in the interest of the profit-takers in the system to ensure people live longer and keep coming, particularly their best customers.

    This if anything tends towards over-investigation and more diagnostic tests than might be necessary.

    With the NHS patients, particularly the elderly, are a drain on budgets and a nuisance. The more they are ignored, diagnosis and treatment delayed, and the sooner they die the better.

    In addition where there is a private market, the provider is not also the insurer and often the patient is part payer too. There is then some tension between providers and insurer which helps keep things in balance, and the patient being a part contributor guarantees quality and downward pressure on price of treatment… in other words free market competition.

    I just wonder how high the pile of corpses in the NHS has to be before the dozy British realise it is time to sling out the NHS and get a free market in health care. My money is on a peaceful settlement between Israel and the Palestinians first… by miles.

    By the by. I live in France and the health propaganda… 5 a day, exercise more, avoid fat, sugar and salt, don’t booze, don’t smoke, obesity crisis, alcohol crisis, etc is identical and I am told by other EU Nationals it is the same in their Countries.

    That on the one hand torpedoes the notion that the British have uniquely ‘unhealthy’ lifestyles, and on the other indicates another scheme to micromanage us, by Intervention Central in Brussels.

  • PaulH

    “In other for-profit health systems, a patient is a revenue generator.”

    A small amendment – for the doctor/hospital a patient is a revenue generator, for the insurer a client is a revenue generator, a patient is a cost. That shifts the incentives the various parties have, though doesn’t necessarily negate your argument.

    “In addition where there is a private market, the provider is not also the insurer and often the patient is part payer too. There is then some tension between providers and insurer which helps keep things in balance, and the patient being a part contributor guarantees quality and downward pressure on price of treatment… in other words free market competition.”

    Can you give an example or two of countries with advanced health care that have such a thing? I’ve lived in the UK and the US and (unsurprisingly in the case of the former) it’s not an accurate description of either, so I’d be interested in some examples to study.

  • A point that has been made here by someone in the past, and is worth repeating: it is all a question who the customer is. For a private company it is the individual, for a government institution it is the government. As we all know, customer satisfaction is the key to survival of any enterprise.

  • Classic example of a ‘meta-context’ level issue.

    The majority of Guardianistas cannot… can… not… see the NHS as something other than an intrinsically Good Thing because the notion exists at the unspoken axiomatic meta-contextual level.

    So anything they say/think/do will be with the NHS=GOOD as a given. The very laws of physics would be nominated for adjustment before the notion that the NHS might be an intrinsically bad thing could even be entertained theoretically. Indeed thinking that almost defines ‘lunatic fringe’ in Britain for a very large number of people.

  • Lee Moore

    I don’t know if this meets PaulH’s challenge, but I am a regular visitor to the US and I use medical services there fairly frequently – say four or five times a year including check ups and scans and so on. I always pay directly, ie no insurance, and the rates I get are always considerably lower (say 30-40% lower) than the insured person rates.

    The main difference I observe between US and UK health services are :

    (a) in US doctors offices one’s fellow patents are mostly between 215 and 250 years old; while in NHS surgeries one’s fellow patients are mostly drug addicts or alcoholics
    (b) it would be unfair to say that all NHS reception staff are surly and quite content to let you wait for five minutes before they acknowledge your existence, perhaps it would be kinder to say that all US reception staff that I’ve come across are either friendly and polite or jolly good at pretending to be, and never keep you waiting more than a few seconds. (UK private clinics are more like the US experience.)

  • Jim

    @Lee Moore: I had no idea that life expectancy in the USA was so high 🙂

  • Jaded Voluntaryist

    @ Jim,
    You can’t spell Methuselah without U, S and A 😉

  • PaulH

    Lee – Not really what I was looking for. I’m sure there are many incidences where the US system works on free market principles, but it’s clearly distorted so pervasively by medicare, medicaid, and the role of employers that I struggle to think of it as a passable exemplar. And to provide a counter-anecdote, it appears I will always remember standing at the hospital pharmacy window at 3am, with my nauseated, 9.3 months pregnant wife sat nearby, being asked whether I wanted to pay for her prescription myself or investigate an alternative medicine, because what was prescribed wasn’t on my HMO’s formulary. Now shame on me, perhaps, for not having considered whether the anti-nausea meds covered by my HMO would suffice were she to need some while pregnant.

  • The private sector can always help with such things. There’s a new company (which I work for) called MetaMed which sells actually decent health research for large amounts of money.

  • Nick (nice-guy) Gray

    What’s the conundrum? Aren’t we always told that the Mediterranian diet is the healthiest (for Caucasians, I’m assuming)? Tho government must buy up a lot of Med food, and subsidise it through government food shops, and ban all other types of food! Simple.
    Probably a book in there, with fat police everywhere. Not Fascist, Fattist!

  • llamas

    Echo what Lee Moore wrote, only to suggest that the actual cost delta insured vs paying cash can be more like 60-80%. This may vary depending on the type of services being offered, and between diagnostics vs procedures vs medications.

    For example – bilateral mammogram cost.

    When performed on a doctor’s orders at (a major local hospital), and billed to BCBS – $825.

    When performed on a cash-paying walk-in basis at Basha Diagnostics (a leading local provider of diagnostics emaminations like X-rays, CT scans, MRI and ultrasound) – $280.

    The prescription mouthwash I use every day, from the cheapest pharmacy in town (Costco) – if billed to insurance – $25.50. If paying cash – $4.18.



  • Laird

    llamas, just because that’s what is billed to the insurance company doesn’t mean that’s what is actually paid. Take a look at the insurance statement you receive and you’ll often see that the “amount allowed” is a tiny fraction of the billed amount. If Costco is charging you the same amount as it accepts from Blue Cross that’s amazing (and another reason to shop there).

    Procedures performed at a hospital can be monstrously more expensive for the uninsured. Medicare and the major insurance carriers negotiate substantially reduced rates; the shortfall has to be made up by the uninsured cash-paying customers. I’ve seen countless examples of a procedure being, say $200 if paid by insurance (with that being accepted as payment in full by the hospital) and $1,000 if you aren’t covered by any insurance policy and are paying it yourself. Such wildly disparate pricing is one of the major problems with our health care system.

  • PaulH

    Well said Laird, though I find “the shortfall has to be made up by the uninsured cash-paying customers” an interesting way of putting it. The cost of a particular treatment is difficult to calculate. There are relatively obvious costs such as the needles and gloves used, which vary from case to case but can be estimated well enough. Then there’s direct staffing time – how much of a nurse’s time will I need as I recover from my op? That’s before trying to work out what proportion of the billing team / cleaning team / electricity bill should be assigned to my treatment. And of course there’s the challenge for all transactions of what an ‘acceptable’ level of profit is. None of that means that there isn’t a shortfall; it just means that working out what it might be, and who is responsible for it, is a dark art even when you can see at a high level whether a hospital is running a profit or loss.

  • Midwesterner

    Laird is right. This article introduces this study. For just one example off the top of my head, I saw a bill for an ‘in bed’ chest x-ray that required two x-ray techs, the portable x-ray machine and about 1/2 hour of time billed at ~$120. I was there to observe the procedure. When the statement came, I saw the Medicare allowance. Medicare payed less than $9. And of the cash customers, it is the poorest and most desperate that are least likely to know how to barter and bully down the obscene markups for those who pay cash. Poor uninsured (along with normally insured patients) are subsidizing Medicare and Medicaid.

  • llamas

    Everything everybody said. I just provided a couple of data points, but all of the other data points prove similarly show that pricing for all these things is a) all over the map and b) responsive to many factors, none of which seem to reflect the actual costs.

    The one constant is that the supposedly self-funding, State-run Medicaid and Medicare systems are subsidized (in the the greatest part) by ‘traditional’ private insurance, and this state of affairs was begun and permitted to continue because most of the consumers weren’t paying for any of it out-of-pocket and so really didn’t care what trumped-up inflated prices their insurers were paying for their healthcare.

    I Sometimes Wonder, in my cynical way, whether one reason that the Feds have started to de-emphasise some of the alternatives to ‘traditional’ health insurance (like high-deductible plans, HSAs, FSAs ASF) is that these things gave the consumers more visibility to what was being charged for healthcare, and more incentive to reduce prices – all of which would tend to reduce the hidden subsidies that Medicare/Medicaid had been living off for so long (along with the various other scams and trickery used to keep them alfloat). Most people yawn and switch over to the Kardashians when the subject is the ‘doc fix’, but let them actually have to reach into their pockets and pay some bills, and you have their undivided attention upon the price. Can’t have that – they might start to ask where the money is really going.

    As the days of full-boat, no-deductible, gold-plated private health insurance start to fade away, expect to see extensive wailing and gnashing of teeth as people start to actively beat down the costs of healthcare and the secret taxes that supported Medicare/Medicaid are inevitably whittled away. Obamacare already imposed direct taxes on medical devices and other things, execpt to see a lot more to replace the hidden revenue.



  • Richard Thomas

    These ranking charts annoy me. As I’ve said before, they mean extremely little. In a room full of rich men, somebody had to be the poorest. The only thing it’s good for is if you’re in a dick waving contest about who lives the longest and if you’re going to do that, don’t use my tax money, please.

    What would be more interesting is the mean lifespan, each country’s deviation from the mean and the standard deviation from the mean. Then there’s something to talk about.