Tag Archives: National Health Service

A coin has two sides

Every coin has two sides and I am beginning to wonder whether or not that is the most important political statement that can be made. On the face of it, that is a ridiculous idea but I will try to demonstrate that it could be the key to the political problems that we face here, in the UK, today.

Personal freedoms are important to many of us – the freedom freely to express an opinion with fear being pretty well at the top of the list. But that freedom creates problems unless it is exercised with great care. I don’t think the idea of one person’s freedom being almost always at the expense of others occurred to me until I stayed with a cousin of mine in the delightful village of Bottmingen just outside Basel. (In passing, I haven’t been there for over thirty-five years and I expect it is now just another suburb of the city so, if you know that to be true, please don’t tell me – I want to remember how it was then).

My Canadian cousin and her Swiss husband had very different ideas when it came to personal freedom. One of the laws (whether local or national I am not sure) stated that at weekends it was forbidden to have a record player or radio on in the garden. As Max pointed out this meant that everyone could be in their gardens at the week ends knowing they would have peace and quiet. Joan, on the other hand, considered this to be as near as maybe an infringement of her personal liberty. That coin had two sides and both side could claim the moral high ground if they wanted to. It is, actually, a political coin.

So who was right, Max or Joan? As a libertarian who, by definition, considers most regulations to be a response to a human failing of one sort or another I find myself siding with Joan. I feel we should be able to rely on the good manners of those with whom we live and that cultural pressures should be sufficient to ensure people respect their neighbours. Yes, I know that is hoping for more than can be expected but regulations reduce the sense of community responsibility within the population generally and I do not believe that to be a good thing.

This all started, I suppose, because I and others became antagonists on Twitter in the matter of the so-called bedroom tax. I explained all this on a previous post (Capping Housing Benefits). For the record, as a result I have now discovered one person who has been adversely effected by that cap and I shall be meeting her soon to hear her side of the story. Why we got ourselves into a muddle was that we did not think of it as being a coin with two sides – which is exactly what it is.

On the one side you have all the people who, often through no fault of their own, are living in housing the cost of which is being borne by the state and on the other side you have all the people who are giving up a part of their earnings in order to meet those costs. In a properly grown-up democracy, we would look at both sides of that coin and seek a modus operandi that removes the present conflicts that are causing so much fear and hostility.

That is a big ask.

Any move to alleviate some of these costs is seen as a personal attack by those to whom the state says, “you are taking more than your fair share of the available resources”. I am pretty certain that if I were to be in that position I would feel the same.

Meanwhile any move to suggest that it is reasonable to increase taxation to meet what could so easily become a bottomless pit (as has the NHS) is seen as an attack on people who would describe themselves as decent, hard-working and responsible members of society who put in far more than they take out.

Both view are, of course, wrong. Both views are, of course, extremely human – as are the people provided for by the state and the people fortunate enough to be able to not only support themselves but to be able to make a contribution to the well-being of others. But we humans are by no means perfect: some are selfish, some are greedy, some are lazy. You will find them on both sides of the coin. Also on both sides of the coin are people who are unselfish, generous and hard working.

So it is that some of those who have been told to find smaller accommodation have (if it is available) said, “Fair enough” and they got on and done it. Some feel the same but can find nowhere suitable without moving away from those who support them or make life worth living: friends and family. There needs to be provision for these since moving them could well increase the overall cost to the state despite a reduction in housing benefit. However, there are also those who seem to seize the opportunity to become victims.

Likewise among those who pay taxes you will find those who say, “There but for the grace of God go I” and are happy to pay higher taxes but there are also those who feel very differently.

Do I have an answer to that big ask? Not really but I have the hint of a suggestion.

During my lifetime I have seen that the people who suffer most when the nation’s “cake” becomes smaller are the poorest and most dependent.

When the national coffers dry up, there is no possibility of increasing welfare benefits and existing benefits tend to be eroded by inflation. Furthermore, reduction in activity in the private field and the need to economise in the public field both add to unemployment – and the unemployed pay very little in tax and need a good deal in benefits. Thus the existing poor become poorer and they are joined by more of their fellow citizens.

When the country is really open for business and doing well, however, welfare benefits can be increased in line with (and possibly above) inflation and more and more people will find gainful employment or self-employment. The existing poor may not be better off but are no worse off and their number drop as more and more people find work.

Thus I want to see a regime that does all it can to increase the size of the national wealth to provide the resources required to support those in need. This can be achieved only be reducing the regulations that strangle the growth of businesses and that will mean that some employees would have to lose some of the protections they presently enjoy. It will also mean accepting that the wealth generates will become wealthier and that the gap between the poorest 5% and the richest 5% will widen.

I do not have a problem with either. This country has been built in large part by people putting themselves on the line and starting their own businesses which means no guarantee of income and no guarantee of the business remaining viable. Compare their situation with those in employment (and especially those in the public sector) and I find myself thinking that it is time these people shared some of the pain. As to the gap between the rich and the poor: I do not mind how rich the rich get but I do want to live in a country where none are suffering from poverty. If the price of lifting everyone above a certain level is a an increase in the wealth gulf, so be it.

However, I want to add another burden on whomever is running the country: yes, get the wealth generating machine running properly but always ensure that you have the compassion to use that wealth for good.

I do not expect my left-wing friends to agree with this.

The first crow – danger (part three)

2013 09 16 Crow

Illness, which I suggested in Part Two, is not an easy condition to determine. Here I want to begin to look at things that we might all consider to be “not-illness” but with which the National Health Service is lumbered – mainly. I would suggest, as a result of unintended consequences.

At all times we need to remember that the founding fathers of the NHS really did believe that as the NHS improved the health of the nation so the costs involved would reduce. This was but one of the many serious mistakes that have been made by politicians over the years.

First up, then, is being old: being old is not an illness (which is not to say that old people do not become ill). Being too weak to do the housework properly or to go out shopping is not an illness.

In the old days people in this situation were usually cared for by their families or friends. That is how it was for my grandmothers, both of whom lived with the family after their husbands died. Would we have done the same for my parents? My father looked after my mother until she pre-deceased him and then we did offer him a home with us. He preferred to be independent and remained quite able to look after himself until a few days before he died.

 Some, sadly, received no such care and generally succumbed to one of the illnesses that the old and frail are prey to: pneumonia, influenza, etc. It was not all good and that was not a golden age. 

Now the position is different. In part it is that “nanny state” has taken over but we cannot just put the blame on that. We have all enjoyed more personal space than previous generations and all (old needing care and young capable of giving it) hate the idea of losing that personal space. Multi-generation families together are now a rarity. 

Then there is a difference between the relationships of parents and children (and thus grandparents and grandchildren). It is all, frankly, a right old muddle. It is probably true that the parents of those born in the 1960’s or 1970’s were the first who wanted to be friends with their children – and that has had interesting consequences that my wife sometimes explores in her novels (where, unlike here, there is room for such thoughts).

Back to the frail but not ill. Within the concept of our modern society there is a requirement for the needs of the vulnerable to be met but this should not be the job of the NHS. How has it become the dumping ground for other authorities who will not (perhaps cannot) take responsibility?

 *    *    *    *    *

Does being hurt in an accident qualify as ‘being ill’? Not according to insurance companies who separate out illness and accident when offering cover. Even then there are limits to what they cover. The following is rather interesting: it is taken from the Key Facts Sheet issued by Aviva regarding their personal accident insurance. I have put the three really interesting ones in bold. 

What are the significant or unusual exclusions or limitations? 

War and similar risks.

The Insured Person serving on active duty in any Armed Force.

Suicide, attempted suicide or self inflicted injury,

regardless of their state of mind at the time the incident

occurs.

Accidental Bodily Injury does not include any sickness,

disease, bacterial or viral infection (unless this is a direct

result of an accidental bodily injury), naturally occurring

condition or degenerative process, or the result of any

gradually operating cause.

Deliberate or reckless exposure to danger (except in an

attempt to save human life).

Radioactivity. Any claim caused by ionising radiation, or

radioactive contamination.

Participation in any crime which that involves deliberate

criminal intent or action.

Pregnancy, childbirth, miscarriage or abortion.

Flying other than while travelling as a fare-paying

passenger on a licensed aircraft.

Hazardous pursuits.

Intoxicating liquor or drugs taken by the Insured Person.

Driving or riding any vehicle while the alcohol level in

their blood is higher than the legal limit of the country in

which the accidental bodily injury occurs. 

Is riding a cycle through a red light at a road junction “deliberate or reckless exposure to danger”?

Is riding a horse “a hazardous pursuit”?

Is tripping over a kerb stone, falling and breaking a wrist after a glass of wine or a pint of beer going to present you with a problem when you make a claim? 

In all these cases, I’m pretty sure that an insurance company would refuse to pay up. Not so the NHS: all of these would be treated without charge and without any thought of there being a charge. All. A rather sideways thought: unless attended to by the A & E department in accordance with the targets laid down there will be trouble for the people running the department – and none for the idiots who, through their own stupidity, arrived there in need of care.

I hope that doesn’t make me sound heartless. That is the fate for anyone who tries to take a rational look at the way the NHS has developed. Of course we want these people to be looked after but if we go on as we are the level of care will fall away as funding becomes more and more impossible.  However, if we want the service to survive we must decide what it should be doing – and what it should not. So far we have looked at no more than the tip of a very big iceberg.

How do they manage these matters in other countries? We’ll look at that question in the next blog.

 

The first crow – danger – (part two)

2013 09 16 Crow

Illness, if you remember, was the word to be explored in this, the second part of the first crow.

We all know what we mean by illness, don’t we? Sure? Quite – it’s not really that easy, is it?

Think about ‘speed’ in the same way. Speed, as such, is meaningless. It suggests that there is a continuum from not moving to very fast: stationary to the speed of light (if, as I understand it, that is the fasted speed possible within our universe) – and that is all. Nevertheless, we all know what we mean.

In motoring terms, when there is an accident it is usually assumed that someone was going ‘too fast’. We try to ensure that this doesn’t happen by using speed limits. These don’t work. Speed does not kill, as the proponents of fixed speed limits would have us believe. Vehicles kill and need to be carefully controlled to ensure they do not. It never amazes me to realise how very good at controlling these beasts we drivers have become. Sure, car designers have done all they can to protect the people inside the vehicles but that does little for the ones on the outside. Nevertheless, when you consider that the number of car/miles that are driven for every person killed by a driver failing to control his/her lethal beast it becomes clear that, on the whole, we are actually very good drivers. Not that anyone says so.

I think this is the first time I have said that and my guess is that it has never crossed your mind. Why should it? Good driving is not news: good driving goes unnoticed: you are a good driver (I’m sure you are) and I know that I am a good driver but over there I see a bad driver and something needs to be done about it. So we do what we can: we impose more regulations (usually lowering speed limits). What does this do to reduce deaths (or injuries)? 

Probably very little because it cannot take into consideration an infinite range of variables: the weather conditions, the state of the road (bad road engineering and poor maintenance is certainly the cause of some accidents although this is rarely acknowledged), the car (model and condition), the actions of other drivers, distraction caused by trying to read and assimilate instructions from numerous signs, light conditions and, of course, the ability and condition of the driver.

Speed limits achieve two things: in places they make people feel safer. I have asked some people living in a 20 mph zone where a fairly main road passes through the narrows of a typical Devon village what the introduction of the 20 mph limits has meant to them. Answers ranged from, ‘Nothing much,’ to ‘well, I feel safer walking down to the shop’. How many accidents were there before the speed limit was lowered? ‘None, but there were plenty waiting to happen,’ was the general consensus of opinion.

I said they achieved two things: the other is connected to attempts to enforce these regulations and especially by the use of cameras. Here the effects are totally negative. They are a cause of further friction between the police and the public at a time when trust in the police is at a low ebb whilst remaining essential in the running of a civilised country: they have become a form of sneaky taxation (as have car parking charges): they have done nothing to improve the ability of drivers to control their lethal vehicles.

Determining the right speed when driving is by a moment by moment appraisal of the overall situation and an almost entirely subjective reaction which (luckily) usually results in the right answer.

We see almost exactly the same problem with the word ‘illness’ which is a central plank of the National Health Service. Just what is meant by section 1(b) of the Secretary of State’s duties as laid down by the National Health Service Act of 1977 – ‘ … the prevention diagnosis and treatment of illness … ‘?

This matters when the end product is to be free of charge and the taxpayer is expected to meet the costs. Nevertheless, trawl as I may, I cannot see what that word is meant to mean in this context. The obvious definition, ‘Poor health resulting from disease of body or mind; sickness. ‘ is of no help. All it does is to move the problem down onto two other words: disease and sickness.

The insurance world has, of course, found the need to have a say in the matter as when it insures people against illness. They have found this a pretty difficult task and a surprisingly large number of claims end up in court simply because of the essentially subjective nature of this whole matter. Just to give you an idea of how subjective, the Association of British Insurers issued some guidelines in (I think) 2005 and this little extract gives you a feel of the problem. 

Please remember that the name of each critical illness is only a guide to what is covered. For example, some types of cancer are not covered. The full definition under each heading shows what your policy covers. You can ask your insurance company for this information. The model definitions are grouped into “core” and “additional” conditions. The “core” conditions are generally the critical illnesses most likely to happen. 

The “core” conditions are:

  • cancer
  • coronary artery by-pass surgery
  • heart attack
  • kidney failure
  • major organ transplant
  • multiple sclerosis
  • stroke

The “additional” conditions are:

  • aorta graft surgery
  • benign brain tumour
  • blindness
  • coma
  • deafness
  • heart valve replacement or repair
  • loss of limbs
  • loss of speech
  • motor neurone disease
  • paralysis/paraplegia
  • Parkinson’s disease
  • terminal illness
  • third degree burns

There does not appear to be anything like this approach in the NHS. Should there be? After all, we have defined the things for which we will charge (most of which are not included in the ABI’s list: dental care, prescriptions, spectacles but not hearing aids).

I leave you with three thoughts.

The first is that the answers do not lie in tick boxes or governmental edicts. The right judgements will be made by subjective assessment and therefore we have to find a way of placing trust in people to take those judgements and not to pillory them if every now and then they ‘get it wrong’. Now and then we all ‘get it wrong’.

The second is that the one things that seems NOT to be covered by the Act is injury. No definition of illness includes injury and yet we have no problem with expecting the NHS to treat our broken bones, sprains and gashes. Here the insurance world does things differently. Accident insurance is completely separate from Critical Illness insurance and whether or not you are covered will often be determined by what you are doing at the time and whose fault it was (assuming blame can be apportioned).

The third is that this blog does nothing to provide an answer. Sorry about that but it will require far wiser heads than mine to find a solution. I just feel we should be aware of the muddle at the heart of the NHS lest it is that muddle that finally causes it to collapse.

The first crow (part one) – danger

2013 09 16 Crow

That’s him, sitting on the top of the tree doing what crows do – looking for carrion on which to feed, seeking that has or is about to die. His eyes, vigilant and indifferent, scan the scene and stop, narrowing slightly as he considers what he sees. The National Health Service in terminal decline. Soon it will be carrion, food for many crows and other scavengers, but for now he waits: death has yet to arrive and there is always the possibility that, against all the odds, it will survive.

How did the NHS end up in such a parlous state? Perhaps to answer that question we need to go back to the beginning and see where it began to go wrong. This is a huge subject which will take more than one blog so I ask you all to be patient. This part is only an introduction. 

I was born before the NHS and in 1947 was rushed into hospital with acute appendicitis. Luckily for me my parents could afford to meet the costs involved: what would have happened to me if that had not been the case? Then, some fifty-five years later, I suffered a heart attack. Thanks to the prompt and wonderful treatment that I received at the hands of the ambulance and hospital staff, I recovered with little damage. How much did that cost? I have no idea and I have not been able to find accurate figures from for the NHS but from other sources it is reasonable to say at a very minimum £3,000 in simple cases and up to £30,000 in complex situations. Then my wife needed treatment for a very aggressive melanoma. This was removed surgically and she remains in remissions. How much did that cost the taxpayer? As an article in the Telegraph stated in June of last year, modern anti-cancer drugs are staggeringly expensive: one for this particular cancer running at £1,750 per week per patient. 

From the above I hope you will accept that I am greatly in favour of the state ensuring that all can have access to suitable healthcare which does not mean that I believe we are going about it in the right way. 

1945 and the country is celebrating a great victory. To everyone’s surprise (and not least his) Winston Churchill loses the election and Labour, with its manifesto promise to implement the findings of the Beveridge Report of 1942 finds itself in power. 

That report had identified five areas where actions was needed: squalor, ignorance, want, idleness, disease. None, I believe, would argue with those headings and I suggest most would claim that we have yet to find the right solutions to them all. However, it is the last – disease – that concerns us today.

It is perhaps important that we read the basis for the guiding principles to the recommendations contained in the report: 

  1. Proposals for the future should not be limited by “sectional interests” in learning from experience and that a “revolutionary moment in the world’s history is a time for revolutions, not for patching”.
  2. Social insurance is only one part of a “comprehensive policy of social progress”.
  3. Policies of social security “must be achieved by co-operation between the State and the individual”, with the state securing the service and contributions. The state “should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family”.

It is only fair to say that, as means testing tends to create a high marginal tax rate for poor people, Beveridge opposed them proposing instead a flat rate contribution rate for everyone and a flat rate benefit for everyone.

With this as the foundation, the National Health Service Act was drawn up and passed into law in 1946 to come into effect in 1948 (the position is Scotland was slightly different). In essence the act stated that:

It shall be the duty of the Minister of Health … to promote the establishment … of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention diagnosis and treatment of illness and for that purpose to provide or secure the effective provision of services.

The words I have put in bold are of vital importance. Those who drafted the bill, discussed the bill and finally passed the bill shared on conviction: as the health of the nation improved so the cost of dealing with ill health would fall. Therefore it was an affordable suggestion which would not place an over-heavy burden on the taxpayers. We have lived with the consequences of that mistake ever since.

In 1977 the bill was repealed and replaced, not unsurprisingly, with the National Health Service Act 1977. The Secretary of State continues with much the same duties:

  1. The Secretary of State’s duties to continue the Promotion in England and Wales of a comprehensive health service designed to secure improvement in:-
    1. the physical and mental health of the people in those countries
    2. in the prevention diagnosis and treatment of illness

    and for that purpose to provide and secure the effective provision of services in accordance with this act

  2. The services so provided shall be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

We still see the requirement to secure improvement in physical and mental health but we see a few other things as well. There is a duty to prevent, diagnose and treat ‘illness’. Next time we shall look at what that word ‘illness’ is intended to cover.

We also see that there is a duty to provide and secure effective provision of services – regardless of cost? That needs to be explored.

Exactly what ‘services’ did those who passed this act have in mind should be provided ‘free of charge’? Where are these defined and what do we think that means?