NHS IT Project (NPfIT) Could be cancelled

A recent article in the Times reports that the NHS gargantuan IT project is at risk of being cancelled:

http://business.timesonline.co.uk/tol/business/economics/pbr/article6946336.ece#cid=OTC-RSS&attr=2015164

>>>>The multibillion-pound national progamme to overhaul NHS computer systems could be cancelled in this week’s Pre-Budget Report, Alistair Darling has said.<<<

There are those who rejoice, those that commiserate and many who will probably say “I told you so” this is a sad result after so much money and effort. The project has been watched by many. The results have been less than stellar with 400 Million GBP spent and fewer than 20 hospitals trusts that have installed despite an initial deadline for the whole country by 2010.

But there is a generally accepted principle that the delivery of healthcare is broken not just in the United Kingdom but many other countries including here in the US. As such the project in the UK provided a vision of some of the challenges and solutions. Recognizing the differences between countries and healthcare systems the concepts and ideas learned may not all be suitable in every circumstance but loosing the project totally would be a very poor outcome for everyone.

Who Should Pay for Healthcare

A recent twitter on my part to an article by Health Imaging titled: “Americans want healthcare reform, but divided on how to pay for it” raised some comments that are worth exploring. The simplistic 4 word response I got back from one individual:

The Government should pay

Simply passes the responsibility from individuals to a group who receive power, authority and most importantly money from the same individuals . They are then charged with the responsibility of sharing out the limited resources “fairly”. As history has vividly demonstrated the challenge with fairness and charging a smaller group with equal distribution and fairness is problematic. George Orwell’s allegorical novel Animal Farm detailed some of these challenges.

Healthcare remains a central challenge to countries worldwide. Those with more resources do spend more of them on healthcare for their population. But there is no bottomless pit of money to pay for healthcare and unfortunately as the population gains increasing access to better healthcare their reaction is not satiation to the higher levels and increased life expectancy but wanting more. Countries approach this challenge in different ways – the UK healthcare system rationed healthcare with waiting lists and limited availability. In recent years they have attempted to define the rationing standards for healthcare under the banner of the “National Institute for Health and Clinical Excellence (NICE)“. A recent ruling on drug therapy

… it ruled that four drugs for advanced kidney cancer were too expensive for NHS use. The four treatments, NICE acknowledged, ‘have the potential to extend  progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year’.

Their methodology assesses value against “Quality Life Adjusted Years” (QALY’s) that attempt a cost benefit analysis on treatments relative to potential outcome and quality of life. This is a difficult calculation even in the best of circumstances because the assessment of benefit changes dramatically from the perspective of the individual who in most cases assesses the value even if limited in time or effect.  In the case of the drugs for kidney cancer drugs NICE’s QALY assessment was”

Translated into QALYs—quality adjusted life years—that works out at between £71 000 and £171 000 a year; well above the rough threshold of £30 000 a year that NICE broadly applies other than in exceptional circumstances.

I commented on the NICE measure before where an individual wanted to pay for the drugs himself but in doing so fell out of the group coverage and was refused access.

There is no such thing as “free healthcare” – free at the point of service removes personal responsibility and encourages abuse. A simple case in point is the nuisance charge or co-payment. The United Kingdom has provided free home visits and free access to their General Practitioner for years.  But you only have to spend a night with an on call General Practitioner, especially round any holiday to experience the abuse. Calls at 3am for a headache. And not a new onset headache but one the patient has been suffering from in some cases days, weeks and even months. The introduction of a payment for all visits would discourage some of this and those opposed would suggest that it might discourage patients that should make the call. It might but the underlying issue of value would be solved – if the service is “free” then the value is perceived to be the same.

Providing healthcare to as many people as possible is right but in all cases a line must be drawn that is entirely dependent on the resources available. One can imagine that the availability of healthcare is much diminished in Zimbabwe. There the provision of midwifery delivery services to a preganant mother would require the patient to personally provide $20 Billion  Zimbabwean dollars (nearly US $40). But the resources available make this a bridge to far. And so to in all other countries – where we continue to consume every available healthcare resource made available. There is no instance where a country so much makes healthcare available that there is resources left unused, clinics and doctors desperate for patients because they are underutilized.

So what is the answer – personal responsibility and a full understanding of the cost and benefit of healthcare resources available. Attaching value to those resources helps comprehension. Patients can make informed choices in the same way that consumers do – why pay more for the iPod when a Micosoft Zune or SanDisk Sansa does the same job at a lower cost. Some do make the choice for iPod, others do not but they do so based on the available data and a cost benefit analysis. But if all the MP3 player’s were free or the same “cost” to us then the selection is harder and less informed. Free healthcare is a misnomer – everything has a value and attaching a value to healthcare but making it accessible to as many as possible is better strategy than just making it free.

Featured in the March issue of the British Journal of Healthcare Management – Stimulus and Effect: Rationing (full pdf subscription required)

Healthcare US vs UK Comparison

There are many comparisons of the US and UK health care system but there is hardly a UK citizen living in the US that does not worry that the nightmare described in this essay “Fragile American Dream – Part 1 and Part 2….

It boils down to the catastrophic coverage and end of life issues that have yet to be addressed or resolved. For those who grew up in the system there is probably some degree of concern but a vague acceptance that this the way it is. Rising costs as featured in the rising costs here manifest in escalating drug costs, covered to some extent by the insurance while you have it but at some point when it is either no longer possible to be employed (age or health reasons) you enter the nightmare scenario

Then came the day that I had to give up work, I worked for a Company who treated me very well when I retired. However this is when the American Dream started to turn into a nightmare. I was eligible for 6 months free medical coverage then a further 6 months at a cost to me of what the Company paid; a substantial hike, especially on an income reduced by 40%. After this period something calls COBRA kicks in for one more year and this is when it gets really expensive, approximately 3 times more than the cost the Company was paying but I would still have coverage. When COBRA runs out, effectively I am uninsured, yes there is Medicaid, but from what I have found out it is not easy to get coverage even with a terminal disease. I have overhead enough hardship discussions for people being treated at my Oncologists surgery to understand that everything has to be “battled for”. With a pre-existing condition it becomes almost impossible to get Insurance, some Insures say they will do it, but the cost for good coverage becomes prohibitive.

As the author states luckily he has a choice albeit less than ideal – leaving the country and returning back to the UK for treatment that will not bankrupt him and his family. He finishes with this statement

the UK has many faults but at least the NHS is a safety net for when
things go seriously wrong, unlike out here when effectively you are on
your own.

And that pretty much sums it up…….. there is no effective safety net in the US.

The Balance Between Private and Welfare Medicine

The British National Health Service (NHS) has long been cited as an example of a system that is broken and a system that works and the viewpoint often depended on the the individual making it and their personal beliefs

Those that have experienced it find it hard to complain too much and like Social Security in the United States it is considered the “third rail” in politics. Don’t mess with it! For the British public it is an essential component of life and while it has failings and difficulties for the most part it delivers excellent care to the the British population. Coming form that circumstance to the United States was a severe shock to the system and the wallet and loosing what certainly feels like a fail safe coverage option is very difficult to swallow as you struggle to provide for yourself and your family.

So this article form the NY Times in February this year (Paying Patients Test British Health Care System) that covered the issue that has been for the most part glossed over for many years the “hopscotching between the two systems – private and public. If you have money you can pay for portions of care that might otherwise not be covered by the NHS. In the case detailed Debbie Hirst’s was ready to sell her house to pay for treatment with Avastin (Bevacizumab) a recent monoclonal antibody treatment with a very high associated cost – $120,000!!! But even though she is willing to make those personal sacrifices:

Officials said that allowing Mrs. Hirst and others like her to pay for
extra drugs to supplement government care would violate the philosophy
of the health service by giving richer patients an unfair advantage
over poorer ones.

Unfortunately for Mrs Hirst she is the straw that broke the back or the focal point for the issue that has been present in the system for many years. IN fact there is a whole insurance industry that supplements NHS  treatment with private offerings that essentially allow line/queue jumping and access to treatments or choices that would not ordinarily be allowed.

Is it just me or does this seem entirely wrong – there is an existign system that provides a catch all, it fails in some circumstances often due to overwhelming needs and insufficient resources. The things that end up missing or delayed are elective non-urgent care and very high cost care. Those that can afford off load the burden from the already stretched system, access the care and everyone wins. No doubt there is resistance because some of the problems associated with inappropriate care or poor choices end up back in the NHS system (ie the NHS ends up paying and treating others mistakes). While that’s true it is an inevitable part of any system that offers choice.

I’d bet dollars to donuts that if the patient had been Alan Johnson’s (The Health Secretary in the current UK government) wife, parent, daughter or <insert close family relative> the result and reaction would be different.

Meanwhile the “good news” is that Mrs Hirst’s condition deteriorated and now she is eligible as a last resort for Avastin (not a cure but to extend her life) but as she says

“It may be too bloody late”

My sympathy goes out to her and her family – all this is difficult no matter how you deal with it but with all things balance and reasonable behavior should prevail. Do I wish al patients who coudl benefit it coudl receive it sure. If that’s nto possible those that can should be able to access the care/treatment.

In my mind the more fundamental issue and concern is how ANY drug can have a cost so high – we understand the high costs of developing drugs and much of this is regulation and supposed protection but the prices and difference in prices charged is not part of that reasonable behavior. Fix that problem and we might have a better chance of fixing some of these problems