Saturday, January 5, 2008

British National Health Service and behavior

With the talk of health care as a campaign issue in the upcoming election, I've heard some people say we should move to a national single payer health care system, similar to the National Health Service of the UK.

So, when I saw this article it caught my attention, especially as the author is described as doctor.

He makes some interesting comments on the National Health Service:

When the NHS was born, there was widespread rejoicing. People were grateful that, almost overnight, they could receive treatment for illnesses and diseases that had previously ravaged those who could not afford to pay for a doctor. However, somewhere along the way, we've forgotten this. The NHS, despite its many faults, remains remarkably popular. But several generations have now been born and brought up under its care, and no longer know anything different. They take it for granted, not making a connection between the cost of health care and the taxes we pay. We think of the NHS - its services, medications, investigations and procedures - as "free", when of course it's not: it's a pooled resource which we all pay into, and can all use.

Here in the US, some 47 million people, or 16 percent of the population don't have health insurance. Considering the need most people have for some level of medical care, this seems an alarming statistic. Some even go so far as to say we should all sacrifice some ( in the form of higher taxes ) to provide health coverage for those without. In the UK, they thought such sacrifice was warranted and created the NHS.

Note, however, that according to the author, attitudes have changed in the UK so that many take medical care for granted. It's not so much a sacrifice to some as air; just something that's there.

So, what effect has that had on the health care system in the UK?

Yet on New Year's Day, NHS services were stretched to breaking point. The London Ambulance Service handled 1,825 incidents in its first four hours, a 16 per cent increase on last year, and 30 per cent higher than the year before that. Ambulance crews in the North West attended 1,013 incidents, an increase of 38.5 per cent, while the West Midlands saw an increase of 37 per cent on last year. The vast majority of calls were due to alcohol and fights.

When I saw these statistics, all I could think of were the genuinely sick people on that night whose care was compromised not by Whitehall directives, but by other people's thoughtless selfishness. Visit any A&E department on a Friday or Saturday night, and you will see row upon row of beds taken up with inebriated individuals. Not people who have fallen over after having a few too many, but people who are so drunk they simply cannot be allowed to leave the department, people who have to have fluids pushed through their veins to sober them up, and who then roll straight back in next weekend after passing out on the same street.

Now that's interesting. If health care is taken for granted, then risky behavior is, well, less risky.

If, for instance, one binge drank in the US so much that a hospital visit was required and the patient didn't have health insurance that would be an expensive trip to the ER. Less so, perhaps, if the patient did have health insurance, but it would cost the patient something.

In the UK, with the NHS, that same event wouldn't cost a patient anything.

So, what's the authors reaction?

The principle behind this is known as "risk pooling": the greater needs of one person are offset by the lesser needs of another. We are unlikely to use the full extent of the services our taxes pay for in a particular year, but this excess provides for who have need to call disproportionately on those shared resources. Insurance companies work on a similar principle, but because they are concerned about profit margins, they must exclude individuals who may place higher demands on the centralised pool. A nationalised system is egalitarian and just, because it provides for those with chronic diseases, or who require expensive treatments. Not only is socialised medicine the hallmark of a civilised society, it is also economically viable. The UK has one of the lowest expenditures per capita on health amongst developed countries, and yet produces similar outcomes.

But this only works if we all take care of the demands we place on resources. Yes, many of the problems faced by the NHS have been caused by the government - for example, its agenda for a "mixed economy of care" has led to a reduction in the overall number of hospital beds, with subsequent problems when additional pressures are placed on services, while the introduction of targets and league tables has seen a proliferation of paperwork on an unprecedented scale.

But in my experience, and that of the doctors and nurses I talk to, the problems are also a result of the inappropriate use of NHS resources by patients.

Emphasis mine.

So, given that easy access to medical care leads to more risky behavior, the author of the linked article seems to be saying that people need to moderate their behavior so they don't overuse shared resources ( i.e. the NHS ).

I can easily see that "for the good of the community" a government would at least try to impose certain restrictions on behavior if they wanted to "protect a shared resource".

These could be economic; say, billing bars which serve patrons enough alcohol that they end up in the emergency room the cost of treatment or legal in the form of, say, heavily restricting the hours of operation for bars and restricting the times / days alcohol may be sold.

Either way, it would seem inevitable that a government response to this tragedy of the commons would be to regulate citizens behavior one way or another.

1 comment:

Illicit Dreams said...

The funny thing is even here in the US people abuse the medical system.

People use the emergency room as a family doctors office. The thing is most of the folks that do this, don't have health insurance, and don't plan on paying for the trip to the ER anyways.

IIRC the hospital I work at loses over a million a month due to non-paying folks, and charity care. Now don't get me wrong I do believe there should be some charity care given... the homeless being the most prominent example of folks needing it. But that's still alot of money to lose on a monthly basis. I think the amount lost is much higher, but I'll go with that as a conservative figure.