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Public Health

The NHS needs more money, can we have some please

Securing the future Securing the future: funding health and social care to the 2030s

I read some (but not yet all – it is 190 pages) the Health Foundation / IFS report calling for more resources for the NHS.

https://www.ifs.org.uk/publications/12994

the Exec Summary is excellent

Basically, the NHS needs more cash, can it have some please.

I had a very well retweeted thread on twitter last night, seems to have gone a bit viral

My tidied up version of response to my initial read is as follows.

I have linked to a lot of the blogs I have done in this space, which are in turn well referenced in the main. I’ve only linked to the blogs I have done as they are the way I have organised my own thoughts. Others may think differently.

Thanks to the few I nicked ideas off in this space. Credited where I remember.

1)

The NHS is underfunded.

Within this primary care is grossly under funded

The situation is worse still in social care (accept LA funded and as that’s not “the NHS” nobody really cares, but it DOES matter)

There is a caveat to this. It’s a big one. I have (using Helen Irvine’s work) have said before about the consistent evidence from a macro perspective that the key drivers of cost growth are:

disease incidence (prevention),

high cost technology (manufacturer pressure & patient expectation) and

over diagnosis (clinical culture and system pressure)

And NOT demographic pressure or the “ageing population”

Similarly, the spectacularly Glasgow work by Helen Irvine and others found that the current problems in NHS in Scotland are as a result of

1) falling % of NHS £ to “community” led to hike in non elective (and a range of other issues)

2) problems not due to too little funding overall

3) worried well – especially in most affluent population

4) systemic and cultural incentives leading to over diagnosis

5) degradation of primary and community care over 10 years, including social care.

One might characterise the problems as the NHS being structuraly underfunded, not managing demand at all well, maybe having too much supply, or too much of some forms of supply, the wrong set of incentives and maybe all of the above.

It’s not a problem of the ageing population, it is an issue associated with faltering healthy life expectancy and healthy life expectancy (see comment here) and the wrong mix of supply to meet demand.

2)

We should carefully think about our objective with new resources.

Do we want to buy more health or more health care. These are not the same.

If we choose health care, and i can see the arguments for it – they are on the news daily, there is a massive danger we will commit additional £ to gizmos, gadgets and low value treatments. This is a form of gizmo idolatry. Innovation is not the same as invention, we aren’t short on inventions and we tend to focus our attention and cash on these as they look good and are shiny. This crowds out resources for far more valuable upstream interventions, like Neil. Neil is valuable, far more valuable than many of the gizmos we commit vast sums to. Neil is an embelematic statement of opportunity cost, we should measure opportunity cost in units of Neils, not cash or QALYs. Thanks to @drchrisgibbons for the story.

3)

Gizmo idolatry will make net pop health worse by reducing allocative efficiency, reducing equity (sharp elbows of middle classes) and exposing us all to the opportunity cost of low value gizmos…. thus depriving us of more valuable upstream interventions (back to Neil)

History has told us this

Again

And again

And again

And again

4)

More £ in the NHS is needed.

Primary care / social care has first call. See here, here and here for my reasons why.

5)

I doubt that public will buy tax increase of order needed

So as the nhs is seen as “special” additional resource will doubtless come at expense of further gouging out of spend in other govt depts and preventive services. History tells us this. See figure 1 the spending on education (one of the more important “health” investments) which has flatlined, and defence has plummeted. I’m no militarist, but defence is also strategically important for a society is it not?

Thus setting up downstream demand in the future Need I remind you of the 50% cuts to the local govt services that buy what some people call the “determinants of health” – aka local govt, good housing, parks, welfare & benefits, social care, Public Health Services. You know, the sort of things that make a difference to population health outcomes.

We all know only a smallish proportion of health outcomes are attributable to health care. this study finds that between 1900 – 1999, life expec at birth increased from 47 years to 77 years. 25 of the 30 years gained can be attributed to PH advances. The aggregate effect of medical care on life expectancy is found to be roughly five years during this century, with a further potential of two years. The Caveat re medical care is re alleviation of the enormous burden of pain, suffering, and dysfunction that afflicts the population for which medical care can provide a large measure of relief. See this blog also

The social determinants of health important part of the debate about how to fund health service. Funding NHS by cutting education, transport and housing not a pro-health agenda. Hence need for tax honesty in the medium term. This shouldn’t be a zero sum game says @anitacthf.

If new money is made available I carry great fear it would be routed through the current infrastructure and either single disease-specific priorities or and organisational pressures such as the 4 hour wait or referral to treatment targets. This would obviously be to the detriment of what Investments are really needed around preventing and delaying and managing the complications of multiple morbidities.

For example wants social prescribing & greater social support 4 patients and citizens. Sadly on account of immense funding pressure and the issues around needed to maintain statutory services social prescribing is not statutory many local authorities are having to dismantle the infrastructure particularly the Voluntary Sector infrastructure that is the backbone of these schemes

Social support is fabulous but it’s not free.

 6)

We must learn from history

Yes, I am a little angsty about it “Health” is NOT “the NHS”

The (HMT commissioned) Reports by Wanless told us all this 20 years ago We studiously ignored him. To remind you, Wanless did three reports

1. Spend more money on the NHS

2. Don’t ignore social care, or yer doomed

3. Don’t ignore the need to prevent stuff, or yer doomed.

If we only attend to 1, we WILL repeat this cycle every 15 years or so. The NHS suffers from a kind of Moral Hazard in all this and pulls money from other higher value social goods HT Steve Laitner.

Doctors demanding more money for the NHS should stop doing so many useless investigations and procedures of limited value HT @mellojonny. Economists demanding more money for the NHS ought to think about the health v health care question. Instead of buying cancer drugs of very marginal (no) value, buy parks, social workers and bike lanes!

So whilst the NHS is special, it is no more special than many of the other things that might buy more health gain and thus prevent downstream demand on the NHS. Do we want more health, or more health care – the concept of the flat of the curve is important, look up diminishing marginal returns in health economics 101.

Maybe we need to reconsider our approach to transforming things. I once summarised what I thought to be the critical issues in health policy in pictures.

And lastly – none of this is really to do with the “ageing population” that’s just lazy shorthand. Please reframe ageing

 

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