Wednesday, January 02, 2008

Conditional Healthcare

The real story of Wexham Park

2008- sixty years of socialist medicine.

Rictus smile Commissar Bean was straight off the blocks. During a vomit inducing photo op at Wexham Park Hospital Slough, he announced his grand "NHS Constitution"- "a new constitution of the NHS setting out for the first time the rights and responsibilities associated with an entitlement to NHS care."

So how will that work?

As usual, Bean didn't say. All he put in his formal statement was that Lord Darzi would be writing yet more guff, and "over the course of the next year the Department of Health, under Alan Johnson's leadership, will be setting out how the NHS needs to continue to reform to meet the new challenges of 21st century healthcare and 21st century lives."

Simple as that huh? Healthcare expert Commissar Al J (no degree... no A levels... no O levels) will soon be delivering the meisterplan that has eluded previous Commissars Hewitt, Reid, Milburn, and Dobson for more than a decade.

But Al's already one-quarter way through his average two year tenure, and it's just possible someone's let him into the awful secret: the NHS is doomed. Rising expectations, 100 year lifespans, lifestyle diseases, and rocketing costs simply cannot be handled by a free at the point of use, bloated and inefficient nationalised industry.

Something's got to give.

But what?

Here on BOM, we'd go for the continental social insurance model: compulsory health insurance for everyone, competing providers, and some measure of co-payment for routine things like GP visits. Clean, simple, and effective- bringing in the power of a consumer based market to increase productive efficiency, and to incentivise responsible consumption.

The trouble is, none of our Westminster politicos are brave enough to suggest anything so definite. They'd prefer yet more "NHS safe in our hands" fudges, and yet more "we'll magic away plague hospitals" muddling through.

Hence yesterday's unattributed media spin, that this new NHS Constitution will keep free treatment but might make it conditional on maintaining a healthy lifestyle- ie no smoking, and no getting overweight, or else:

"Sources at the Department of Health said that laying out what was expected of patients in return for healthcare would mean addressing issues that have posed dilemmas for health professionals for years.

One source said: “If you are smoking too much should you be entitled to an operation? Should we say you can have an operation if you give up smoking and change your pattern of behaviour? Or, if you don’t turn up for a hospital appointment should there be a penalty for that?”

No, of course they won't actually do it: even as the DoH was spinning one way, a Downing St spinner "played down the prospect of sanctions if people refused to comply". And can anyone seriously imagine NHS doctors refusing treatment simply because someone hadn't stuck to a diet? Or the rest of us being forced to watch fat people dying in the gutter?

But what we see once again is just how busted the concept of tax funded "free" healthcare really is. In trying to manage demand (which is what they're doing here) the commissars have access to only the bluntest of instruments- your healthcare is free, except if you don't use it as we direct, we'll have you shot! (or at least, leave you to die in the snow).

Compare and contrast with the persuasive subtlety of the market. Private health insurers are already having success offering discounts on premia to those who adopt healthier lifestyles, such as not smoking and taking regular exercise:

"Health insurers have begun slashing premiums for customers who lead healthier lives by offering discounts of 75 per cent for those who allow their diet and exercise regimes to be monitored.

Under the Pru Health policy, customers earn premium reductions for each vegetable or piece of fruit they buy at Sainsbury's stores. They also wear pedometers and qualify for discounts if they take 10,000 steps a day or attend the gym at least twice a week. There are further reductions for giving up smoking and agreeing to be randomly tested...

Each healthy choice earns the customer points, with premium discounts of more than 75 per cent on offer on a sliding scale.... the programme could be extended to include discounts for people who reduce their drinking."

With a market based system, there's simply no need for do or die orders from the bunker. There is a whole range of choice, with the emphasis shifted from stick to carrot (literally). And by using ongoing premium rates to influence behaviour, the incentives are applied in real time when they can have the gretest effect- while the punters are actually smoking all those fags or eating all those Mackies- and not rolled up into some far distant Final Day of Reckoning.

And if it turns out the punters would actually prefer to carry on stuffing their faces and pay the higher premia, hey presto, the healthcare suppliers have the additional funding they need. Suddenly we are no longer dependent on the commissars to decide and decree how much healthcare we can have. We can decide for ourselves.

What's that? Cream skimming? Cherry picking? Insurance companies stacking their premium rates so as avoid insuring people with expensive conditions?

Clearly, under compulsory social insurance schemes, suppliers cannot be allowed to avoid customers with expensive pre-existing conditions. So they must not be allowed to select on the basis of medical conditions.

But incentivising healthy behaviour is not the same as penalising medical history. Yes, there would need to be guidelines (insurers would be prohibited from penalising limbless ex-servicemen for not running 6 miles a day etc), but there's no reason why that lifestyle scourge of fags, booze, and obesity should not attract higher premia.

How much better than the Stalinist Conditional Love fantasy world imposed on us by Commissar Bean and Rockin' Al J (who, as you will recall, was obliged to become a postman in Slough after his teenbeat career in pop failed to take off).

PS Since The Bloke made that vid outside Slough's mega Tesco, the company has run into a spot of bother. In order to build their new store, they had to demolish the old one. So they moved temporarily to another store they bought from the Co-op a couple of hundred yards away. The deal with the Council was supposedly that once they moved back to the new store, they would then let the old Co-op store to a competitor. Yeah. Right. Instead, they knocked it down and started building a couple of smaller units apparently to let to some non-competitor like DFS or World of Leather. They've now been stopped mid-build by the Office for Fair Trading who say the move "has resulted in a substantial lessening of competition in the market for grocery retailing in Slough", and it is "now consulting on potential measures in relation to the former Co-op site to address the loss in competition". The Bloke informs me that Slough already has a couple of Sainsburys and an Asda within a 10-15 minute drive, the Co-op was never a real competitor, and its old site isn't big enough for a like-for-like Tesco competitor anyway. But we'll see what the OFT in its wisdom comes up with. Meanwhile, Tescos, with its on-site Halal butcher and Indian sweet shop, continues to give its Slough customers what they evidently want.