Unhealthy survivors and the A&E crisis – why NHS managers should pay more attention to local healthcare inequalities

A&E admissions keep rising due to the “unhealthy survivor” effect. Rather than dying prematurely, people are surviving longer, accumulating chronic illnesses – and going to A&E. The A&E crisis is thus partly a consequence of medical and social success – more effective hospital treatment, better prevention and management of disease, improving living conditions and health behaviours.

But the A&E crisis is also a consequence of social inequality. Poorer people are more likely to attend A&E than richer people. Richer people tend to be healthier survivors. They are more likely to enjoy what epidemiologists call “compression of morbidity” – i.e. to live a long and healthy life, followed by rapid decline and death. The poorer you are, by contrast, the more likely you are to spend many years of your life staggering under the burden of multiple, severe illnesses – placing you at greater risk of repeated A&E admission. Much of this illness is preventable, and many A&E admissions could be prevented by improving the co-ordination of care between hospital and primary care settings, and reducing inequalities in the quality of care.

The social gradient

The statistics are striking. Allowing for age and sex, people living in the most deprived fifth of neighbourhoods in England suffer nearly two-and-a-half times as many preventable emergency hospitalisations as people living in the least deprived fifth. These are emergency admissions for long-term conditions – such as dementia, diabetes, respiratory and cardiovascular diseases – that could be prevented by more effective primary care or outpatient care. And this is a problem affecting everyone in society, not just the poorest. There is a “social gradient” in A&E admissions, whereby the further down the social spectrum you go, the greater your chances of suffering an emergency hospitalisation.

Social gradient in preventable hospitalisation. Source: Richard Cookson, based on data from our NHS inequalities research cited below

As the graph shows, preventable emergency admissions would be nearly halved if everyone had the same rate of A&E admissions as the least deprived in society. In other words, nearly half of emergency hospital admissions arise from social inequality.

Pressure on the NHS

In our recent research on NHS inequalities, my colleagues and I at the University of York and elsewhere estimated that social inequality was associated with more than 158,000 preventable emergency hospitalisations in England in 2011/12 and nearly 38,000 deaths from treatable conditions.

Preventable emergencies like these are putting huge pressure on the NHS. The pressures are likely to increase in future decades, as health and social care continue to absorb an ever larger share of public expenditure due to cost-increasing medical innovation, people living longer with multiple illnesses, and wage inflation in a labour-intensive industry. The NHS thus needs to develop new approaches to dealing with these pressures if it is to survive in its current form as a universal and comprehensive tax-funded health system.

The aspiration of proactive co-ordinated care

The NHS is good at providing equal access to reactive care when people suffer a health emergency. But it needs to get better at providing proactive care to people before they suffer an emergency. This is mostly about prevention and disease management in primary and community care settings, but hospitals can also play an important role. For example, hospital patients at risk of repeated emergency admission may need following up to check they are taking their medicines appropriately, or being cared for appropriately in the community, or being given appropriate advice and support to change their health behaviour.

Successive governments have correctly identified that the NHS needs to improve the co-ordination of care between specialties, between primary and hospital settings, and between health and social care. Current initiatives such as the Better Care Fund, new models of care and the Vanguard sites are thus all steps in the right direction. But there is a world of difference between setting policy aspirations and delivering measurable, beneficial improvements for patients.

Healthcare equity indicators can help

Generally speaking, people at the very top of society are the best at co-ordinating their own care – they have the best information, the best support networks from family and friends, the nicest home environments in which to recover from illness, the sharpest elbows. Everyone else – including people in the middle, as well as the most deprived – needs proportionately more help. So to deliver co-ordinated care more effectively, managers need better information about healthcare inequalities within their local area. To help provide this information, we have developed health equity indicators for the NHS.

We applied these indicators retrospectively to the NHS under the Blair/Brown government in the 2000s. We found that investments in GP services led to improved primary care for all socio-economic groups, particularly among the poorest, between 2004 and 2011. There was, however, only a modest reduction in inequality in preventable deaths and admissions through A&E. If NHS England were to start producing our indicators on an up-to-date annual basis, this would help managers address this problem more effectively. It would also help monitor the healthcare inequality duties introduced in the Health and Social Care Act 2012 and inform the public about healthcare inequalities within their local area.

Of course, the NHS cannot solve the problem on its own. A&E pressures are partly a barometer of wider social ills, and cannot be dramatically reduced unless Britain becomes more equal. Wider action is needed by social services, education services and other public services that impact on people’s health. Action is also needed to change people’s health behaviour – for example, through taxation, regulation and “nudges” to reduce consumption of tobacco, alcohol and sugar and to encourage healthy habits such as physical activity. More fundamentally, action is needed to reduce the inequalities in childhood circumstances that help to generate lifelong inequalities in health. The need for wider action on inequality, however, should not be used as an excuse for inaction by the NHS.

Reducing healthcare inequality is a matter of social justice. Since the NHS is under such severe pressure from preventable emergencies arising from social inequality, it is also a matter of common sense.

Disclaimer and further information:

The views in this blog are my own, and do not necessarily reflect those of the NHS or the NIHR who are currently funding my research.  Further details of the research mentioned in this blog can be found on this NHS equity indicators research project page.

Bean counting and the NHS

Richard Cookson, 11 July 2014

I was recently questioned about the future of the NHS, during a live debate on the BBC Radio 4 programme “the moral maze”, on 9 July 2014.  One of the panelists took me to task for being a “bean counter”.  I got side-tracked by this somewhat less-than-flattering characterisation of my professional role as a health economist, and so only managed to get across three of the six points I had planned to make.  For what they are worth, this blog sets out all six points.  And, as an added bonus, it then concludes by explaining why I am proud to be a “bean counter”.

This blog sets out personal ethical views on a number of controversial matters of social value judgement.  That is what the BBC programme makers asked me to do, and I hope my professional colleagues will not “tut tut” too loudly when they see me doing it.  Professional economists are supposed to help decision makers and stakeholders think through the implications of a range of alternative value judgements, rather than to impose their own particular personal or professional value judgements.   However, this blog merely voices my own value judgements – it does not impose them on anyone.

Point number one is that the NHS performs rather well compared with other health systems across the world.  It is relatively cheap, relatively good, and very fair.  The UK currently spends about 9% of national income on health care, just under the OECD average, compared with 18% in the US.  People in the UK are on average healthier than those in the US – even rich people with access to the best available health care in the US.  And the UK regularly comes top of Commonwealth Fund surveys of fairness in high income health systems.  The UK NHS is widely regarded as the fairest health system in the world, with the possible exception of Cuba.

Point number two is that financial strain on the NHS will get worse in decades to come – potentially much worse.  This is due to a fundamental clash between health economics and tax politics.   The tax politics is obvious.  Voters do not like high taxes, so there is a limit to how far taxes can be raised, even to pay for something as popular as health care.  The health economics is less obvious, but surprisingly simple when you think about it.  As countries get richer, they spend a higher percentage of national income on health care.  There is a simple reason for this.  As we get richer, which is more valuable – a third car, yet more electronic gadgets, or an extra year of life?  (I am here paraphrasing Hall and Jones in their 2007 paper in Quarterly Journal of Economics, which predicts that health spending in the US will rise to 30% of national income by 2050).  In the technical economic jargon, health care is a “superior” or “luxury” good.  Do not be misled by this jargon – it does not mean that health care is an unimportant frippery.  Quite the opposite.  Effective health care that extends life and improves quality of life is much more important than fripperies.  That is why rich people want to spend such a large share of their incomes on it.

Point three is that my own preferred solution to this problem – and here you will notice that personal ethical opinions are coming thick and fast – is gradually to ration NHS care more explicitly and extensively, within whatever budget the electorate are willing to vote for.  That would enable the preservation of a tax-funded national health service that continues to provide a fairly comprehensive package of cost-effective health services to all citizens, that is nearly free at the point of delivery.  (The NHS has never been 100% comprehensive or 100% free at the point of delivery).  The rationing should be done through a transparent deliberative process, and based on a range of ethical principles, including cost-effectiveness, need, and compassion.  Chief among these principles, however, should be cost-effectiveness – the principle that scarce NHS resources should be used to do as much good as possible in terms of extending people’s lives and improving their quality of life.

Point four is that more extensive rationing is a better and fairer solution to the problem of preserving the NHS than more extensive user charges.  User charges should not be imposed on cost-effective forms of health care, such as GP visits.  Charges for GP visits deter people – especially poorer people – from seeking preventive and diagnostic care.  Without effective prevention and diagnosis, health problems progress to become more harmful to the patient and more costly to the NHS.  If health care is cost-effective it should be provided free on the NHS; and otherwise not.  People can then pay for non-cost-effective care themselves, either out of pocket or via “top up” private health insurance.  The slogan “all necessary care should be free” should be re-interpreted as the slogan “all cost-effective care should be free”.

Point five is that fervent ideological debates about “competition” and “choice” and “markets” and “privatisation” are largely red herrings.  What matters is that the NHS provides a fairly comprehensive range of cost-effective care to all citizens, so that everyone receives the care they need at a cost they can afford.  Who owns or manages health care provider organisations does not matter directly in and of itself.  Ownership and management may matter indirectly, of course – but only insofar as they impact upon the cost, quality and social distribution of health care.  The direction and size of such impacts in different contexts is a factual matter, to be settled in the court of evidence and experience, rather than a matter for fervent ideological debate.

Point six is that a more extensively rationed NHS can still preserve the founding principles of the NHS.  On the delivery side, it can preserve the principle of “equality of access” to all necessary health care – where “necessary” means “cost-effective”.  And on the financing side, continued tax funding continues to preserves the principle of “solidarity”, that the strong should help the weak – the rich should help the poor, the young should help the old, and the healthy should help the sick.  Finally, the NHS also preserves the benefit of financial risk protection.  As was stated in the public information leaflet sent to all UK citizens at the founding of the NHS in 1948, one of the main benefits of the NHS is that “it will spare your family from money worries in time of ill health”.

In conclusion, the best way to preserve the NHS is to engage in more explicit and extensive rationing.  This in turn will require more of what my “moral maze” inquisitor called “bean counting”.  More evidence will be needed to inform a suitably transparent and deliberative rationing process.  In particular, more evidence will be needed about the impacts of different NHS services on cost, length and quality of life, patient experience, need, compassion and dignity, and other ethically important outcomes and processes.  This form of “bean counting” is not an ignoble exercise.  The “beans” in question here are people’s lives.  People’s lives matter, and if seeking to improve the length and quality of people’s lives makes me a “bean counter” then I am proud to be one.

Manifesto Check: health tourism only costs as much as UKIP’s free parking pledge

Richard Cookson, University of York

The Conversation’s Manifesto Check brings academic expertise to bear on the political parties’ key election pledges.

In essence, the UK Independence Party (UKIP) propose to solve the problems of the NHS by spending more money. The risk, of course, is that the NHS could swallow this extra money without delivering improved quality and outcomes for patients. UKIP do not explain how they will get value for money from this spending. And like the other parties, they do not spell out what tax increases and spending cuts in other areas of public spending will be required to accommodate the NHS’ ever increasing share of public expenditure.

The UKIP manifesto does, however, devote a substantial amount of space to the issue of “health tourism”, whereby foreign nationals come to the UK to obtain free health care. As set out later in the article, this kind of “health tourism” actually costs less than one fifth of 1% of the NHS budget. The space devoted to this issue by UKIP is therefore wholly disproportionate to its economic importance.

The UKIP diagnosis

According to UKIP, the NHS is in crisis due to “our ageing population”, “the dramatic increase in the numbers of people suffering chronic, long-term conditions”, “uncontrolled immigration”, “EU directives”, and “endless political interference.“ The party claims that “David Cameron’s government wasted billions on a top-down reorganisation he promised would not happen.”

UKIP is right about the first two claims. As people live longer due to improved socioeconomic conditions and medical technology, they acquire multiple different chronic long-term conditions – known in the trade as “multi-morbidity”. This is putting a strain on health care resources across the globe. It also poses a challenge for clinicians who typically specialise in one type of disease, and find it hard to treat multiple different diseases at the same time.

UKIP also has a point about top-down reorganisation. Successive governments over the past 60 years – this one included – have indeed spent a fortune in administrative costs, on what Professor Alan Maynard calls the perpetual “re-disorganisation” of the NHS.

But the party’s points about immigration and EU directives are red herrings. Arguably, immigration actually provides a net benefit to the NHS, with an influx of foreign born workers and the migration of mostly young and healthy workers, who rarely use the NHS, yet contribute their share in taxation. It is is true that the EU working time directive has slightly increased NHS costs, by reducing the long working hours of trainee doctors and hence reducing a source of “free” labour to the NHS.

But this issue is trivial in comparison with the other main economic drivers of increased health care expenditure that are not mentioned by UKIP, which include cost-increasing medical technology, rising expectations of health care in the consumer age, and the “cost-disease” of rising costs and stalling productivity in all labour-intensive industries.

UKIP fails to diagnose these problems, or to offer solutions for how they will arrange for the introduction of new technologies, manage people’s expectations of health care, or improve the productivity of the workforce.

The UKIP cure

UKIP proposes a number of remedies for the NHS, the first of which is extra spending. The party pledges to spend £12 billion over five years, which includes £300 million a year of additional funding for mental health services, £130 million of which is earmarked specifically for dementia. The party also promises to expand the medical workforce by adding 8,000 more GPs, 20,000 more nurses, and 3,000 more midwives.

UKIP also plans to shift the medical workforce towards A&E, by improving working conditions for emergency medicine consultants and piloting the use of GPs in A&E. Experimentation such as this should be welcomed; policies like this could work, but there is currently not enough evidence either way.

The party wants to regulate NHS managers through a “license to manage”, and by transferring regulatory functions from Monitor and the Care Quality Commission to local authorities. UKIP describe these measures as “effective and powerful health care monitoring”. Yet these are peculiar proposals – successful private sector managers need no “license to manage”, and it seems odd to hand over a national regulatory function to local authorities. And UKIP provides no evidence that either of them will deliver benefits. All we can be sure of is that they would both impose administrative costs as NHS officials shuffle from one organisation to another, yet again.

The UKIP manifesto also pledges to end PFI contracts, and negotiate op-outs from the EU Clinical Trial Directive, the EU Working Time Directive, and the Transatlantic Trade and Investment Partnership (TTIP).

Health tourism

The UKIP manifesto claims:

Every year the NHS spends up to £2 billion of UK taxpayers’ money treating those ineligible for free care. This bill includes foreign nationals who come to Britain to deliberately seek NHS services at no cost to themselves; those who live here but who do not qualify for free care; treatment for illegal immigrants and those who overstay their visas.

This is misleading. The £2 billion figure comes from a European Commission report on migrant EU citizens who have residency, but do not work in the country they have moved to. But most such EU citizens are eligible for free NHS care under EU rules –- the same reciprocal rules that allow UK citizens to access free health care in other EU states.

Although accurate data do not exist, the best available estimate of the cost of treating people who deliberately travel to the UK for free NHS treatment is between £70 million and £300 million, from a report produced for the Department of Health by a research consultancy firm and cited in the British Medical Journal. The approximate mid-point of this estimate – £200 million – represents less than one fifth of one percent of the £112 billion spent on the NHS in 2013/14.

UKIP have form in making exaggerated claims about health tourism. During a TV election debate, Nigel Farage claimed that people “can come into Britain from anywhere in the world and get diagnosed with retroviral drugs that cost up to £25,000 per year per patient”, and that 60% of people diagnosed with HIV are “not British nationals”. But figures from Public Health England actually show that 44.8% of new HIV diagnoses in 2013 were in people recorded as foreign born, who may be British nationals, and most of whom probably acquired HIV while living in the UK.

Hospital car parking

UKIP estimate that offering free parking would cost NHS hospitals about £200 million a year – about the same as the annual cost of health tourism. They fail to mention that travel costs more than parking, that financial support for travel and parking is already available for people on low incomes, or that free parking could increase congestion and stress for those unable to find a space – see this report by the University of York Centre for Health Economics.

This article was originally published on The Conversation.
Read the original article.

The psychology of tax and spend

Richard Cookson, 18 July 2014

Following my recent foray into “The Moral Maze”, I was invited to join a live public “phone in” debate about the NHS on the BBC Radio 4 programme, “You and Yours”, on 15 July 2014. This was a slightly less fulfilling experience, for two reasons. First, it meant being stuck in a cupboard in BBC Newcastle, without meeting any of the programme makers or participants. Second, the promised opportunity to make some final remarks never materialised. This was frustrating, as I wanted to challenge the naive “tax and spend” approach to the NHS advocated by some of the other participants in the programme. This blog is a slightly longer version of what I would have said.

It is sometimes claimed that the financial problems of the NHS can be solved simply by raising taxes and spending more on the NHS. No rationing. No charging. No market reform. Indeed, no reform at all. Just spend more on the NHS, and let doctors and nurses get on with it. That claim is naive. Raising taxes and spending more on the NHS may help in the short term – but it will not be enough to preserve the NHS in the long term.

Like all supporters of the NHS, I want to preserve a high quality “Volkswagen” NHS for everyone, rather than see us gradually shifting towards a private “Rolls-Royce” service for the rich and a “Donkey Cart” NHS for the poor. In the long run, this will require increases in taxes and spending on the NHS. But a strategy of “tax and spend” alone is doomed to fail.  As the economy grows and we get richer, we will want to spend an ever higher proportion of our national income on health care. Just possibly, we may also be willing to pay a higher proportion of our income in taxes. But only up to a point. There is a political limit to the “tax” part of “tax and spend”.

That clash between health economics and tax politics is the fundamental strategic problem the NHS must address if it is to survive. Something else is needed, as well as tax and spend – either rationing, or charging, or reform, or a combination. Sometimes you can have your cake and eat it. Sometimes you can’t. In this case, you can’t.

Why do some of my fellow NHS supporters resist that uncomfortable logic, and cling to naive “tax and spend” advocacy? I can think of three possible motivations. In his classic 1974 book, “Who Shall Live?”, Victor Fuchs memorably dubbed the first two as the romantic and the monotechnic points of view, respectively. The romantic point of view denies that public spending decisions have opportunity costs in terms of alternative beneficial uses of scarce resources. The romantic believes that resources can be found for their own favoured cause without impinging on other people’s favoured causes – for example, by making “efficiency savings”, by diverting resources from disfavoured causes (such as defence spending) or by clamping down on the high pay and tax avoidance behaviour of the super rich. Fuchs criticises this viewpoint, writing that: “Because some of the barriers to greater output and want satisfaction are clearly man-made, the romantic is misled into confusing the real world with the Garden of Eden.” He goes on: “Confronted with an obvious imbalance between people’s desires and the available resources, the romantic-authoritarian response may be to categorize some desires as ‘unnecessary’ or ‘inappropriate’, thus protecting the illusion that no scarcity exists”.

By contrast, the monotechnic point of view fails to recognise the legitimate plurality of individual and social objectives. The monotechnic fixates on a single objective and is unconcerned if allocating additional resources to this objective imposes opportunity costs in terms of other objectives. According to Fuchs, the monotechnic view is “frequently found among physicians, engineers, and others trained in the application of a particular technology”. He goes on to write: “The desire of the engineer to build the best bridge or the physician to practice in the best-equipped hospital is understandable. But to extent that the monotechnic person fails to recognize the claims of competing wants or the divergence of his priorities from those of other people, his advice is likely to be a poor guide to social policy”.

The third possible motivation for naive “tax and spend” advocacy, of course, is straightforward political lobbying. NHS staff may know perfectly well that tax and spend alone cannot solve the problems of the NHS. But they may nevertheless wish to lobby for additional NHS spending, in the same way that teachers may wish to fight their corner for additional public spending on education, soldiers for defence spending, BBC Radio 4 staff for BBC Radio 4 spending.

Luckily, academics like myself would never stoop to special interest lobbying of his kind. That’s why more research is needed, and taxes should be raised in order to spend more money on academic research.