Bedsheet, spreadsheet

Yes, but what did it cost?

We have all read anecdotes about hospital treatment in the British National Health Service (NHS) – the good, the bad and the terrible.

What I always miss in these accounts is any idea of what any particular encounter with the health system cost, irrespective of its quality. It appears that only someone with a spreadsheet in the upper reaches of the NHS might be able to answer that, but I have a feeling, probably not: the system doesn't work like that – and that is its greatest weakness.

I live in Switzerland, where health care is financed by an insurance model. Needing medical treatment is just the kind of unforeseen event that insurance is designed to cover. What follows is a financial, not anecdotal account of your author's recent brush with the Swiss health system.

The Swiss health insurance model

First, some background about the Swiss system for UK readers. In the following I have given money amounts in GBP using an exchange rate of 0.68 and have rounded numbers as appropriate.

The Swiss government specifies the benefits provided by a basic health insurance policy. In essence the basic policy covers you for everything except glasses and non-medical dentistry. Everyone has to have as a minimum the basic health insurance. If you want, you can top it up with special benefits such as two-bed and single-bed hospital rooms (with the basic policy you are in a four-bed room). The premiums for children are about a quarter of what adults pay.

Around October every year the insurers publish their rates for the coming year. If your current insurer's rates are no longer to your liking you are free to change your insurer for the coming year. In the last ten years I have changed my insurer three times. The medical side of the system is entirely privatised. Doctors and institutions invoice the patient or the insurance company for their services. The patient has an almost unrestricted choice of supplier. The suppliers work for the patient not for the government.

Insurance companies offer a range of annual 'franchises' on their premiums. In my case I have the maximum franchise of £1,700 a year, which means that I agree to pay the first £1,700 of health costs for the year, after which amount the insurance company has to pay. In essence I am undertaking to cover all my low-level health costs myself. For me, the insurance premium is there just to cover disasters.

Those who can't afford health insurance receive support from the welfare system - they don't go untreated. But, unlike the British system, the cost of the 'free' treatment is not borne by the health system, it is made up by the social security system. The health system always gets the cost of its services covered.

The bottom line

Some numbers for the last four years. Until my recent brush with doom I hadn't needed any medical attention at all during this time.

My nominal premium has been £175 per month, £2,100 per year, £8,400 over four years. With a franchise of £1,700 my actual premium has been: £90 per month, £1,100 per year and £4,375 over four years, meaning that the franchise has saved me £4000 over four years.

I can therefore now say what no NHS patient can say, that my health care costs me around £1,100 a year when nothing happens, but could cost me a maximum of £2,800 if the worst happened.

Testing the system

At the end of August last year I lost patience with my prostate, or perhaps it lost patience with me. Go to the loo in a pub and your friends will eventually send out a rescue party for you.

My GP referred me to a urologist. I got an appointment with him a week later. After a month of swallowing pills it was clear that a physical problem required a physical solution. About two weeks later, on 9 December I had the operation, followed by three days with a hosepipe up my todger.

During the operation the urologist came across what turned out to be a small, aggressive tumour. Because of this, in the remaining three weeks of December I had a colonoscopy, a CT scan, an MRI of my pelvis and an MRI of my prostate. They did not hang about.

Let me complete the tale before you ask where to leave the flowers, balloons and teddy-bears. At the beginning of January I had another operation, three more days with the damn hosepipe. The tumour problem appears to have been solved and, since you ask, I can get 350 ml from our balcony, over the neighbour's garden, over the road and into the lake in well under ten seconds. On any medical measure: success!

Let's also get the usual anecdotal stuff over in one short paragraph. The whole process was stunningly efficient, very friendly and reassuring and utterly competent at every level. As a rule I never had to wait more than 10 minutes for an appointment to begin. I can grumble with the best of them, but the best I can do here is a small moan about the quality of the coffee.

The bills roll in

There can be no doubt of the quality and expeditiousness of my treatment. But what did it cost? Simple!

It cost me £1,700 using up my franchise for 2015, it cost the insurer £3,480 and therefore the total cost for everything, GP included, was therefore £5,180. Every one of these invoices passed before my eyes.

Given the prompt and excellent service I received from teams of highly-trained specialists I find those amounts extremely reasonable. My total health costs for the last four years were therefore £6,075, which makes roughly £1,500 per year averaged over four years, a sum which covers the most important factor in human life, health.

The patient as customer

A UK resident might be reeling at these figures – £1,500 a year for my health! – but you really have nothing to say here. You currently have no idea what your health costs you and how reasonable or not that unknown amount might be. Do you get value for money? You don't know. What you pay for your health ultimately depends on the amount of tax you pay. In contrast I know exactly what I pay without reference to my tax bill and it seems reasonable to me.

The National Health Service stumbles between funding crises, having to scratch ever more money out of the taxation pot in competition with every other spending department: it's just a soup kitchen, in fact. You can only turn up with your ration book clutched in your hand and hope for the best.

The Swiss also grumble about the inexorable increase of health service costs, but at least they all know what the numbers are and they are always treated as valued customers not expensive nuisances by their health service.

Update 15.04.2016

The National Health Service in Britain, as noted above, is a soup kitchen:

A&E waiting times are the worst on record – forcing tens of thousands of elderly patients to languish on trolleys in hospital corridors.

Almost 230,000 urgent cases waited at least four hours to be dealt with, the latest monthly NHS figures reveal.

They include 50,000 patients – most of them elderly – who were lined up on trolleys waiting for a bed to become available. Labour warned that the NHS was 'on its knees' and heading back to the 'dark old days' of the 80s and 90s, when casualty departments were overflowing.

And yesterday one Trust said it is downgrading its A&E unit to a minor injuries centre and diverting ambulances elsewhere because it is too understaffed to guarantee patient safety.

Update 16.04.2016

Because the NHS is a soup kitchen, throwing ever more money at it will achieve nothing apart from creating a bigger soup kitchen:

Boris Johnson and Michael Gove will call on Friday for billions of pounds of taxpayers' money that is currently sent to the EU to be spent on the NHS instead.

Mr Johnson will open the first day of official campaigning with a speech in which he will say that the UK's contribution to Brussels would be better spent on building new hospitals.

Update 18.04.2016

The NHS is a soup kitchen in all its parts. In the Swiss system one phone call gets you an appointment, same day if you need it. Once there, I can't remember ever having to wait more than ten minutes in the waiting room.

This is how the NHS – a.k.a. Envy-of-the-World™ – manages:

More than nine million patients are suffering inferior GP care, damning inspection reports have revealed.

Some surgeries have made patients call up to 34 times for an appointment, or stocked medicines nearly 20 years out of date. Others hired bogus locum GPs with no medical qualifications.

So far, 15 percent of practices in England have been rated either 'inadequate' or 'requires improvement' in ongoing inspections by health regulator the Care Quality Commission.

This is equivalent to 1,140 surgeries, covering just over 9.1 million adults and children.

Figures also show one in four patients last year waited a week or more for a GP appointment – or did not get one – a rise of 500,000 in a year from 13.8 million to 14.2 million.

CQC inspectors visited 3,200 of the 7,600 practices in England, rating 11 percent as 'requires improvement' and 4 percent 'inadequate'. These included the Dr Zaheer Hussain surgery in Fulham, west London, where inspectors found contraceptive pills that expired in 1998, as well as out-of-date aspirin and heart medication.

They could not confirm how many were given to patients but any that were may have been ineffective.

Princes Park surgery in Liverpool, also inadequate, was criticised for making patients wait too long on the phone. One said he tried 17 times to get through while another reported calling 34 times.

'We also hear about misdiagnoses and problems when patients are not being sent for tests, often resulting in late diagnosis. Long waiting times not only prolong a patient's suffering, but can also cause their condition to deteriorate.'

Several inadequate practices failed to carry out criminal record checks on locums or ensure they were qualified. These included the Goodwood Court surgery in Hove, East Sussex, which was last year closed down by the CQC because care was so poor.

It mistakenly hired a chiropractor – trained to treat muscular conditions, but without medical qualifications – who posed as a GP.

At the Victoria Medical Practice in Washington, Tyne and Wear, also deemed inadequate, receptionists chatted loudly about patients' confidential details, including their illnesses, names and dates of birth.

The CQC will complete inspections later this year and expects the proportion of practices that are inadequate or require improvement will remain at about 15 percent.

Update 25.04.2016

Another report from the NHS (a.k.a. Envy-of-the-World™) front, this time from the estimable Anna Raccoon:

Still an 18 week wait for surgery is not the end of the world – people wait far longer to get a new hip. I've just been quoted seven weeks to get an appointment with the GP. But then I'm only on the 'Gold Standard for End of Life' care. No rush.

Update 27.04.2016

Yet more soup kitchen (a.k.a. Envy-of-the-World™): Nearly half of adults don't pay income tax.

Barely half of British adults now pay income tax and the top one per cent of earners will pay a third of it by 2020, a new report revealed yesterday.

Rapid increases in the tax-free personal allowance since 2010 have led to a sharp decline in the number of people paying any income tax at all, according to analysis by the Institute for Fiscal Studies.

The comprehensive study found that the proportion of adults paying income tax fell from 65.7 percent in 2007/8 to just 56.2 percent last year.

The fall came despite a surge in the number of people in employment during the period.

The IFS said there was growing evidence of an ‘increased reliance on a small number of taxpayers’, with the proportion of total income tax paid by the top one percent of earners rising from 24.4 percent to 27.5 percent at the same time. The figures mean that some 300,000 individuals now contribute more than a quarter of the Government’s entire income tax take.

In soup kitchen terms: for nearly one half of adults in the UK the NHS is a charity service, paid for by the other half.^[1]

Update 02.05.2016

Yet another bit of soup kitchen documented:

The official audit of 9,000 dying patients, conducted by the Royal College of Physicians, reveals that one-in-five families were not informed that a “do not resuscitate” order had been put in place - equivalent to the families of 40,000 patients.

The same study showed that in 16 percent of cases, there was no record of a conversation with the dying patient, or explanation for the lack of one, for the decision to put in place a do not resuscitate order.

Amanda Cheesley, RCN lead nurse for end-of-life care, said: “You have to be a decent human being to look after people who are dying. A lot of this is about common sense - about what would you do instinctively. And we’ve terrified nurses into not doing things instinctively.

“It’s become about doing a job, a task, writing a form, doing a really good care plan - all of which are terribly important but we do need to use our common sense and our instincts more perhaps than some people do.” Too often nurses walked away from patients who were in pain, or asking difficult and distressing questions about their fears, she said.

“By ignoring people we actually give an indication that we don’t care, that we are not bothered – that is in my personal opinion a criminal offence,” she said.

Studies have found that while 72 percent of people want to die at home, it happens in just 23 percent of cases. Baroness Neuberger, who led the review of the Liverpool Care Pathway, said too many dying elderly people were being rushed into hospital, only to die on corridors, in distressing scenes.

She said she was particularly concerned about actions taken by care homes, who did not want to have a death on their hands. “There is criticism to be made of care homes for saying actually you can’t die here so instead you have people dying on hospital trolleys,” she said.

Prof Keri Thomas, Honorary Professor at University of Birmingham said: “The medical input into care homes is not good enough round the country – sometimes really abominable.”

An NHS England spokesperson said the audit showed some improvements.*

* Always look on the bright side of death.

Update 03.06.2013

Switzerland, Friday 27 May, 08:15: Telephoned doctor's surgery.

• Can I make an appointment, please?
• Sure. This afternoon?
• Great. What time?
• Would 14:00 be OK?

Wait on arrival: under five minutes. Two follow-up appointments the following week. Course of treatment (pills) began Friday 3 June.

Update 05.06.2016

Cognitive dissonance: the discomfort felt by people holding two contradictory beliefs and the techniques they use to reduce that discomfort.

However, when it comes to the belief in the National Health Soupkitchen (NHS, a.k.a. Envy-of-the-World™), contradictory information seems to cause no discomfort whatsoever. No amount of factual information has any effect on a belief whatsoever. Today's example:

Fact:

More than 60,000 Britons are condemned to an early death every year because of failings by the NHS and other public health bodies, a damning new report reveals.

The shocking findings show that the UK performs worse than almost every other nation in Western Europe – and even former Soviet states such as Slovenia – at keeping alive patients aged under 75.

Just over a third of the 185,500 Britons in that age group who died in 2013 did so needlessly, according to a report comparing all 28 nations in the European Union. The report says a third of the 185,500 Britons under 75 who died in 2013 did so needlessly due to failings by the NHS or other public health bodies

These 63,442 deaths ‘could have been avoided in the light of medical knowledge and technology’, according to experts at Eurostat, the statistical office of the EU . In France, just under a quarter of deaths before the age of 75 were ‘avoidable’.

The appalling gulf highlighted Britain’s ‘patchy’ record at fighting cancer and other major killers, a leading oncologist said last night. Professor Karol Sikora warned: ‘The NHS lacks enough capacity when it comes to diagnosing cancer and other serious diseases quickly.

‘Access to your GP, prompt access to hospitals for tests like CT scans – these are things we just don’t do well enough compared to other Western European countries. If you have a symptom of something that might be cancer, on the Continent it gets investigated in a week. Here it can take months. It’s just too slow. Such delays can mean the difference between life and death.’

Belief

Health professionals have been equally clear about the implications of Brexit for the NHS. Questioned about the likely impact, NHS England chief executive Simon Stevens was unambiguous. 'Very dangerous,' he said. Dave Prentis, leader of the largest health union Unison, warned Brexit would 'place untold pressure on the NHS's already perilous finances'. The Royal College of Midwives said 'patient care is safer' as part of the EU.

The special irony comes from the fact that it is an EU body that is bringing the NHS fans this shocking news.

Those who will commemorate the hundredth anniversary of the first day of the Battle of the Somme on 1 July this year, perhaps even going to France to do so, might reflect that the Envy-of-the-World™ kills more than three times the number of people who died in the Fourth Army on that terrible day (19,240) every year without a shot being fired. Or even anyone being fired.

Update 16.11.2016

This article could have been updated with new horrors almost every day since it was written. A piece today by Anna Racoon, an experienced customer of the NHS, reminds us of what a dark place the 'Envy-of-the-World™' is, for those who are thrown on its mercies:

Other than a couple of days last week, I have been in hospital for the past three weeks. First Sepsis, then the effects of the attempts to cure me of that. I am now the original Christmas Turkey – being fattened up so that I can die comfortably of the cancer. The irony is not lost on me.

Last Tuesday, I sat in a wheelchair in the hospital, waiting for a bed to come free. Unable to stand or walk, unable to move from facing the wall in front of which I had been put, unable to reach the bottle of water which was in a bag behind the chair, and in gob smacking pain, pain at a level of which I had no idea existed…

I learnt, as I sat on a shattered and bloody bowel, on a bone hard wheelchair (do not try this at home children) waiting for a horizontal surface in the ‘envy of the world’ that…

The most remarkable thing about her account is that it is an aside to the main subject of her posting.

References

1. ^ True, there is indirect taxation such as VAT, fuel tax etc. But indirect taxation is an even barmier way to finance a health system. Do you remember the appalling Anthony Blair welling up during the fuel price protests in Britain in 2000(?) and blubbing that lower fuel taxation would mean fewer hospitals and angels-in-uniform – you heartless, motorised swine!
   Why should health provision depend on the consumption of fuel?