October 25, 2014

UK healthcare workers to be quizzed about fighting Ebola in west Africa

UK healthcare workers are being encouraged to complete a survey about helping with the Ebola outbreak in west Africa.

The results will help to identify and, therefore, address any modifiable barriers there might be.

So far, in the UK 800 people have volunteered to go to west Africa, but Tom Solomon and colleagues from the Institute of Infection and Global Health at the University of Liverpool say this is far short of the thousands more that are needed.

In a letter to The BMJ, they say they are launching the survey to better understand the factors that hold people back from signing up.

They hope this will identify any modifiable barriers that policy makers and those recruiting staff could potentially address. “This would encourage more healthcare workers to volunteer in west Africa, which should in turn help lead to a swifter end to the epidemic,” they write.

They point out that a range of factors may influence healthcare workers’ decisions on going to west Africa. Some of these, such as fear of becoming infected or personal home circumstances, are not easily changed, they say. “But there are other factors, which potentially could be dealt with if it were clear that they are important. These might include reassurance about the training to be given, clarity over payment and backfill of posts, and allaying uncertainties over repatriation for anyone who becomes unwell.”

The survey is part of a programme of work the University is undertaking to help tackle Ebola. This includes tracking the risk of further disease spread to developing new treatments.

Bringing the outbreak under control, “would not only benefit the people of west Africa but also help to protect the UK from imported cases,” they say – and they encourage all UK healthcare workers to complete the survey, which can be found atwww.surveymonkey.com/s/HPRUebola

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October 24, 2014

Over 600 patients win NHS refunds for operations overseas

Over 600 NHS patients who have had surgery in other European countries have now successfully reclaimed their medical costs from the NHS under a new law introduced a year ago.

Tomorrow, Saturday (25 October) marks the first anniversary of the introduction of the EU Directive on Cross-Border Healthcare, which gives UK patients the right to receive treatment anywhere in Europe.

Effectively it means that UK patients who are waiting for treatment can choose to have an operation at a private hospital in Europe and reclaim the cost, provided the treatment is medically necessary and would cost no more than it would in an NHS hospital.

According to figures revealed by the Department of Work and Pensions under a freedom of information request, 855 patients have submitted claims so far under the EU Directive. Of these, 621 have been successful and between them they have reclaimed a total of £833,491 in total – an average of £1,342 per claim.

The DWP figures, revealed at the request of Operations Abroad Worldwide, the UK’s leading provider of treatment overseas, show that France, Germany and Poland were the most popular countries for operations. The lowest cost for a hip replacement was £4153.35 which was carried out in the Czech Republic, and the lowest cost for a knee replacement was £2756.16 which was in France. However the DWP warns that the costs may reflect the requirements of individual patients and therefore not necessarily a standard price.

Ruth Taylor of Operations Abroad Worldwide said the EU Directive gave patients greater choice and could also help the NHS achieve savings: “The EU Directive makes treatment in Europe a more attractive option,” she says. “For those who are on NHS waiting lists and considering private treatment, having their operation in Europe means they benefit from prompt treatment and will be able to claim back their medical costs, although they will have to cover their own travel expenses.

“While refunds are limited to the cost of an NHS operation, medical costs in Europe can be up to 80% lower so it is possible for patients to receive treatment in a top-class private hospital for much less than it would cost the NHS. Therefore patients may also benefit from better quality care with more intensive rehabilitation and little or no risk of infection. Meanwhile the NHS benefits from cost savings and reduced waiting lists.”

To illustrate the difference in prices, a hip replacement which would cost the NHS £5,943 or £12,500 at a private hospital in the UK, would cost £3,970 at SurGal Clinic, one of the leading private hospitals in the Czech Republic.

One patient who chose to have an operation overseas after reading about the EU Directive is Lesley Catlin of London. She had a knee replacement at SurGal Clinic and has applied to the NHS for a refund. Lesley had been in pain for over a year when she was put on the NHS waiting list for a knee replacement and during that time had had physiotherapy and a arthroscopy procedure but to no avail.

She said: “Although I had been told that there were ‘no waiting lists’, I had had to wait for almost a year to see a consultant. I was in constant pain and unsure about how much longer I would have to wait. I had also been warned about the risk of infection and I was concerned about standards at the hospital I would have gone to.

“I saw an article in WeightWatchers magazine about operations abroad and the EU Directive and decided that this would be the best option. In the UK I would have been in hospital for four days, but at SurGal Clinic I was in for nine days and had twice-daily physiotherapy sessions after the operation, initially in the hospital and then in the hotel right up to the day of departure.”

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Cost of the Market in our NHS

We appear to be edging to a consensus that even with heroic “savings” our care system needs significantly more funding. In an era of austerity and tax resistance that is hard but has to be discussed. There are no magic solutions.

But sadly we have had yet another rounds of claims that £10bn pa could be saved if the market was removed from the NHS. Yet again the only basis for the claim is one line in a Health Committee report – in fact misquoting what was actually said. This has the kind of credibility attached to claims the Lansley Reforms have saved money or that we can eliminate errors and save £2.5bn.

The claim is that the introduction of the internal market increased NHS administration costs from 5% to 14% of total expenditure; so removing the market will save 9% or around £10b.

The source for the claims about 5% and 14% is the 4th Report of the Health Committee, Session 09/10 on Commissioning. The following extracts are from the report.

According to the official historian of the NHS, Dr Charles Webster, the service has traditionally scored highly on account of its low cost of administration, which until the 1980s amounted to about 5% of health-service expenditure.


An estimate of administrative costs made by a team at York University concluded that management and administration salary costs represent, as a very crude approximation, around 23% of NHS staff costs, and around 13.5% of overall NHS expenditure.

Ignoring the figures it is clear that the costs of management and administration in the NHS did rise significantly over the period from the 80’s to the 00’s. That this was due solely to the internal market is not based on anything at all.


Two things should immediately be pointed out. The quote about 5% is from an excellent book, A Political History of the NHS by Charles Webster, but the passage in the book does not itself have any references to where the 5% came from or what it actually contained. It is almost certain that in the era pre 1980 many tasks which might now be characterised as “administration” or “management” were only done as part of a wider job and so would not have been recorded in any way.

And the York University Report – NHS Management and Administration Staffing and Expenditure in a National and International Context, from March 2005, time and again sets out that comparison of costs between countries and between periods in our own NHS are beset with many issues around classification. So for example the 14% did not include any “estimate” of consultants and others time which might be classed as administration or management.


In fact the report actually put its estimate of administration and management costs on an internationally comparable basis at between 17% and 21% (not the 14% as is often used).

As the York report sets out:-

There are no agreed definitions of ‘administration’ and ‘management’ in health care between (and sometimes even within) countries’ health care systems. Substantial ambiguity exists around any comparisons, particularly as definitions shift as groups of workers are recategorised. Consequently, all cross-national and cross-sectoral figures must be viewed with extreme caution.

Even if we had reliable and comparable figures (and we don’t) then arguing the whole of any increase between the cost base in the 80’s and the costs base in 2003 (the base year for the York study) was due to the internal market and that this was wholly without any compensating gains is not justified.


In a paper which uses the same base information (the 5% and 14%) Colin Paton1 suggested that only half of the increase was due to the internal market – although he gave no rationale for the 50% figure.


None of the claims about £10bn set out what costs could be reduced. Reducing management and administration costs by £10bn would be a reduction of over 50% and these costs account for around 25% of NHS jobs (depending again on what is included). A 50% reduction equates to many tens of thousands of jobs.


So far as can be ascertained given all the definitional issues we can see that the NHS since the 70’s has changed dramatically in terms of the role and significance of “management”. The rise in the use of IT for collection and analysis of cost data occurred not because there was a market but because it was agreed that the health system needed to have some elements of management. We did not need to know how long the queues were when they were not managed and we did not collect outcomes or activity data and nobody would have used the results. Managererialism not marketization probably accounts for most of the rise in administration costs.


There is one recent study which might give us a better idea about what might actually be saved from removing the internal market. Information about the costs of various types of health systems has recently helpfully been provided by a study by Himmelstein et al2. This looks only at the costs of management and administration within larger hospitals across various countries with varying degrees of “market”. Of particular interest is that it treats Scotland and Wales separately from England in its analysis.


Like the York report it needs to be read with some care but to summarise; the highest costs per capita (after numerous adjustments) are in those systems with complex payment systems. Systems which have single payer and block funding have the lowest costs. Systems like ours in England are in between. For hospitals the best estimate for England is for administration and management to account for between 17% and 21% of total expenditure. (Spookily but coincidentally similar to the York finding of a decade ago.) The study suggest that a base level of around 12% is necessary for any system.


In comparisons of relative expenditure England comes out slightly higher than Wales but Scotland is significantly lower. The explanation though appears to be a technical one in that management of capital in Scotland is more centralised. In fact there is not a lot of difference between the three nations. What differences there are appear to be due to costs of administration not of management and to be due to numbers of people not wage levels.


In terms of quality the most recent comparison across the UK from the Nuffield Trust3 showed no great outcome differences between the various systems even though they had very different structures.


But there are cost differences between systems which can be seen mostly to do with the costs of information used to drive the payments systems, which in England is DRG and activity based plus a bit of block funding. If we went back to very simple single payer funding with no competition for funding, no “commissioning” and a centralised management structure looking after major issues, shared services and capital it appears that there could be savings of the order of 1% to 2% in hospital costs. (That assumes that much of the information used to drive payments systems will have to be used anyway.)


In England there are also commissioning costs and system management and regulation costs. Opinions vary about what we would have to do in terms of planning if there is no market and about how much system management and regulation would still be needed. But we could envisage savings from the £1.2bn spent by CCGs plus spending on CSUs, and much of the regulatory infrastructure. Maybe £2bn in all. But much of what is actually done within these bits of the NHS still has to be done somewhere. We do need to know how much various things cost and how variable outcomes are and we do need someone designing pathways and we do need some kind of oversight. That can be done in many ways.


Anyway nothing even at the wildest extremes of what might be possible gets to savings of even one quarter of the claimed £10bn. Still the mythical £10bn is so firmly entrenched the facts are unlikely to be of much use.


When the H&SC Act is repealed and the competitive market is removed then there will be scope for savings but not of the order of £10bn. Further savings could come from reducing the number of NHS organisations through consolidation, but merges and other transactions have a bad track record. We can only “guesstimate” but this might over time be of the order of 1 – 2% of total English NHS expenditure, but there would be considerable transition costs to be met and neither change would be easy and consolidation would be contested!

Richard Bourne, 23rd October, 2014.

1 Centre for Health and the Public Interest, At what cost? Paying the price for the market in the English NHS; Calum Paton

2 Health Affairs, 33, no.9 (2014):1586-1594. A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far; David U. Himmelstein, Miraya Jun, Reinhard Busse, Karine Chevreul, Alexander Geissler, Patrick Jeurissen, Sarah Thomson, Marie-Amelie Vinet and Steffie Woolhandler

3The four health systems of the UK: How do they compare? Professor Gwyn Bevan, Marina Karanikolos, Jo Exley, Ellen Nolte, Sheelah Connolly and Professor Nicholas Mays. The team was led by Professor Nicholas Mays of the London School of Hygiene and Tropical Medicine. Nuffield Trust, London, 2014.

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October 22, 2014

Employers welcome King’s Fund report about more consultant doctors in the community

NHS Employers has welcomed the King’s Fund report ‘Specialists in out-of-hospital settings: findings from six case studies’, published today

Gill Bellord, director of employment relations and reward at the NHS Employers organisation, said:

“This is a useful report and we agree that consultant doctors have the potential to provide more care in a community setting, where it is best for the patient. Employers and consultants have shown their support for innovation – and the job planning process, both at team and individual level, is a good way of discussing and agreeing new ways of delivering services to meet ever-changing patient needs.

“This is early days and the NHS will want to explore relevant demand from commissioners and how training would be re-shaped to make this happen. However, the systems behind how they work needs to be modernised and quality care delivered in a cost-efficient way. So more work will be needed to take this forward in a sustainable way.”

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October 21, 2014

Smoking rates continue to fall in the UK

The Office for National Statistics latest survey, the Integrated Household Survey, shows that the prevalence of smoking in the UK fell from 19.8% in 2012 to 18.7% in 2013.

The study which surveyed over 260,000 adults found that 16.5% of women smoked compared to 21.1% of men. Men were more likely to be current smokers than women across every age group. Smoking decreased in England, Scotland and Wales but remained the same in Northern Ireland. Scotland reported the highest overall smoking rate of 21.1% , and England the lowest of 18.4%.

Looking at the different regions of England the survey data showed a north-south divide with smoking prevalence in London, the South East and the South West being significantly lower than in the North East, the North West and Yorkshire and the Humber.

George Butterworth, tobacco policy manager at Cancer Research UK, welcomed the news of the falling rates but warned that smoking rates will not continue to fall unless the government safeguards NHS smoking cessation services, and protects children from tobacco industry marketing by introducing plain, standardised packaging of tobacco products without delay.

The ONS survey also collected information on perceived general health and found that across the UK, 75.9% of adults said that they were in good general health in 2013, a similar level to that in 2012. Current smokers were less likely to report good general health than those who had never smoked. Among adults aged 50-64 years who were current smokers, 56.7% considered themselves to be in good health compared to 75.9% if adults who had never smoked.

BMJ 2014; 349:g6113

Editorial comment. It will be interesting to see in future surveys the impact of electronic smoking on the prevalence rates. And how much further can smoking prevalence fall before reaching an irreducible minimum?  Paul Walker.


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