I note that Atul Gawande (who is in general great, let me clarify where I’m coming from) published recently on two specific examples of a relatively unsuccessful health system, per dollar spent, versus a very successful health system, per dollar spent. The unsuccessful health system was the USA as a whole, and the successful health system was Costa Rica, a middle-income Central American country of five million people.
The reason this is interesting is that Costa Rica is not Singapore, it is not Switzerland, it is not a country that jumps out as having the general organisational talent that tends to translate to successful export-oriented industries, and the associated very healthy GDP per capita with resources to spend on healthcare. It would be completely unremarkable for one more newly-industrially-impressive country to have good health outcomes, and Prof Gawande is correct in underlining how important and interesting this is.
I am writing this post today to give some related perspective, on the difference between health care in the Republic of Ireland (non-NHS) and Northern Ireland (also technically not NHS, given that it is devolved, but on the health side, the HSC in Northern Ireland is pragmatically much the same as the NHS). My own context is that I am a GP who works in both, in Northern Ireland currently in Emergency Medicine.
In Ireland, and elsewhere in the English-speaking world, there is a lot of attention given to the NHS, and there are many voices in .ie that focus on how attractive the NHS is. I fully agree that where I work in the Republic vs. where I work in Northern Ireland, the NHS is more attractive to patients attending hospital, and usually to doctors and nurses, than is the situation in the Republic; but this isn’t the complete picture. A salient fact arguing in this question is that people the Republic live slightly longer in slightly better health that people in Northern Ireland.
Prof Gawande mentions this, but to clarify further: the more we learn about health on a population level, the cheaper the interventions get. Getting the population to not smoke is much cheaper than dealing with the myocardial infarctions and lung cancers that will arise in an appreciable proportion of those who smoke develop them.
Implementing the marketing and agricultural incentives to have people not be obese is much cheaper than paying for the knee replacements and the polypharmacy of dealing with type 2 diabetes, and the home supports to have meals delivered to people who can’t make it to the kitchen to cook because of their body mass index of 70 kg/m².
Vaccinations are cheap, cheap, cheap and very effective.
The most bang for the buck is in this sort of population-level intervention, and this would be even more true if you could amortise it across the population of the US (320 million!).
Unintuitively for most people, the next most effective intervention is likely an available, affable and able primary care physician, see Barbara Starfield’s work. Most people are terrible at judging the possible underlying severity of any symptom, and it turns out, if they can see a doctor soon and without fuss for almost anything, it seems to make them live longer.
And on this subject: statins and blood pressure control are cheaper (especially for the exchequer in our mixed system where many people pay for their drugs) than rehab for debilitating strokes or emergent stents for STEMIs. Cancers picked up earlier are easier treated than cancers picked up later. Type 2 diabetes avoided (or controlled by diet) is cheaper than complicated type 2 diabetes managed with amputation
Secondary care (the hospitals) comes next after primary care. The North and the Republic are reasonably comparable when it comes to public health. The North is a little bit worse on primary care; while there is not (in theory) a need to pay a GP, care is rationed by willingness to keep calling the phone line of the surgery. The incentive to do this is less in the Republic, where private patients are not going to pay without having had contact with a doctor. The two jurisdictions are much less comparable in secondary care, and this comes down to differing political will. In order of most pleasant to least pleasant interactions for patients:
Because you need to train in the public system, because that’s where the medical indemnity is cheaper, and because the public system is so stressful, the usual approach from the (many, the country trains far more doctors than it needs) Irish doctors is to emigrate to Australia after their intern year. This works out well for Australia (.ie offers a good medical education, they get good junior doctors basically for free) and well for the doctors (better weather, more money, better quality of life).
A huge thing I admire about the NHS is NICE, the National Institute for Clinical Excellence. They have spent the money to sit down, hash out, and come to a freely-available conclusion on many questions that twenty years ago would have required the input and the interaction from consultant, a specialist.
Both jurisdictions do the wrong thing in terms of how to direct resources for an individual patient. The German and Dutch model of regulated, private insurance, a »gesetzliche Krankenkasse« that you pay yourself and that is covered by the government once you are unemployed or retired is the correct model; it means that resources follow the sick patient, and the waiting lists that are the scourge of the Irish model (and, but less so, of the NHS model) don’t arise, because suddenly it makes more financial sense for an orthopaedic surgeon to do more hips or knees on Saturday or of an evening. There is less direct financial conflict of interest where the entity paying for the service is not responsible for choosing the standard of care provided, and this reduced financial conflict of interest is to the benefit of the patient.
My understanding (and I may be wrong) of why we haven’t adapted this correct model is that those who are willing to come here to work as managers to change things are mostly from the NHS (rather than the Netherlands or Germany (or, theoretically, Switzerland)). There’s an easy answer to that for the first few managers to implement things; pay more money. Five to ten years of it would do, if these managers are willing to train locals, this isn’t the brain-drained country of 1989, there are plenty of locals perfectly capable of picking up what to do and how to do it. And then you can drop back to the prevailing rate for the current civil servants.
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