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18th of October, 2021 POST·MERIDIEM 11:41

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:

  • Southerners and Northerners who interact with private hospitals in either jurisdiction, are completely happy with the private system. They are seen quickly, have their investigations and interventions quickly, the quality of the decision-making is excellent. The private hospitals are funded by non-obligatory health insurance ± fee-for-service, so the money follows the patient. There is indirect cross-subsidy in that those providing the service generally train in the public system and have long-term jobs there; their education is in general funded by the exchequer
  • Next comes the public system in Northern Ireland.
    This is funded to quite a high level per patient seen; the GDP per capita in Northern Ireland is substantially below England, but e.g. the ED locum doctor rates are much better. The will to address waiting lists for e.g knee replacements is also higher than in the south, so the waiting lists are shorter.
  • Then comes the public system in the south.
    In terms of patient experience and in terms of mental health for the doctors, this is a mess. Long waiting lists for anything non-life-threatening, doctors who have limited insight into your social circumstances (because they are not long off the plane from Sudan or Pakistan (interestingly the East European doctors subjectively tend to perform worse than the Commonwealth doctors, despite being fellow Europeans; it’s likely that the system is more similar in the former British Empire, and that makes the biggest difference)) when you do see them; the consultants (the doctor managers) are usually stressed beyond belief at the patient load they are carrying because the doctors making the decisions (comparable to residents in the US system, but with no guarantee of an attending (consultant) post at the end) tend to be, well, not all doing everything they can to get a good recommendation letter (which to be clear, would involve full-intensity caffeine-needed engagement at a level appropriate to someone with the local cultural background who got 625 points on the Leaving and a perfect score on the HPAT).

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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