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Funding Public Health Care Provision

How to pay for good health.

Funding public health care, a world wide problem.

Only the most draconian dictatorships decide to not provide some sort of public health care, funded at least partly by the state.

Most nations in the world realise that they need healthy people if they are to prosper as a nation. There are some exceptions but this article is looking at the problems of funding in those nations that would like to provide health care for all.

Paying for health care, on a national scale, has several problems to overcome. The ever increasing reliance on the global pharmaceutical companies, with the attending fact that these companies control the prices paid for drugs, the normal market forces which bring down costs do not apply since each global big pharma business claims patentee rights on its products. The next major problem is the ever increasing size of the population. Until such a time when population reduction becomes a reality, the demand for public health care will go on increasing. A third factor is a little paradoxical, since the success of any public health programme lengthens the life expectancy of the people, it adds to the length of time each person potentially needs public health care. One other, a little less obvious issue, is how the health care provision is managed and organised. Management costs money, a lot of it. In a democratic state, the governments insist on some form of control over spending. This control mechanism is usually in the form of a bureaucracy, and these cost huge amounts unless the politicians are really very smart.

Looking at this last part of the problem first, there is a clear example. A published report on March 1, 2018: The NHS keeps claiming it needs more tax money to fulfil the needs of British citizens, and they are probably right, BUT a recent report showing, that in the last recorded year they increased the number of “senior managers” all on well over £65,000 a year by 7 percent while the numbers of nursing staff was reduced, makes it very hard to believe they are short of money. Any enterprise that recruited more managers while failing to satisfy their customers, would be out of business in a year. I know the NHS is not a commercial business but it users tax payers money and so has a duty to provide good value for that money. Note it is MORE managers, not replacing those who fail to deliver what is needed, but more.

This is not just a British problem, all states—well all non dictatorships; try to restrict the costs of corruption in the provision of sate enterprises. They try to do this while also trying to give the impression they are giving the electorate what is needed. So they appoint “officials” to oversee the plans the politicians have made. Over the years, political direction, especially political priorities change but the bureaucracy keeps on going, they get bigger and constantly obey the old “law,” that as the time exists so does the work to fill it. Most bureaucrats get paid and obtain status based on how many people and how big the budget, they are responsible for. This is why any bureaucracy is an organisation designed to keep expanding itself.

The British NHS needs a radical overhaul from very top. The political cabinet minster, the bureaucracy that is the department of health, the way NHS trust are organised and funded, the way these distribute money, the organisation of mega-sized impersonal and disconnected GP surgeries, right down to the cleaning staff and car park arrangements. Every part of the NHS need to be radically changed and improved. The number of senior and second level managers is far too high for an enterprise that does not intend to make profits. Since the hospital does not have to market its services it has no need for public relation or market linked activities, no need for press officers. The hospital service should aim to run within the budget it is allocated, it is up the the top managers to personally fight for the budget allocation they are told they need by the clinically qualified staff. Any and all managers who find it necessary to involve management consultants should lose their jobs and be replaced by the consultants. A serious independent examination of the data transference and communication is needed, but this must not be a bureaucratic exercise, this must be by industry experts. Organise a hospital as you would a lean and growing business. The senior managers must know the business, from the bottom up.

The whole system of governance needs to be enshrined in law, the ratio of medical to non-medical staff, the percentage of total funding, spent on management etc.,  and a fixed percent of GDP (as is the over seas aid budget) agreed, all enshrined in law and then politics should be taken out of it.

All round the planet, medical science, improved diets and a reduction in the mass casualties of global conflict have all increased the average life span of human beings. This increased life span is supported by increasingly complex and expensive medical care.

It is natural for people to want to live longer, it is natural for people to want to remain mentally and physically active while alive.

The unnatural way the majority of people now live, (unnatural compared to the historic way humans lived while evolving into the creatures we now are) means we both live longer and are simultaneously less physically fit and more prone to ill health. We are also now subjected to a vast array of pollutants that our bodies have not yet evolved to cope with. These range from electromagnetic waves to toxins in the atmosphere and the fantastic mixture of additives in our foods. Each separate additive is tested but no one can test the multitude of combinations most people now ingest.

The human body is still evolving but the rate of external change being imposed on that body, is faster then evolution can cope with. This leads to greater and greater reliance on medical and health care to keep us alive and active. The expanding population, combined with the factors of medical science getting more complex while being controlled by commercial companies, companies that exist to make profits and pay investors. (This is what these companies are set up to do and so this is what they should be doing. Pretending that they have a moral duty to do anything else is absurd.) These factors (increasing population, longer life spans, more complex health care, and commercialization of health care) are the largest reasons for the increasing costs.

What do we do about it?

Obvious first answer is decrease the population. Not a morally acceptable solution? So the best we can do is slow the rate of increase by education and persuading people to have fewer children.

Can we go down the route of artificially shortening the life span, that in some cases medical science has artificially lengthened? Again, morally unacceptable, but it is a solution that some, younger, people will consider.

Going back to an earlier statement, the ever increasing reliance on the global pharmaceutical companies, with the attending fact that these companies control the prices paid for drugs; the normal market forces which bring down costs do not apply since each global big pharma business claims patentee rights on its products. We have to consider the world wide moral and pragmatic considerations of the use and the ownership of medical science. Is it justifiable to consider taking all medical and health care aspects into “public” ownership? Nationalize—actually I guess internationalize the pharmaceutical industries, make all health care, delivery, research, production etc. state owned? Make the world health organization the owner, the supplier of all health care world wide? Would this work? Given the over bureaucratic nature of nationalized industries, given the political conflicts that would beset such an institution I think not. It would be a disaster eating up even more of the total money in the world and getting less and less results from it. The present system is very badly flawed and in great need of change but creating a world wide publicly owned monopoly, run by bureaucrats would be far worse.

One way to reduce the costs of health care is to reduce the need for it; this seems to have been the basis of the anti-smoking, anti-drinking, eat more healthy food, and similar campaigns run by the British government. They do not seem to have worked. The NHS is constantly claiming not enough money, drugs have to be “rationed” as too expensive etc.

Can we reduce the range of conditions we now define as “illness that need treatment?" Some of the “psychological” illnesses have only been defined as illness, relatively recently. Are they all actually diseases that respond to treatment?

In most countries, the initial starting point for an individuals need for state purchased medication, is the general medical practitioner, who makes a diagnosis and prescribes an existing pharmacological medication. This is where the costs start. Most general medical practitioners are incredibly dedicated to the welfare of their patients, but they are also over worked and over whelmed by the time spent dealing with the controlling bureaucracy. In order to ensure the doctor does not spend too much sate money the bureaucracy imposes controls that cost more than the doctor could possible “waste.” The result is the diagnosis and prescribing are rushed and have become dependent on information that originates with the big pharma companies. It also means that the follow up and outcome assessments are not carried out. As long as the patient does not come back, the treatment, however long it is for, is rated a success. The compliance, the actual taking of the medication at the correct time and with the correct diet etc., is left entirely to a patient, most of whom do not have any knowledge of what they are supposed to be doing.

One solution is more general practitioners to reduce the pressure to hurry and write the first prescription that comes to mind should result in far less waste due to wrong products being given to the patient. (A better way would be to reduce the controlling paper work.)

More follow up time should result in greater compliance by the patient and also better re-evaluation, the reducing of the number of medications needed.

The costs of medication is another huge factor to be reformed. Drug supply companies claim the large notional profit on some medication is caused by the cost of research and safely proving a new drug. May be this is an area where a state owned, but scientist run, enterprise should get involved. All testing of new medication to be carried out by the state owned enterprise, independent of the companies producing the medication. A huge amount of work will be needed to ensure it does not become yet another bureaucratic empire and to stop unscrupulous firms trying to influence the work.

The improvement in the quality of diagnosis and care, that the first medical practitioner contact provides, will have large cost implications; but earlier diagnosis, better monitoring, better re-evaluation of the initial diagnosis, will reduce the need and so the cost, of more expensive hospitalization service.

Doctor training should include re-evaluation and an ability to change the diagnosis. The dentists provide regular check-ups, even to non-paying patients on benefits. Doctors should do the same. Every patient has to have an annual check up and a proper check up, not five minuets telling lies about how much they drink or smoke.

Another area is the post hospital care of a patient.

In theory this is done by the general practitioner and if the GP services were improved, as described above, it could do this but the communication, the accuracy and the supply of data must be improved. How costly is it when notes go missing? Not just costly in wasted time, but in patient confidence and patient mental well-being.

There is an old truth called the 80-20 theory. This, applied to health care, suggests that 80 percent of the time and money is spent on 20 percent of the total potential patients. Make an effort to identify this 20 percent, take extra time to reduce their dependency on health care and the whole cost falls, and the patient satisfaction goes up.

Intertwining with these areas are the transport and administration of patients and the training of medical staff.

There is a case for forming an “emergency service” combining the ambulance service, the fire service, the road traffic divisions of the police forces and the major incident services of hospitals police and armed services. If this is to work, it must be organized and financed properly. Even in a relatively small land mass, such as Britain, there are far too many regional managers and far too few local public contact points. Local contact points could all report to one central computer managed (with triple back up systems) by genuine experts with wide experience. These should be staffed by local people who may be have retired from the health or emergency services. They can be small if well organized. Even in relatively small geographic areas, such as Britain and especially in much larger areas, such as the United States of America, there is a need to finance and use airborne movement systems, aircraft and helicopter systems. Unmanned to reduce costs and preferably, vertical take off and landing capabilities, so they could be used in urban areas. These could overcome the problems of distance and of traffic congestion. There are air abundances in operation but the future must be to enhance and improve the use of air transport. This costs money, money that could be “found” by better organization and deployment of assets. It could be found by the use of artificial intelligent systems to replace existing bureaucracies. Note replace not assist.

Training of doctors needs improving, Firstly the trainee must have an ability to converse with patients in the language of the country they are in. The trainee must have an assurance they will be employed when they graduate and they must be trained not just in drug administration but in diagnosis. Get the diagnosis right and the treatments can be looked up on the internet! Well a state run medical part of it anyway. The armed forces provide training for its medical specialists, not just medical training but training the person to cope with decision making while under great stress. How many armed service trained, medical, personal get to later work in senior positions of the public health care sector?

The important things in training a Medical doctor, are the ability to communicate with patients, the complete knowledge of anatomy and physiology, a good understanding of human psychology, and the ability to diagnose what is going wrong.

They must also be trained to always carry out outcome assessment, to recognize if things are not improving as they wish, to re-evaluate, and if needed, to change the diagnosis. Ego must take second place the the well- being of the patient.

Training should not be drug orientated, it should include diagnosis methods that may seen “unconventional,” but have been used in the folk medicine of some countries for hundreds or even thousands of years. Take out the training in the administration of drugs and widen the training in how to diagnose.

If the treatment can be accessed by looking up a computer, there does not seem a reason why an intelligent person can not do the basic training in three years (140 weeks each of five days) all spent in academic situation, they then do a five year apprenticeship with a GP practice, (may be more than one practice, spending a year or two with different practices would be best) then if all satisfactory, they become a fully qualified General Practitioner. For those who wish to become a surgeon the training should be extended after qualifying as a General Practitioner.

The specialist in direct medical support services, such as radiography and the specialised areas such as audio assessment, need not undergo the full eight years to be a general practitioner. There should not be a reason suitable applicants can not be trained in two years, the second year spent assisting a fully qualified person. The training should include the design, servicing and workings of the equipment they are to use. Continued professional development should include at least three weeks a year getting to know the latest equipment and future technologies from their field.

In health care, and in many other aspects of life, correct and early diagnosis of the developing problem is fundamental to the solution. In heath care vast amounts of money are wasted, many people die unnecessarily and public vexation is grown, because correct and early diagnosis is not achieved.

One way of reducing this waste and vexation will cost money but will ultimately save vast amounts more than it costs. Every person (regardless of age, gender, social group, race, or anything else) should have a full diagnostic medical check every year. I do not mean a patent telling lies to a survey about life style. I mean a full body MRI scan, a complete analysis of blood, urine and organ functions. I can hear the bureaucrats wailing about cost but the expenditure on such a service would save vast amounts down the line.

If such services became universal, the equipment would be designed to speed up the processes and costs would fall. Specialist centres only administering the check ups could be established. Every year, every person would go to the centre have all scans tests (hearing eyesight, cognitive responses etc.) and have samples of blood, urine, and anything else needed, taken. The results would be supplied via the registered general practitioner, if the person is registered or by a recall to the testing centre if not. It is not beyond engineering science to make mobile centres for visits to rural situations. There are already, in Britain, mobile X-Ray systems.

Compliance, of the patient with the treatment regime recommended by the doctor, would be improved if the diagnosis was accepted as accurate. At the present time everyone, including the medical practitioners, know that diagnosis is uncertain, so many prescriptions are offered to patients with words such as, try this, take this for a month then we will see, this may help, etc. The legal profession must accept the large part of responsibility for this vagueness in offering treatment. Any and every health care practitioner is now aware that they will be sued and bankrupted because they seek to offer reassurance to a patient, who may not even follow the advice given but will still go to ambulance chasing legal people if they do not make a rapid and full recovery.

The lawyers must be kept out of the health system, I do not mean a badly advised patient or one harmed by malpractice should not have redress, but the public health care provision must take genuine and proper responsibility for these things without recourse to external lawyers. The law can not cure sickness and has no part in a genuinely caring and proactive health care system. Admitting errors and correcting them should not involve damage to the career of a good practitioner nor in involvement of payment of fees to lawyers. Bad practitioners should be ejected from the profession by the professionals in it.

There was a situation in Britain where a person applied for and got a job as a manager on a salary of over £100,000 a year. Two years later it was discovered that the person was a fraudster, had no genuine qualifications or experience for the job and he was dismissed. Apart from the fact that they were appointed without anyone checking the credentials; the worst thing is that for two years, no one realised they should not be in this management position. The work they did was not questioned. Which implies anyone can walk in from the street and do the management job without previous experience and training. This is an indication of where money is wasted in public health care provision.

The whole system, in Britain at least and I suspect in other nations, needs reform. For far too long the top officials and the middle managing bureaucracy have been able to avoid scrutiny because it is politically unwise to be questioning a public health provision. It is far too easy to brief rival politicians and allow the suggestion that one or other political party wishes to stop proving publicly funded health care for all. I am not suggesting stopping public health care provision, I am saying it is in urgent need of reform.

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