kwlf wrote:
Where do you see waste within the NHS? I’m sure there is plenty… Just curious as to where you see it? I’ll give some examples later when I have time.
I’d imagine it is across the board. I’ll use a recent anecdote to give an impression.
A good friend of mine and her boyfriend recently (on the same day) quit their jobs working for a US healthcare-related mulitinational. They live together in London and both work from home. My friend took a job running the bids and tenders process for a specialist medical imaging company. Her boyfriend joined the NHS in some sort of ‘data science’ role.
The other day she sent me a text message. “We’ve now been in our new jobs for six weeks. Today I am doing my job – getting bids out to customers. Today he has fire safety training and a happy-clappy session where he discusses his experience of the pandemic with other new starters. Yet to start any real work.”
I was not surprised at all, and that’s the sort of thing I expect from the NHS.
Fuji_Abound wrote:
On the other hand, as I mentioned the per capita spend is relatively low. I believe for example Sweden spends 20 times as much as the UK.
I’m afraid that claim (20 times as much) does not pass a sniff test.
UK healthcare spending. in 2018 was £214.4bn, or £3,227 per capita.
For Sweden to spend 20 times as much would mean a per capita spend of £64,540, and with a population of 10.12 million a total healthcare spend of over £653 billion. Doesn’t sound very likely….it is more than Sweden’s GDP!
It turns out Sweden spent 52,200 SEK per capita in 2018. At 0.085 to GBP this is £4,420 per capita, or 1.4 times the UK spend. So not 20 ;-)
Outrageous claims of how much more other countries spend are very common in the ‘more money for the NHS’ arguments. Not only are they usually riddled with apples-to-apples issues, but they are often just plain false – and often so far out as to be ridiculous. The problem is, and I don’t target you here @Fuji_Abound, is that people just say these things and they sound authorative and so people repeat them without fact-checking (or even sanity-checking!)
Obviously I know nothing first-hand but the NHS is often criticised for using too many external management consultants.
And it is normal for these consultants to be of a highly variable quality. I’ve met many over the years and while some were good and offered good insights into how things can be improved, most could not run a fish and chips hut on the M25. It is too easy these days to pickup a “fake” MBA in [insert the current trendy topic e.g. risk management] 
I can now report that somebody I know has had CV19. Male, white, age mid 50s I guess. He wasn’t too ill at the time but got a bad long term one afterwards. I reckon the CAA will be after a few k’s worth of tests, starting with the radioactive thallium heart scan for ~1.5k, before he gets his Class 2 back…
Peter wrote:
I reckon the CAA will be after a few k’s worth of tests, starting with the radioactive thallium heart scan for ~1.5k, before he gets his Class 2 back…
Assuming he mentions it to an AME or the CAA?
Looking at the tests he has had, his GP will prob100 know. But, yeah, for a Class 2, your record doesn’t normally get examined. Would be a potential insurance issue though, and some recent CAA prosecutions showed somebody who got done for nondisclosure.
I don’t know how you would fairly compare the costs of healthcare in Sweden and the UK (Sweden has a higher cost of living and most healthcare costs consist of paying the salaries of healthcare workers) but on the face of it, even a 50% difference in funding is quite substantial.
The NHS fails in many respects. I don’t really see how things work at a management level so can’t comment on how many management consultants are involved.
As Malibuflyer mentions, procurement is one area where the NHS has underperformed. You would have thought that an organisation the size of the NHS would have huge purchasing power and the ability to rationalise procurement, but the NHS was redesigned so that various elements within it compete against one another. One hospital I once worked in got called out for selling its supplies of a drug that was in shortage, to hospitals in another country. Capitalism in action! Personally I don’t think it really works as a philosophy – you end up with the worst aspects of both systems.
IT is awful. Every hospital trust seems to develop its own systems, and they all underestimate the complexity of doing so and end up with products that simply don’t work very well, and certainly don’t work well together. Accessing results and images can be markedly slow.
Staff retention is poor. We are haemorrhaging nursing and medical staff. On the front line most people work a considerable amount of unpaid overtime, and within their constraints work as efficiently as they are able to. People cost a small fortune to train then leave with burnout or because of bullying.
The interface between healthcare and social care really needs to be sorted out. There is a huge overlap in what we do, but as the budgets are different we are operating in opposition rather than in harmony.
A lot of inefficiency is driven by regulatory and legal mechanisms. One of my sister’s friends is a physiotherapist. Her parents are Swiss so after training in the UK she moved to Switzerland and was astounded at how little paperwork she needed to write. Our physios prefix every entry with a comment that the patient ‘verbally consented’ to having physiotherapy. Patients who don’t know their own names have a specialist nurse sit down with them and write pages and pages about whether they have capacity to insist on going home rather than to a dementia care home. Again, Malibuflyer mentions theatre throughput within the NHS. The modern-day slowness of theatres is a perennial cause of grumbling in older staff who remember the good old days when you just cracked on with things. A lot of time is used in going through checklists. "If it wasn’t documented, it wasn’t done’. We do all these things for a reason, often a very good reason, but somewhere along the line people have lost a sense of proportion.
There are many faults within the system. That said, there are two types of waste in healthcare: one is doing something inefficiently. The other is choosing to do something unnecessary.
How many CT scans should a country perform?
The US performs about 330 per year per 1000 people
Finland performs about 70 per year per 1000 people
Britain is somewhere closer to Finland and Germany is somewhere in the middle.
Generally speaking I feel that we perform too many scans already. For example if a 90 year old with advanced dementia bumps their head, any CT performed is being done primarily for medicolegal reasons. Yet there are clear guidelines that such CTs should be done, and we do an awful lot of these. And CT scans are dangerous. I often wince when I order one, even when it is clearly indicated.
On the other hand, if a working person hurts their wrist and has a painful scaphoid bone, we usually put them in plaster for two weeks as it can be very hard to see scaphoid fractures on an X ray. It would be lovely to be able to do an immediate MRI and tell them that they don’t need a plaster (most don’t). However we are not resourced for this.
I don’t pretend to know the answer to the question of how many CT scans is optimal, but I think there is a great value in a system which allows a doctor (in conversation with the patient) to ask ‘what does the patient need?’. And that isn’t always the most expensive option.
Getting somewhat off topic from COVID…
Graham wrote:
Fuji_Abound wrote: On the other hand, as I mentioned the per capita spend is relatively low. I believe for example Sweden spends 20 times as much as the UK.I’m afraid that claim (20 times as much) does not pass a sniff test.
UK healthcare spending. in 2018 was £214.4bn, or £3,227 per capita.
For Sweden to spend 20 times as much would mean a per capita spend of £64,540, and with a population of 10.12 million a total healthcare spend of over £653 billion. Doesn’t sound very likely….it is more than Sweden’s GDP!
It turns out Sweden spent 52,200 SEK per capita in 2018. At 0.085 to GBP this is £4,420 per capita, or 1.4 times the UK spend. So not 20 ;-)
Outrageous claims of how much more other countries spend are very common in the ‘more money for the NHS’ arguments. Not only are they usually riddled with apples-to-apples issues, but they are often just plain false – and often so far out as to be ridiculous. The problem is, and I don’t target you here @Fuji_Abound, is that people just say these things and they sound authorative and so people repeat them without fact-checking (or even sanity-checking!)
Quite right, 20 is obvioulsy wrong and I didnt mean to type that, 2 times the UK was the number I had in mind which is less outrageous but enormously more!
kwlf wrote:
The modern-day slowness of theatres is a perennial cause of grumbling in older staff who remember the good old days when you just cracked on with things. A lot of time is used in going through checklists. "If it wasn’t documented, it wasn’t done’. We do all these things for a reason, often a very good reason, but somewhere along the line people have lost a sense of proportion.
Rumour has it that operating theatres got the checklist idea from airlines?
Anyway, I wish they’d been using one when my mother went in for a knee joint replacement. This was maybe 20 years ago. They cut her knee open, and then opened the kit of parts to discover that a piece they needed was missing…. so they stitched her up and apologised for unproductive and unnecessary general anasesthic and wounding. My father is not a litigious person, but there was a cast-iron claim for negligence there.
I agree that simply should not have happened. I suspect however that the missed instrument will have escaped several checklists, even back then.
The idea that checklists are new in medicine is, I feel, a little unfair. Anaesthetists have been using them for decades, and I presume they will have been a crossover from the aviation world. There are regular anaesthetic machine checks which are very reminiscent of the Check A and Check B, for example. Nurses have counted instruments out (to stop them being left inside patients) forever as well.
In general I feel that in general trying to make medicine more like aviation is a bad idea. People differ more than aircraft do, and as they get older and collect diseases, they start to differ physiologically even more from one another. Treating them all the same isn’t good medicine – for example I know of a proforma full of tickboxes designed for admitting patients with hip fractures. However it has no sensible place to describe any head injuries they may have suffered at the same time as falling down and breaking their hips. I think it’s very difficult to design documents that anticipate every eventuality, but in attempting to do so you tend to end up with monstrous pieces of paperwork that are dangerous both clinically and medicolegally because it’s impossible to find the important information there.
If you have a blank piece of paper you have the opportunity to write ‘Josephina Bloggs was headbutted in the hip by a sheep which then kicked her in the head. She lay on the ground in the cold for two hours before she was found by her granddaughter…’ Immediately you have a picture of what has happened and what you need to worry about. Josephina Bloggs was not in a nursing home, but was an active lady capable of going for a stroll in the hills and possibly still farming, given that sheep rarely attack people who aren’t farmers. She is probably a lot stronger than most patients who break their hips, but we need to worry about her head and her body temperature.
If you have a proforma you have a long list of boxes… When was the time of the fall? Did she feel dizzy before the fall? How many falls has she had in the past year? Did she hurt her left knee? Her right knee? Her left ankle? Her right ankle? Was she using a zimmer frame before the fall? Was she having chest pain before she fell? You’re so busy answering the questions they ask that you forget to ask the questions they didn’t think of asking, which included some more obvious ones such as whether the patient had injured their head or neck, which is pretty common, or how long they were lying on the ground, which is also important. You have to scribble in the margin ‘Jo Bloggs also suffered a head injury. Please see accompanying note. And if it’s a computerised proforma you can’t even do that.
“the 2x increase for people who get home delivered food seems more complex.”
Hypothesis:
People who are identified as contacts of a Covid-19 case are more likely to get infected than those who haven’t been in contact.
They are required to self-isolate, and therefore get home delivered food.
