Thursday, 5 December 2013

Do markets improve healthcare?

Tim Worstall's UKIP-supporting blog is where I go to get a different angle on the news.  He didn't disappoint me with his spin on a Guardian story from which he quotes "More than 2,000 people have died of dehydration or malnutrition while in a care home or hospital in the last decade".  "Just shitty care" he concludes, "Wonder of the world."  Which is his stock sarcasm about the NHS.

My immediate reaction was that it's foolish to blame the NHS for this.  It's not the hospital's fault if a usually elderly patient is too weak to be saved when admitted with dehydration or malnutrition.  Nor is it the hospital's fault if a patient refuses to eat or drink.  And, while there have reports of patients becoming dehydrated or malnourished while in hospital, I doubt that accounts for more than a few of these two thousand cases, if only because the doctor completing the death certificate will usually rely on the medical problems detailed in the patient's hospital notes.  Hence this statistic tells one little or nothing about the quality of NHS care.

So what did the original story have to say?  The headline in the Guardian story is "Dehydration and malnutrition led to 2,162 deaths in care since 2003", wrongly suggesting that the deaths occurred in care homes, as most of them did not.  Worstall must have read past this, since he's blaming the NHS.  The body of the story is more careful about the statistic, but concerns itself entirely with care homes not hospitals.  And it links prominently to a story in the Telegraph.

Now, Worstall's usual choice of newspaper to link to is the Telegraph, so why has he chosen to use the Guardian for a story it's lifted from his favourite paper (and not even had a go at its misleading headline)?  Because, I suppose, the latter's story doesn't mention hospitals at all.  And Worstall wants to bash hospitals, which are mostly in the NHS, not care homes, which are mostly privately run.

The source of the numbers in both newspapers' stories is this spreadsheet published by the Office for National Statistics, "following an ad hoc request by the Sunday Telegraph".  (The spreadsheet notes that it does not distinguish between state and private provision of either care homes or hospitals.)  Only 14% of deaths in the last year "where either malnutrition or dehydration were mentioned on the death certificate" took place in care homes, but the newspapers are quite right to concentrate on the role of care homes because they are unambiguously responsible in a way that hospitals are not.

We should be cautious in assuming that poor care is likely to be involved in all these deaths.  There may be cases in which dehydration or malnutrition are unavoidable.  And it may something be better to keep a dying patient in familiar surroundings rather than dispatch them to hospital.  But assuming, to oblige Worstall, that the statistic is telling us that some care homes are providing "shitty care", then what?

Care homes in the UK are a mixture of private for-profit (72%), not-for-profit (14%), and local council or NHS provision (14%, numbers from here).  A meta-analysis in the BMJ has reported that "the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes".  And an unscientific online survey suggests that most (but not all) cases of alleged neglect which reach the press occur in the private sector.  So we can't just blame poor care on state provision.

Advocates of private provision of health care have achieved a massive shift from state to private provision of care homes in the last 30 years (page 13).  Even those sceptical, like me, about how well markets can work in healthcare provision can see potential for their application to care homes.  Relatives of a potential resident can visit several care homes, talk to the staff, see the residents, and smell the air - I've done it.  They can ask themselves whether they'd be content to live in the home if need be.  They can choose to pay more for better care too - while local authorities cover the basic cost for many residents, that's at a standard rate which one can choose to top up.  And if a care home proves unsatisfactory, you can move to a different one.  All this should allow market mechanisms to work better than they can in the choice of doctors or treatments, where the patient has no good way to compare competing providers.  So if in fact the care home market is not working - if care homes are killing their residents through neglect - then that calls into question the whole notion of markets in healthcare.

Let's find out whether care homes are doing an adequate job, and if not why markets are failing to work their magic, before we spend any more money and goodwill on introducing competition to the NHS.

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