Praising the National Health Scapegoat

August, 2008

Simcha Levia
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All over the world babies are babies, and birth is birth, but having a baby in Oxford is certainly quite a different experience than having a baby in California. The comparison is mostly favourable to Oxford, in our experience. The prime directive of the NHS (which recently celebrated its 60th anniversary) is borrowed from Douglas Adams: Don't Panic.

The NHS is a great success by any definition. When you factor in the constitutional niggardliness of the British taxpayers and Her Majesty's government -- leading the UK to spend per capita on healthcare substantially less than half what the US spends, and much less than any major industrialised country except Japan -- it seems a veritable miracle of efficient socialism. Whereas health research in the US is dominated by the profit motive, producing marginally improved drugs at breathtakingly higher prices*, the NHS has a brilliant record of pioneering cost-effective healthcare solutions, which may be individually trivial, even slightly absurd, but which together add up to systematic and measurable improvements in public health. (For example, this scheme to prevent complications due to chronic lung disease by providing patients with automated telephone warnings of impending cold snaps. Or something as simple as reducing infections by requiring doctors and nurses to wear short sleeves.)

The NHS has one major public-relations problem, which is the flip side of its advantages as a national system. It's hard to make headlines with the everyday marvels of saving lives and keeping people healthy, whose merit redounds to the individual doctors and hospitals; but the headlines represent every delayed or erroneous diagnosis, every botched operation, every iatrogenic infection, every neurologist who sets off a car bomb at a British airport, as a blot of shame on the vast monolith NHS. (Of course, the NHS also gets burdened with clearing up the mess left behind when private clinics botch elective plastic surgeries.) In a less centralised system, these would be isolated crises for individual hospitals and private practices. Of course, there is much disquiet when terminally ill patients are denied the latest hyper-expensive experimental drug, particularly for cancer. Indeed, it is hard to know what to say about these people who can point to a treatment found to have provided patients with a precious extra month or two of life on average, and is being freely provided in France and Scandinavia, but which the NHS has ruled insufficiently cost-effective. And there is no denying that the UK has relatively poor cancer survival rates. In the end, though, once you have decided to spend a finite amount of money on healthcare, spending on some treatments will mean excluding others, and will lead to heartbreaking instances where there is no plausible treatment available to patients with some conditions, such as advanced kidney cancer. Of course, the patients themselves have other priorities, and those of greater means will spend their own money on the forbidden treatment, undermining the principle of inequality that is the bedrock of the NHS. Recent attempts to rescue the principle, and block the slide into the dreaded "two-tiered" health system, with heavy-handed ideological rules that would bar patients who buy their own too-expensive drugs ("top-up") from receiving any of their other treatment free in the NHS have not helped the credibility of the system. At the same time, at least the agency responsible for making these cruel decisions --- with the Orwellian name "Nice", a pseudo-acronym for "National Institute for Health and Clinical Excellence" --- is subject to public oversight and control, works under transparent directives with no ulterior motives, and makes decisions that apply equitably to the whole country, more or less, regardless of wealth or status.

Ultimately, the NHS is the victim of the British penchant for whining about public services, without considering themselves responsible for making them better -- by, for instance, paying appropriate taxes. My somewhat uninformed impression is that UK politicians encourage this impression, blaming the doctors and NHS bureaucracy for its failures, both because it spares them some blame, and the duty to explain why higher taxes are needed to provide a continental level of health security. I remember listening to broadcasts of the 1994 US Senate debate over the Clinton healthcare plan, and being amazed that every senator prefaced his speech by reference to the US having "the best healthcare system in the world". (After that, they diverged, supporters emphasizing the need to make that excellent healthcare available to all, opponents warning of the dangers of tinkering with perfection.) No one seemed to feel any need to bolster this claim with actual comparisons to actual existing healthcare arrangements in actual other countries. But in the UK, with a healthcare system that is truly the envy of much of the world in many (though by no means all) respects, particularly as regards the achievement of true equal access, no one -- at least, no one I've seen quoted in the press -- seems to express pride in this national accomplishment. Together with a lingering thatcherite deification of the private sector, this generates some of the true disasters of UK healthcare, like the recent attempt to pare down the bloated waiting lists by sending patients to private clinics, without proper oversight, leading to stories like this and this. (For all the grumbling one hears about the NHS, the stories I have heard about the sheer incompetence and carelessness of private medicine are truly hair-raising. They are fast, but caveat emptor.)

My own family's experience with NHS has been modest, but positive. GP appointments seem to be generally available on the same day in urgent cases, or within a couple of days otherwise. We just had a wonderful birth (result above) supported by the NHS. There wasn't much for them to do, but they did what was needed. Births are presumed normal, unless proved otherwise, and the NHS has at least as a goal that all women should be able to choose where to give birth, whether at home or in hospital. Over all, home births should be cheaper than hospital births, not only because it reduces the investment in hospital maternity ward infrastructure -- certainly, the way American hospitals structure their bills, with enormous hourly room charges, it would be easy to demonstrate that home birth is cost-effective -- but it does require higher staffing levels, since there is more variability in the demands on staff when you have to send them out, and one midwife can't cover several women in adjacent rooms simultaneously in a pinch.

In the UK currently only about 2% of births are at home (I've been told the fraction is higher in Oxford, about 4%), but the NHS is committed to making the option available to all birthing mothers with uncomplicated pregnancies. At the same time, there does not seem to be any effort to encourage home birth in NHS, although the national assembly in Wales (where 3% of births were at home in 2006) set a goal of 10% home births. I found it interesting, when at 32 weeks our fetus was still in a breech orientation, that the midwife made no particular fuss about it, or warning that we need to consider hospital birth, recognising (correctly) that this problem would fix itself in all likelihood.

The GP came to our house 36 hours after the birth to do a second check of the baby's health. Not much fuss, and he mentioned that his own second child was also born at home. The cost of all this home service was, of course, nothing. To a beancounter this might seem like a waste of resources, making medical professionals travel around the city for housecalls . On the other hand, at least we didn't make him spend half an hour in our waiting room. From a larger economic perspective, there's more expensively educated brainpower being wasted when the two of us wait for the doctor than when the doctor comes to visit us, not to mention the midwives. But of course, that's not a fair analysis, nor should the services depend on the economic value of the patient/client. More important is that it's a good idea -- medically -- for mothers to get plenty of rest after the birth, and for the newborns to stay away from doctors' offices full of sick people. In the Netherlands, the health services send a maternity nurse around to new parents to do household chores. Is that a medical need? Well, not exactly, though it may encourage women to get the rest they need, preventing medical complications that would be far more expensive. I've been told that the reason US hospitals used to keep women in for a week after a normal birth was to protect them from household chores. Given the costs of hospital stays, it is surely more efficient to provide that help at home, where it will be more useful to the new parents, regardless of their personal household division of labour. The problem, as always, is to be honest about motives and outcomes. The US, I find, tends to be ideological rather than pragmatic, and thus depends heavily on linguistic subterfuge to smuggle in practical solutions. The Dutch can be ruthlessly pragmatic. The British are in between. I found it striking that it is the leader of the Conservative Party in the UK who has been advocating for a copy of the Dutch system, as well as a liberalisation of parental leave to recognise the possibility that fathers may also have a role in raising children. This confirms my impression that the largest parties in the UK have slipped their mooring on the political spectrum. The identification of the Tories as right-wing and Labour as left-wing is mostly

California Birthing

Back in Berkeley, with our first pregnancy and birth, it seemed that we were constantly having tests, screening for this or that, and the results of all these tests were frequently on the border of concern. So we kept having anxiety and conflicts with our midwife, who herself was under pressure from the hospital to make sure that protocols were followed, regardless of obstreperous pregnant statisticians who have their own opinion of the benefits of screening tests. They also don't like babies to be late; and "late" for them means more than 40 weeks after the date of the last menstrual period. It's a bizarre dogma. I wonder if it's largely a linguistic confusion, arising from the unfortunate choice of the term "due date". Anyone with medical training must know that babies are not "due" on a particular date in the way a library book is due, so that it is "late" when that day is past (though perhaps with a brief grace period). It is more like baking a loaf of bread, which you might expect to be done in 30 minutes, but you should check it after 25, and it might take 35 -- with the difference that you can't check it, but the bread will usually come out when it's ready. But it's hard to escape the power of a word. As long as it's called a due date, one can hardly escape the feeling that the later half of babies are "overdue", and that sounds suspiciously like a medical problem.

Even as a median the standard date is problematic. The source of this date is the early nineteenth-century German physician Friedrich Naegele determined that human gestation should last exactly 10 lunar months, which he identified with 280 days (Naegele was a gynaecologist, not an astronomer) minus 14 days to ovulation, so 266 days.  In fact, the average length of first pregnancies is currently about 274 days, and of later pregnancies is 267 days. (This is for white American women. In the UK, at least, white European mothers take about a week longer than black or Asian mothers.) In any case, the standard deviation is about 12 days, with normal distribution. The due date should really be called the average birth date, meaning that about half will be born before and half after. (Without interference, only about 4% of babies will be born right on the "due date".)

So anyway, our Oakland midwife wanted us to go to the hospital for twice-weekly fetal stress tests once the "due date" was past, though it never came to that, since she also performed a "stretch and sweep" right on the due date (which, based on ultrasound dating and the usual slightly longer gestation in first pregnancies, was actually perhaps two weeks before even the correct median date), without asking our approval, or indeed even telling us what she was doing. The procedure was probably responsible for triggering what turned into nearly 24 hours of only intermittently efficient contractions. Everyone was happy and healthy in the end, but we suspect that labour would have been a touch less stressful for all concerned if it had been left to start at its natural pace.

* “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, [Peter Pronovost] pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.   (From Atul Gawande, The New Yorker, Dec. 10 2007)

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