I would agree with some of what Keith has to say about the problems of our state medical systems, but I am dubious about many of his proposed remedies. By the way, I was diagnosed with prostate cancer a little over a month ago, and so I will be following the trail he has blazed once Cancer Care Ontario sets up radiation treatments for me. Detailed comments below. Victor Milne ----- Original Message ----- From: "Keith Hudson" <[EMAIL PROTECTED]> To: "Ed Weick" <[EMAIL PROTECTED]> Cc: "Brad McCormick, Ed.D." <[EMAIL PROTECTED]>; "Timework Web" <[EMAIL PROTECTED]>; "futurework" <[EMAIL PROTECTED]> Sent: Sunday, July 01, 2001 3:51 AM Subject: An X-Ray example (was Re: Shorter reply (was Re: Scotosis (a long story) ) ) [snip] > This treatment is being carried out on the NHS (National Health Service) > that is, free. (As a brief aside, it is useful to remind ourselves that the > NHS, was instituted by the Attlee's Labour Government in 1945, immediately > after the war, and was negotiated with great difficulty against the fierce > resistance of the medical profession by one of our greatest politicians, > Nye Bevan. In order to bring the NHS about, Bevan had to compromise on many > matters, particularly on the matter on the recruitment and credentialism of > doctors and consultants, the restrictive practices of which were retained > [even to this day] by the various medical professional bodies and colleges > -- or, in other words, their trade unions. Agreed about the problems caused by doctors' trade unions. > > (I will continue the aside a little longer by saying that it is also > apposite to say that the NHS was founded on a fallacy. This is, that once > the huge investment [and it *was* huge for those days] was out of the way, > and the NHS was working normally, then annual expenditures would gradually > decline over a period of a decade or so to a low standing level because > everybody, particularly the working class, was restored to full health and > did not need much more by way of medical treatment. This notion now seems > ridiculous to us but it was universally believed then. I think the problem here is that ever since the 19th century western medicine has worked with the magic bullet model. You let the disease make an appearance and then shoot it with the magic bullet appropriate for that particular disease. This of course does not produce a healthy population but simply ever-increasing medical costs. I think the idea currently promoted but hardly put into effect of preventive medicine would work much better. That is things like better diet, better nutrition for poor children, preventive dentistry for children, improved environment--the Ontario Medical Association estimates that smog in Ontario costs the health care system one billion dollars annually or about 5% of its budget--better public health procedures, like getting rid of the neonservative idiots in our province who thought they could cut away all safeguards for drinking water and thereby made possible an E. coli epidemic killing seven people and making 2500 very sick, many of them left with lifelong health complications. (BTW, of personal interest, you may know now, Keith, that an Oriental diet--largely vegetarian, lots of soy, very little red meat--is thought to be strongly preventive of prostate cancer and is recommended for patients even after the disease is diagnosed.) >We now know that > treatments for an ever expanding list of disease and handicap is growing > far faster than can be afforded. How medical treatment is rationed from now > onwards is becoming a very serious issue, particularly in the modern > political climate when everybody thinks they have a "right" to the latest > and best possible treatment for their particular complaint, no matter how > expensive this may be.) I'm not sure that the problem is people expecting to receive the best medical treatment. I think it's mostly caused by doctors misapplying high tech stuff because it's there and because our society has not worked out the ethics of treating the terminally ill. This needs some elaboration. Some weeks ago I heard a shocking statistic. A professor of actuarial science from the University of Western Ontario was interviewed on CBC; he had apparently been on some committee looking at the costs of health care. He asserted that 45% of our health care resources were spent on the last three weeks of life. I do not think the patients want this. Unfortunately, this Professor Brown, as you might expect from an actuary, suggested that maybe medical treatment should be rationed out to those who might be restored to productive [i.e., tax-paying] work. Crap, I say. The issue is quality of life, whether the person is productive in an economic sense or not. Nothing wrong with restoring some kids' beloved retired grandma to another five years of grandmotherhood! I repeat, however, that I don't think that very many people want to be resuscitated at great expense to the public just so that they can spend a few more painful days in a hospital. I mentioned this statistic to my family doctor, and I told him, "Look, I don't want to be kept alive just in the sense of vital signs displayed on the monitors in an ICU. If you are attending me at the end, here is the test I want you to apply: Will the treatment fix me up so that I can go home again, able to communicate with my family, to read a book and to enjoy the company of my dogs? If not, don't bother." [snip] > > Now all these preliminary procedures from the start of my initial interview > with my local doctor to establishing the conditions of treatment took five > months! This involved something like 12 different consultations backwards > and forwards between here (Bath) and there (Bristol -- 20 miles away) with > at least five different doctors. Now I know that had an advanced cancer > been suspected from the beginning and not at an early stage, as mine is, I > would have had emergency treatment (probably an operation), and it doesn't > really matter in my case, medically, that this stage was so prolonged. But > the point is that all this so far has been incredibly inefficient and > costly. If I were an ordinary working person on a hourly rate of pay, these > procedures at the convenience of the consultants/NHS would have taken at > least 5/7 working days -- costing me about (if I were a bricklayer, say) > US$1,000. But the opportunity cost to the NHS (and to me as a tax-payer) of > the repeated leisurely consultations (each one taking a fortnight to set > up, etc) and so forth must be at least US$5,000. It's not clear to me why you think that the leisurely pace of setting up the consultations increases the cost to the public health system. In Canada the view is that the slow pace of medical treatments is caused by the health care system being understaffed as a result of cuts by neoconservative politicians. > > So now to the actual treatment at Bath Hospital. Fortunately, I live fairly > close by and it takes about 30 minutes to get there. Although the treatment > only takes about 10 minutes every day, if I lived much further out (as most > cancer patients do) this would probably cost me half a day's pay each time > (again, if I were a hourly-paid working man). I am an ordinary working person on an hourly wage with no sick leave whatsoever from my generous employer who enthusiastically supports the neoconservative bastards running the Province of Ontario. I think sick leave should be mandatory, but I don't blame that on the health care system, and I accept the fact that until we have a much better government, oriented towards the needs of the ordinary working class person rather than the acquisitiveness of big biz types, it will cost me money in lost wages to see the doctor or have any medical treatment. When I get to radiation treatment, it will be about seven full weeks, just 15 minutes a day five days a week. The nearest center would be Toronto about 120 km from my home. If they can schedule me at the end of their working day, say 5:00 pm, I might be able to work 6 or even 7 hours of my shift as I finish early at 3:30. If, however, they tell me, it's going to be, say, 10:15 AM, and no other time is available, I must reconcile myself to losing seven weeks pay. Losing money out of a tight budget is better than the alternative of an early death. >My treatment consist of > lying on a bench and am shot at with radiation from three different > directions for about one minute each time. My exact position on the bench > and all the other physical parameters of the apparatus are set by the two > radiographers who attend me. (For safety [and legal] reasons, there have to > be two. One speaks out the precise instructions laid down by the Physics > Department, the other sets the position of the apparatus each time and > responds to the other radiographer by repeating the conditions -- exactly > the same as pilot and co-pilot do on a big airplane.) Even though the > radiographers are intelligent and fully qualified people, the procedures > they follow are standardised, and really could be carried out by any > reliable individual of ordinary intelligence. (The point to make here is > that, overall, there is a 40% shortage of qualified radiographers in > England -- because of excessive credentialism and protective practices.) Hey, where my health, or maybe my life, is involved, I like to see failsafe procedures. You seem to be saying that without government enforcement of standards, private enterprise would give us equally good health care. I think not. I work in private industry, building natural gas fireplaces, and we have a pretty good quality assurance program. I work in the department that assembles and tests the burners before they go to the line to be built into the shell. You will be relieved to know that we would never, never pass a unit with the slighest gas leak. However, over on the line some problems of fitting get solved with a hammer, and we've had units returned because of a lousy paint job, etc. All very well for an industrial product, but you can't return your body for a replacement unit if someone has screwed up the medical work. I think we don't have enough qualified radiologists because governments are not willing to fund the training programs so that young people can learn the trade at a reasonable cost and then to fund the requisite number of positions. I think in the past credentialism has been a problem among doctors here in Canada--limiting enrollments at medical schools so that the health care pie does not have to be cut up into too many small pieces. We are now hearing that we don't have enough doctors. We have two problems. The Medical Association appears to be too restrictive about certifying foreign-trained doctors and our neo-conservative government has been jacking up the tuition fees for all post-secondary students, but most especially for doctors, who they figure will be able to pay back big student loans, and it's now as high as CDN $14,000 a year, which certainly discourages many potential students. > I'm informed that this piece of X-Ray apparatus cost well above US$2 > million. It is used from 8.00am to 3.00pm for five days a week. The point > to make here is that if this treatment were done by private sub-contractors > (and if they were given a free hand in the recruitment of non-qualified > radiographers for this rather pedestrian stage of the treatment), then such > an expensive apparatus would be used for at least two daytime shifts -- > morning and afternoon, say, from 8.00am to 10.00pm -- just as an > engineering firm would do with an expensive machine tool. Agreed that this machine should be used for far longer hours. Not agreed that unqualified radiologists should be operating it. Why do you think that the longer hours could not happen with a public health system? Hospitals, which are public institutions in most civilized countries, operate around the clock. Until recently our electricity in Ontario was generated by a publicly owned institution, which certainly kept people working round the clock. Electricity has recently been privatized in Ontario, and even though I am entering the latter part of my life, I suspect that I will live long enough to see the populace adding that to the long list of things that these neoconservative thugs (aka Harris Tories) have done to us. > > I spent 20 years in the engineering industry and am reasonably acquainted > with the costs and maintenance of machine tools and other sophisticated > equipment, having had responsibility for at least US$200m of such, I guess. > I would say that if the X-Ray apparatus were to be made in larger numbers > for private sub-contractors instead of the NHS alone then the cost could be > reduced to that of a luxury car -- probably about $200,000 at the very > most. (Also, at the present time, because of the small demand, the > manufacturers of the apparatus are probably in a monopolistic situation and > they are probably vastly overcharging the NHS.) Your argument for privatization ignores the famous economy of scale. Public systems have the clout to demand lower prices from the suppliers. The Province of Ontario still buys a lot of drugs (in spite of the neocons) for use in hospitals and also for senior citizens whose drugs are paid for (the neocons are trying to end that) and I have repeatedly read that because of its mass purchases Ontario can shake down the drug companies to a much lower price than most American purchasers. Your NHS has probably been very sloppy and inefficient and don't-give-a-damn about price, but if they got hard-nosed and shopped around for a big order of 200 radiation machines, they would probably get a much better price than some private subcontractor looking to buy one. My experience with private enterprise is that they are often quite willing to pay an outrageous price for their tools and supplies as long as they can pass it on to their customers, and if their customer is a government department like your NHS, you can bet they will charge an arm and a leg. There's a fascinating economics study from the 1980's, "Profits Without Production" by Seymour Melman, which looks at the outrageous costs generated by private enterprise hanging onto the government teat, in this case, the US defence industry which resulted in a famously expensive $600 toilet seat in an aircraft and $90 apiece snap-on socket tools, to name only a few amusing examples among tens of thousands. > > I understand that my daily X-Ray treatment is costed out by the NHS at > something like US$250. If, say, there were two or three sub-contractors in > Bath competing with one another, and if they were allowed to recruit > intelligent, but somewhat less qualified, radiographers, I have no doubt at > all that the cost of daily treatment could be brought down to US$50. > Whether this were paid by the NHS or by individuals as a private fee is > beside the point. Also, anybody who has lost wages by attending between > 8.00am and 3.00pm as at present could attend an evening session and lose no > pay. Competition, one of the sacred words of the private enterprisers, is very ambiguous. It's used to suggest to the public that private companies competing for your business will lower their prices to win you over. On the business pages of the newspaper, "competition" is used in a very different, in fact, contrary sense. Aetna, the largest health insurance company in the USA, recently announced that it was "reinventing itself" as a "much more competive" company. And how was it doing this? Why, by RAISING the rates on all its policies and laying off many workers. You're getting old, Keith, like me. I know when I hear "competitive" in a business context, my first thought is lower prices for the consumer, but that is not the way the Yuppie and post-yuppie generations use it. They mostly mean increasing shareholder dividends and thereby boosting the price of the shares on the stock exchange, which is fundamentally incompatible with lower consumer prices. > > So that's my example from my limited experience of the NHS. I have little > doubt whatsoever that the total cost of the NHS, due to inefficiency, and > being mainly labour-intensive, is probably two or three times more than it > needs to be. I have chosen "two or three" times not only based upon my > limited experience in the NHS as described above but also from what is > clear from the privatisation of many state industries in the last 20 years > in the UK -- and also from improvements in efficiencies within private > industry (such as I experienced in engineering) -- where the cost of white > collar overheads, after successive redundancies, are typically reduced to > 33% of the previous. I wouldn't go so far as to say there are never excessive white collar overheads and redundancies. In fact, I think there are often white collar overheads in both private industry and government departments; it's called empire-building, and it's indulged in by many people who get a little taste of power: having more underlings shows how important you are. Nevertheless, I think that often the reforms cut into the bone rather than trimming the fat, or to be more gloomy, they leave most of the fat while cutting off a goodly chunk of bone. I mentioned the E. coli water contamination in Walkerton, Ontario, apparently caused in part by cuts at the Ministry of the Environment; I can't prove this, but I strongly suspect that Assistant Deputy Ministers, told by the government to cut costs, came up with plans cutting out front-line inspectors rather than reducing the size of their administrative staff, and that was fine with our government as long as costs were cut. Anyway, since the era of cost-cutting began, service from both public institutions and private companies really sucks compared to what it once was. You spend hours on hold; you waste hours wading through automated telephone menus trying to figure out which option applies to your case, when a live human being could have told you in five seconds who you needed to talk to and connected you. I think you, Keith, are unintentionally playing fast-and-loose with two different and incompatible measures of efficiency. You were talking about cost-cutting, and then make the leap of supposing that it will result in provision of better service. I disagree: I repeat as the notion of cost-cutting has spread, service has worsened in virtually every sector of society. > > It's also apposite to mention that prostate cancer kills about 20,000 males > every year in the UK. However, the NHS has made no attempt to publicise > mass screening of prostate cancer among males (as they have done under > pressure for breast cancer for females) even though early diagnosis > produces a 95% cure rate. The NHS could not do so for cost reasons. If we > had an efficient and competitive screening and treatment scenario (and > sufficient publicity/advertising) then, probably, at least 15,000 lives > could be saved every year (or, more correctly, death postponed!). Same thing here in Canada. Decades of publicity about breast cancer (and rightly so) and only in this past decade have we begun to see much info about prostate cancer. Maybe that is the fault of us males, trying to be macho, strong and silent, being embarrassed to talk about the reproductive system and the possible post-treatment problems of a limp dick and leaky waterworks. Anyway the result has been that mammograms and other diagnostic procedures for breast cancer are fully covered, but I paid $20.00 for every simple PSA test and $40.00 for the PSA ratio test: I'd had two of each by the time my second biopsy finally found the tumour. As my urologist cheerfully told me, prostate biopsies are much like drilling for oil: you don't always find it on the first attempt. You say the NHS could not promote mass screening of prostate cancer for cost reasons. However, you surely mean that the NHS is being "penny-wise and pound-foolish" as my grandmother liked to say. It must in the long run cost them far more to treat all those cases of terminal prostate cancer than to screen for and treat early prostate cancer. And why are governments being penny-wise and pound-foolish about this and so many other matters. My answer would be the constant pressure from that class of people that Maggie Thatcher represented so well, those influential and well-to-do people who are forever whining about how excessively high their taxes are. You'd really think the poor dears can't even afford to patch up the rust spots on their Porsches. > > And now, needing to take my dog for a walk and have breakfast, I'm going to > delete your original message from this and reply to it separately, > hopefully later today. Well, I've spent far too long on this response. I'm going to have a (vegetarian) lunch and take my two dogs for a walk, now that the high grass in the abandoned fields behind us has had a chance to dry off, and then I'll get back to what I should have been doing on this holiday weekend, website design for a client I do a bit of freelance work for. Victor Milne
