On the Cost of Bespoking Health Care

[danieldwilliam]

I was listening to the Today programme and Andrew Lansley, the Health Secretary was being interviewed. He was talking about we needed to treat people using the NHS as people and not as part of a production process. Then I bumped into a comment about GP prescriptions on LJ. This got me thinking about GP’s and about cost of servicing.

When I go to my GP I’d love to have a half hour consultation that allowed my GP to fully explore the full range of potential health issues I faced and craft an individual regime for me which she would check in with me on in a month’s time.

What I can (or chose to) afford is a ten minute chat where I try to persuade my GP that I’m not trying to get her to prescribe antibiotics for a virus and then she tells me that there isn’t really much wrong with me that she can fix and I should eat better, exercise more and drink less.

I think it likely that in some cases the extra care and attention will allow significantly better diagnosis and / or better treatment with more patient involvement. I wonder if the additional cost of doing this for all cases would be worth it in better health outcomes or better wellness satisfaction outcomes.

I think you would have to have the additional consultation in all cases because there probably isn’t a way to tell in advance if a particular consultation is going to be involved or a more straightforward “Yes, you have a virus. No, there is nothing I can do for you. Go home, go to bed” type.

In some ways, as a citizen tax payer I want the NHS to work like a production line because production lines are an efficent and cheap way of dealing with identical things that need identical things done to them. In many case the improvement in clinical outcome is not worth the increased expense of bespoking the service. In many cases the difference in experiential outcome is not worth the increased expense.

I wouldn’t be happy to pay for a GP or a nurse to go and visit more or less able bodied people in their home to deliver a seasonal ‘flu jab when they could just form an orderly queue outside her office. The wrapper of emotional support that one can put round a patient presenting for a more or less routine cancer screening procedure might make the experience less intimidating but is this extra care and attention a good use of rationed resources? Arguably not.

So I’m left wondering how we make decisions about appropraite levels of bespoking.

Not for the first today I wonder if the accountant’s answer would be understandable or acceptable to the layman.

Comments

[f4f3.livejournal.com]

"Not for the first today I wonder if the accountant’s answer would be understandable or acceptable to the layman."

Is there any such thing as an accountant's answer? I think it's pretty harsh to suggest than an accountant would put forward a purely cost-based answer to any question. You certainly don't here.

I wonder if there really is a gap of understanding "the accountant's answer" except where it is proposed as THE answer. Most folk (and I include accountants in that) see the financial or economic answer as a full solution. It's an element of the solution, and can be a very useful one where resources are constrained. But even then, the choices will still be moral. I've come across a lot of vets who refused to accept that anything except their clinical judgement mattered in treatment decisions. I've known one who applied Stafford Beer's work on systems thinking to her surgery, and tripled the amount of clients who could be seen (she implemented that in a charity, and now is doing very well in private practice).
Where people get upset is when they think their answers are not been given proper weight - as to what "proper weight" is... Well that's a whole different question.

[f4f3.livejournal.com]

Hmm, that wasn't the user pic I was looking for...

[danieldwilliam.livejournal.com]

Yes - I see that.

[danieldwilliam.livejournal.com]

I think it may be around methodology and the presentation of the answer. The accountants’ answer is perhaps a subset of the scientists’ answer but with money.

I was thinking about a cartoon where economists were lampooned for putting a cash value on human life. Folk like to think that they think that human life is priceless but when you look at how much people are actually prepared to spend to avoid a death you very rapidly get a cash value and it's embarrassingly low in some cases.

My observation is that people appear to struggle when you play back what they have told you without any fuzziness. In another allied discussion I suggested that people are in fact happy to accept that GP’s using a production line approach to consultations will give 90% of the right result 90% of the time. I think confronted explicitely with the implication that they are paying for a service that gets by design, a significant amount of its output wrong people rebel.

I think the best example I can point to from my own experience is that for the cost of running three yearly breast cancer screening programmes for a subset of half the population we could run six monthly colesterol screening programmes for the whole population and save more lives by an order of magnitude but we don’t because cancer is scary and high colesterol is not.

Certainly I'm struggling with people understanding the accountants’ answer at work today even in a simplistic sense. A supposedly intelligent man charged with advising a panel of supposedly intelligent magistrates of our realm has just put in writing that he finds Net Present Value analysis too complicated.

[f4f3.livejournal.com]

That last paragraph is very scary. It goes along with the observation that putting Edinburgh councillors on the controlling body of a major transport infrastructure project was not the most productive of decisions.
I'm a bit flabbergasted by that 90% figure. So dropping one in 10 of the babies you treat on their head is fine? (That's not a random example - Motorola's six sigma course used it to highlight the difference between six sigma and five sigma levels of error).
Fuzziness is usually where the interesting stuff comes out, though.

[danieldwilliam.livejournal.com]

The 90% of cases to a 90% perfection figure isn't real - it's a made up for an example figure. The real figure could be 99% of 99% but still leaves some most cases imperfectly dealt with and some cases badly dealt with.

The last paragraph has a) got me striding round my office shouting "Fuck!" and "Jesus Wept" a lot, b) pretty much made up my mind that I need to be slowly edging my way out of this organisation.

I think having councillors on the board is not crazy. They just need to be prepared to admit they don't understand the numbers (if that be the case) and ask for help or be prepared to explain the numbers to their constituents.

Current issues in the wonderful world of accounting for politicians, civil servants and other special needs cases is the concept of "assumptions" and the resulting "outputs".