Tag: Taxes

Great Expectations: The Cost of Misunderstanding the NHS

The NHS has a big problem. I’m not talking about questionable financial management, the dangers of excessive entanglement with the private sector, or even superbugs on the wards. The biggest problem I see in the NHS today is a chronic lack of understanding on the part of the public. The very group of people it was set up to assist is contributing to its downfall.

Sitting in a waiting-room in a hospital department recently, I couldn’t help but overhear some of the comments made by other patients. One gentleman, perusing the reading material set out by the water cooler, complained that the magazines available were old issues. Another voiced the opinion that the department’s nurses didn’t ‘look professional enough’. Yet another, upon hearing that she would be seen by a locum doctor as her usual clinician had been called away on an emergency, demanded to know why she should bother turning up for her appointment if her doctor didn’t.

Expensive uniforms. Robotic medical professionals. Magazine subscriptions. Such are the expectations of a service set up first and foremost to provide decent and affordable healthcare for all who need it. Of what possible relevance would the latest issue of Heat be to your health? How could the last-minute substitution of one doctor for another equally well-qualified one be less convenient than having your appointment cancelled? And why on earth would you think that spitefully missing your appointment would be hurting anyone but yourself?

It’s on this last point that I would like to concentrate – because, actually, you aren’t only hurting yourself. Each missed appointment has a knock-on effect on patients, doctors, and hospital services. Allow me to take you through the process.

Imagine you have an ongoing health problem of some kind. Let’s say it’s a skin condition. It flares up like eczema, but the usual creams and ointments don’t seem to have any effect. You’re scratching your elbows down to the bone and climbing the walls in frustration, so your GP refers you to Dermatology. You are sent an appointment letter from your chosen hospital, asking you to attend on a certain date.

At this point, the following people are already involved in your care:

  • Your GP, who referred you
  • A Consultant Dermatologist, who checked over your referral letter to assess whether you had been referred to the correct department
  • A secretary, who scheduled your appointment, created the letter and sent it to you

These people are paid to work in the NHS. The NHS is paid for through taxes. Taxes are paid by you.

Let’s continue.

So now the wheels have been set in motion. You have your appointment date, but – glory be! – your inflamed skin has miraculously cleared, and you see no need to attend your appointment. Fair enough. It’s your health, it’s your decision. At this point, according to the information detailed in your hospital appointment letter, you contact the Dermatology department to let them know that you no longer need the appointment. They now have an empty slot in that day’s schedule, which they fill by offering it to another patient who needs it, which helps to cut down their waiting-list.

Only… you don’t contact Dermatology. It’s only the NHS, after all – it isn’t like a private medical clinic, or even the dentist, who would charge you if you didn’t give at least twenty-four hours’ notice of cancellation. The NHS doesn’t charge anyone, because it doesn’t actually cost anything.

Before we debate the ridiculousness of that viewpoint, let’s return to our scenario.

We now have two conflicting realities: one, in which you have decided you won’t be attending your appointment, but haven’t let the hospital know this; and two, in which the hospital has arranged for a highly-trained specialist in skin complaints to review you and offer their expert medical opinion in order to help you.

The day of your appointment arrives. Over in the Dermatology department, the receptionist has created a file for you in anticipation of it being filled with notes about your condition. Down the hall, a trained medical professional is waiting in his (or her) office to help you, not knowing that you won’t be turning up. He can’t just call in the next patient, because perhaps you’re running a few minutes late. Perhaps he could use the time to answer some of the many written queries that arrive from GPs and patients every day, but again, he can’t really get stuck into anything, because you might be about to walk through that door.

Any minute, now.

Had you attended your appointment as planned, the clinician would have then dictated a letter to your GP, which would then be typed by the departmental secretary and sent out. Your lack of attendance doesn’t mean that this doesn’t happen. The clinician still dictates a letter to let your GP know that you didn’t attend, and the secretary still types it and sends it. This is part of what is called continuity of care. Communication keeps everyone informed.

Let’s just remind ourselves how many people are currently involved because you asked for help:

  1. Your GP
  2. One secretary
  3. One receptionist
  4. One Consultant Dermatologist

And now for some very rough numbers (because I’m no statistician) – please take the following as averages:

  • A GP earns around £100,000pa (call it £50/hr) – 15 minutes spent seeing a patient and making the referral therefore costs around £12.50
  • An NHS secretary earns £23,500pa (call it £12/hr) – 20 minutes spent typing a couple of letters, scheduling an appointment, and printing and sending said letters costs £4 (not counting the cost of stationery and postage)
  • An NHS receptionist earns £16,500pa (call it £8.50/hr) – 10 minutes making up a file costs around £1.50
  • A consultant earns around £100,000pa – the initial consultation (or, in our scenario, the vacant slot intended for it), plus time to dictate a letter and make any necessary onward referrals within the hospital network, takes about one hour (often longer, in fact) of their time, at a cost of £50.

That’s £68 wasted, according to this rather conservative estimate of time and money spent. That doesn’t include all those little extras like postage, stationery, electricity. I guess if we wanted to include those we could round this figure up to £70. So that’s £70 of public money – your money – down the tubes every single time a patient does not attend an appointment and doesn’t let the hospital know. Taking into account NHS England’s recent estimate that 6.9 million hospital appointments are missed every year in the UK, that’s a sizeable chunk of public money gone for no good reason.

If we, the public, thought of the NHS as a “real” business, rather than a fantasy world where doctors and nurses toil merrily all day and night for free just for the warm fuzzy feeling of knowing that they’re doing good, we’d more easily be able to compare costs and make the right decision – to spend a few minutes and less than 50p cancelling an appointment by phone, or to waste £70 and a good couple of man-hours by not doing so. It’s a financial no-brainer.

And yet the status quo persists, the NHS continues to haemorrhage money, and many people continue to complain about the services. But is it any wonder some of the waiting-lists are so long if patients habitually miss their appointments and fail to give any notice that a slot has become available? And is it any wonder that so many departments are grossly overspending, given the amount of money wasted on empty appointment slots, rescheduling, and extra letters?

I think so many people miss their appointments because they take the NHS for granted. They see it as a free service that they can take or leave. The money that funds it is taken out of our wages straight off – we never see that money so we don’t see it as a loss when it’s inefficiently spent. It isn’t perceived as being the same as missing a private appointment, where you’re charged for it if you don’t cancel in time and the money comes straight from your own pocket. But it is, in a very real, if less direct, sense, money taken out of your pocket and tipped down the drain. And in the case of missed appointments, it’s a very preventable waste of money.

We take the NHS for granted because we don’t think about how it works. We don’t understand it and we only talk about it when it disappoints us. We make demands of it as if it has limitless funds; we complain about the money being wasted, yet we refuse to acknowledge our part in that wastage. This is our own money we’re throwing away! These doctors and admin staff are here to help you, but they can’t help you if you don’t turn up and they certainly don’t deserve your vitriol when the service you receive is inevitably less than perfect. We need to meet the NHS halfway for it to work efficiently and cost-effectively. We have a responsibility for our own health and a responsibility for our public services. It’s time for each and every one of us to recognise our part in it.

Voters Reject Prop 29 for Good Reason

50.8% of California voters have decided against Prop 29, which would have raised the tax on a pack of cigarettes in the state by a $1. The vote was close, but in anti-smoker California this signifies a sea change in public opinion: People are beginning to realize that regressive taxation against a minority is wrong. Skeptics rightfully charge that this money would not have gone towards cancer research for smokers by rightfully pointing to the fiscal track record that tobacco control has already left for us to examine. The truth is that the money extorted from smokers has never gone towards cancer research (for smokers), nor has it ever gone towards the research of reduced risk tobacco products. Lung cancer continues to be amongst the deadliest of cancers, not because its trajectory is so much more deleterious in its nature as compared to that of other forms of cancer, but for lack of funds in eradicating the disease due largely to prejudice. Of all cancers, lung cancer receives the least amount of federal funding in the United States, even though smokers are singled out with the highest rates of taxation. Cigarettes are the highest taxed commodity in the United States. Furthermore, smokers pay more into the system than the cost of smoking related diseases, but are denied funding for the very research that we continue to pay for many times over.

This trickery and embezzlement in the name of public health has been propelled upon the unwilling with a swift and unwavering force ever since 1998 when the Master Settlement was called into action. The Master Settlement Agreement was supposed to have been enacted for the purpose of covering the Medicaid costs of treating smokers. Instead what we have witnessed has been the outright theft perpetrated against a group that has been unable to defend itself. For example, many government officials and bureaucrats have been borrowing against future tobacco bonds (to go into the general fund and “other” needs, such as parks and the purchase of undeveloped land) in cash strapped states such as, surprise, California. California Watch, a government watchdog group, has uncovered some startling facts about California’s love of tobacco money:
Rather than waiting for annual payments, the state and some local governments decided to borrow money against their anticipated future revenue. All told, they’ve issued $16 billion in bonds since 2001.
Could it be that the state of California, via Prop 29, was looking for yet another way to tax smokers into oblivion in order to cover the debt that has been incurred by reckless state bureaucrats who borrowed against future smoker money? Nah….. That would be too cynical, right?
In December, California had to dip into its reserves to cover bond payments.
They’re in debt to future tobacco bonds! How could they borrow our money to spend on other things without our permission? That is supposed to be our money! But, but…MSA money was for the treatment of sick smokers on Medicaid…Yeah, right…and pigs fly and all politicians, special interest groups and lawyers are honest; only tobacco companies lie; and as for the people most affected, well, we don’t exist.
As the state’s finances worsened, officials went back to investors.

Yes, you have read that right: There are people who invest in MSA money. Isn’t that just lovely? For the love of righteousness and justice, I can’t fathom how this could be a legal endeavor. The very people who have kicked us smokers to the curb (under the false premise that we’re a financial burden to society) are investing in the very commodity that they profess to hate. It makes one think that there is something putrid abound, as we smokers are denied the very benefits that we have already paid for. I want to know why we have been denied the lifesaving research that has been paid for several times over. I don’t expect that we’ll get an honest answer to that question any time soon.

I have a striking suspicion that there is a dark and pernicious force in action with the intent of keeping all tobacco products as dangerous as possible in order to justify the continued extortion. The damage done to smokers goes far beyond that of punitive taxation, for any government backed industry that borrows against “sin” taxes is an industry that stands to lose revenue when new and novel reduced risk products are introduced into the marketplace.

Saving the lives of smokers does not appear to be profitable for some. The prohibitionist “quit or die” approach put forth by modern day tobacco control movement is merely a thinly disguised veil for its true intent, which is to abolish and bury any alternative measures (like tobacco harm reduction) that may actually work to save the lives of millions while respecting the sovereignty of individuals and nation states everywhere. For those among us who don’t believe that this accusation carries any merit, I would like to provide unbelievers a mere glimpse into the window of modern science and tobacco harm reduction, which happens to be rife with empirical information that is irrefutable:

It is already possible to eliminate the carcinogenic nature of combustible tobacco cigarettes by 90%. There have been many studies and cigarette models developed which prove this to be the case; many more models are being studied as I am typing this commentary. Of course, none of us have had the pleasure of hearing about these revolutionary discoveries from our public health officials or via the nightly news. This proves that if Prop 29, the MSA, as well as that of all tobacco taxation, were really about the health of smokers, then existing tobacco tax codes would instead ensure that a significant proportion of tobacco taxes go towards reducing the harm(s) caused by active smoking via the marketing and production of future harm reduction products and that of those reduced risk tobacco products that already exist:
Scientists have tried to make safer cigarettes in the past. Haemoglobin (which transports oxygen in red blood cells) and activated carbon have been shown to reduce free-radicals in cigarette smoke by up to 90%, but because of the cost, the combination has not been successfully introduced to the market.
..”Because of the cost”… What about all of that tobacco money that smokers have been coughing up at the local, state, and federal level for all of these years? Clearly, there is enough money to save the lives of many smokers. Nicotine replacement therapy (ie., patches and gum) has a 90+% failure rate. Here we have (thanks to the brave scientists who continue to study harm reduction) access to the knowledge that could actually work by lowering the risk of smoking related disease(s) by 90%, yet it is ignored by the very people who purport to care about public health. Not having the access to and the knowledge of these advancements is an outrage and a violation of human rights. Smokers are dying while politicians and bureaucrats stuff their pockets whilst golfing on the green-grass-manicured lawns that dead and dying smokers have paid for.
Haemoglobin and activated carbon cigarettes should already be on the market (and we should know about it, as well as that of other reduced risk cigarettes such as those who utilize anti-oxidants). Here is another such development listed below:

Using natural antioxidant extracts in cigarette filters, the researchers were able to demonstrate that lycopene and grape seed extract drastically reduced the amount of cancer-causing free radicals passing through the filter.
I’m only approaching the tip of the iceberg here, for there have been many more such studies which have shown how various anti-oxidants can be used to reduce the harms caused by active smoking. I have many of them listed on my blog.
There is no reason why smoking has to continue to be nearly as dangerous as it has been up until the present. This is the 21st century after all. It is clear that the health of smokers has been sacrificed on the altar of heavy taxation and greedy hands. What we need are massive reforms to current tobacco taxation laws, not more taxation to feed a broken system. Smokers deserve to have a say in these much needed reforms. No one wants to be “unhealthy” after all, and no one deserves to die for lack of funding and prejudice. Some of us are aware of the scientific advancements that have been made and we rightfully would like to be the benefactors of such inventions.
Prop 29 failed for a reason: it was an egregious attempt to beat up on an already bruised and battered minority. People from all walks of life are beginning to question the tactics of the anointed anti-tobacco establishment as a result. It is my hope that all similar attempts in the future will fail, and not only in California.