Real problems of socialised medicine

[PainRack]

Just to play Devil Advocate, let's DO examine the issues "socialised" medicine has right now.

Funding- The NHS is funded primarily via taxes, so local trusts are politically pressured to keep things cheap. This unfortunately has not only meant re-centralisation of services that pose access problems and overload others, such cost controls has also limited investment in new services, labs and staff, whereas hospitals in the US, driven by for profit motives had economic incentives to invest in such capital.

Of course, such a problem might be solved if funds were allocated for capital investment on top of operations......

[mr friendly guy]

A few issues I will briefly touch on
1) waiting lists running the risk of blowing out with increasing population and increase elderly porportion of the population
2) mandatory guidelines by fiat declaration without funding to make these actually work
3) risk of hospitals fudging the numbers as a result of 2)
4) lack of government coordination on some other aspects of health

1. This is pretty straight forward, more people and more elderly people (who are most likely to need medical services) leads to increase demand. If this isn't matched correspondingly by increase government funding, problems will occur.

Unlike private organisations, generally hospitals don't have the ability to increase fees, thus they rely on government funding to sustain their operations. Moreover hospitals under a socialised medical system have to see everyone. So not only can they not compensate by increasing fees, they can't just refuse to see patients who don't have the cash. How inconsiderate.

2. Again straight forward. Its all very well to say patients in emergency must have most relevant tests done and accepted and admitted by the relevant specialty team in, oh I don't know, say 4 hours. However it becomes difficult when that team also have their own inpatients to see. This problem could be alleviated with the rostering of more doctors to help the admitting team. Again this comes down to a matter of funding, with the problems mentioned above.

3. From what I have been told from UK colleagues, in that country hospitals which don't make the grade may have their funding reduced. That is if they don't meet certain targets their funding will be cut. This seems to be derived from one sided analysis, as it doesn't take into account whether the hospital is failing because a) its just not efficient enough (in which case you could make a case that funds should be diverted to more efficient areas) or b) the hospital is underfunded given the area it services (in which case it needs more funds, not less)

This directly leads to a temptation to "fudge" the numbers, which can lead to a worsening cycle as problems aren't identified. Don't get me started on the politics on this.

4) One of the problems with an aging population is that hospital beds get taken up by elderly people who don't necessarily need to. To elucidate, these people are incapable of living independently, but could stay in age care facilities such as nursing homes or hostels. While in hospital, the amount of medical management they will require is minimal, not to mention it is much cheaper to run a nursing home bed than a hospital bed.

Now you would think that it would just be a matter of opening more nursing homes. Unfortunately it doesn't seem to get as much publicity as opening more hospital beds. It isn't helping that people have their own vested interests, (eg people calling for more hospital services not surprisingly work in them and are senior in the heirachy) and while these people do have a point, changes need to be done in conjunction with other health services. There is limited money and it needs to prioritise to where we would get maximum utility.

[charlemagne]

To be honest, this whole discussion is nothing but hilarious when you're not living in one of the few western countries that doesn't have "socialised" (this is pretty hilarious just on its own) healthcare.

I don't pretend to be really knowledgeable about the whole issue, but I'll try to touch on some of your points:

Unlike private organisations, generally hospitals don't have the ability to increase fees, thus they rely on government funding to sustain their operations. Moreover hospitals under a socialised medical system have to see everyone. So not only can they not compensate by increasing fees, they can't just refuse to see patients who don't have the cash. How inconsiderate.

Since under a socialised medical system the number of patients without coverage is negligibly small (in Germany, for example, you just cannot have no health insurance under any conceivable "normal" circumstance) your hospital simply won't have patients who can't afford the treatment they need.

2. Again straight forward. Its all very well to say patients in emergency must have most relevant tests done and accepted and admitted by the relevant specialty team in, oh I don't know, say 4 hours. However it becomes difficult when that team also have their own inpatients to see. This problem could be alleviated with the rostering of more doctors to help the admitting team. Again this comes down to a matter of funding, with the problems mentioned above.

That is what emergency rooms in hospitals are for, i.e. whole departments devoted to dealing with emergencies, not the usual patience admittance. Doctors there don't have their own inpatients to see during their shifts at the ER. Granted, not every hamlet has it's own emergency room, but that's what rescue helicopters and ambulances are for.

I don't really get the relevance, though, are there really guidelines in effect in any civilized country right now that doctors can e.g. let car accident victims bleed out because another patient needs his colonoscopy right now?

[D.Turtle]

Some problems with the German system:

The former so-called Grand Coalition implemented a new type of funding the health insurance companies: they get a fixed amount of money from the total pool of health care spending for each person they insure. In order to make sure that the insurance companies don't go broke because they had too many sick people in comparison to other insurance companies, additional amounts of money are added for each person suffering a certain condition. The amount of money, and the sicknesses which result in additional funding were decided in political circles between the SPD and the CDU, and are not always similar to the actual additional costs incurred by people with those sicknesses. This results in insurance companies being interested in getting people diagnosed with certain sicknesses. In short, insurance companies benefit from administering too much care.

Another problem is the blatant two-tiered system between state-funded insurance companies and private insurance companies.

Of course, this is complaining from a very high standard.

[PainRack]

To be honest, this whole discussion is nothing but hilarious when you're not living in one of the few western countries that doesn't have "socialised" (this is pretty hilarious just on its own) healthcare.

I don't pretend to be really knowledgeable about the whole issue, but I'll try to touch on some of your points:

Your comments don't seem to catch the gist of what Mr friendly guy is trying to say though.

Since under a socialised medical system the number of patients without coverage is negligibly small (in Germany, for example, you just cannot have no health insurance under any conceivable "normal" circumstance) your hospital simply won't have patients who can't afford the treatment they need.

The procedures and beds they're using? It still need to be paid for. If the governments don't increase funding to match, in particular, the investment in capital so as to speak by hiring more doctors, opening more facillities or even increasing funds so that operations at existing facillities can cope with the increased demand, then even if the government has paid for all the fees a person use, then the healthcare system will still not meet the increase in demand.

That is what emergency rooms in hospitals are for, i.e. whole departments devoted to dealing with emergencies, not the usual patience admittance. Doctors there don't have their own inpatients to see during their shifts at the ER. Granted, not every hamlet has it's own emergency room, but that's what rescue helicopters and ambulances are for.

I don't really get the relevance, though, are there really guidelines in effect in any civilized country right now that doctors can e.g. let car accident victims bleed out because another patient needs his colonoscopy right now?

You don't seem to understand. Mr friendly guy is talking about ministry guidelines, in his case, that the ER should refer and move patients out of the ER into the respective speciality within......... 4 hours. To do that however, you need THAT speciality team to have assessed and seen the patient. That may not be doable as there isn't enough doctors.

Hell. Or beds for that matter. To put it simply, ERs aren't usually equipped for treatment of specialised ailments, even when said ailments are causing massive amount of pain and discomfort. And place a patient suffering from eg DVT in a stressful environment, just the noise alone would cause his pain perception to increase. Whereas if you get him into a ward, in "theory", the more relaxed environment might do wonders for alleviating discomfort, even if that clexane and tramalaldol hasn't started working yet.

[mr friendly guy]

Since under a socialised medical system the number of patients without coverage is negligibly small (in Germany, for example, you just cannot have no health insurance under any conceivable "normal" circumstance) your hospital simply won't have patients who can't afford the treatment they need.

Here in Australia anyone who attends a hospital will be assessed and treated accordingly. You don't even need insurance for that.

That is what emergency rooms in hospitals are for, i.e. whole departments devoted to dealing with emergencies, not the usual patience admittance. Doctors there don't have their own inpatients to see during their shifts at the ER. Granted, not every hamlet has it's own emergency room, but that's what rescue helicopters and ambulances are for.

You misunderstand. The ER (we use the term ED here) has already seen them. They however require admission to the hospital since their ailment won't be treated / appears won't be treated in 24 hours. That is they may need to stay a few days. These people then should go to a ward bed, which is generally more comfortable, and more quiet than the noisy ED.

What the guidelines are saying is that these people have to be move out of ED onto a ward bed (or at least the ward bed has been requested) within a certain time period. This requires the specialty team to see them, make their own assessment, run any additional tests, start more treatment or continue whatever treatment etc. This won't happen if the specialty team has to manage their own patients or has to see other referals. Thus you need more doctors (not just in ED) but also to help the specialty team. You can do this by having extra doctors on the specialty team, or even better have a second doctor to help out which ever team is admitting. Again this requires funding.

I don't really get the relevance, though, are there really guidelines in effect in any civilized country right now that doctors can e.g. let car accident victims bleed out because another patient needs his colonoscopy right now?

I am not sure what you are getting at here, however
1) there is really not such thing as an urgent colonoscopy according gastroenterologists, although surgeons will tell you differently. Thus its unlikely the need it "right now"
2) colonoscopies aren't usually done in the operating theatre (at least not in the hospital I work at) unless the patient will be an anaesthetic risk, so they are not competing with the same space as the car accident victim.
3) elective operations have been cancelled in my state because we had to keep beds free in case of emergencies, in recent cases it was the scare with swine flu, so yes procedures can be cancelled to make way for the car accident victims. In fact in emergencies in the past, eg a massive bus accident or even the terrorist attacks in Bali where Australians were hurt, there was co-ordination across the board to cancel non emergency surgeries to keep those beds free for the victims.
4) The thrust of my argument was not so much refering to emergencies, but patients who will need a few days in hospital. Like the smoker who comes in confused, with calcium levels sky high and a white mass on the chest x-ray which shouldn't be there. I wonder what he could have, although its most probably cancer. The way to manage this man is going to take time.

For example a) we need to correct his calcium, and that will take a few days of fluids, and drugs
b) we need to check for causes of hypercalcaemia, just in case its not the cancer
c) we need to biopsy his lung mass and wait for the histopathology to come back, since different cancers have different prognosis and treatment, eg small cell lung cancer can't be surgically resected
d) we need to do numerous scans to see if the cancer has spread elsewhere, heck the lung mass may not even be the primary
e) then once we know all this, oncologist will need to be consulted and treatment options need to be discussed with the patient.
f) said patient will usually need social worker input since I don't think they will be able to work any more in the near future

Needless to say, this is a real patient I saw last week, and we are awaiting the biopsy results.

The four hour rule mandates that such patients are assessed by emergency staff, refered to the relevant specialty, in this case general medicine (internal medicine as its called in North America) and a ward bed booked all in 4 hours. If this was the only patient to see, sure no problem. But the medical team will usually get several referals at the same time, and no doctor I know of can be at two places at once, except This guy

And place a patient suffering from eg DVT in a stressful environment, just the noise alone would cause his pain perception to increase. Whereas if you get him into a ward, in "theory", the more relaxed environment might do wonders for alleviating discomfort, even if that clexane and tramalaldol hasn't started working yet.

A lot of the times we don't even admit DVT any more. Its cheaper to get either let them administer their own drugs at home or get someone to come over and do it for them (if they don't want to or unable to inject themselves) than keeping them in hospital. Only if they have a host of other medical issues or the DVT is too painful for them to walk, move, function at home would we consider admitting them.

[charlemagne]

You misunderstand. The ER (we use the term ED here) has already seen them. They however require admission to the hospital since their ailment won't be treated / appears won't be treated in 24 hours. That is they may need to stay a few days. These people then should go to a ward bed, which is generally more comfortable, and more quiet than the noisy ED.

What the guidelines are saying is that these people have to be move out of ED onto a ward bed (or at least the ward bed has been requested) within a certain time period. This requires the specialty team to see them, make their own assessment, run any additional tests, start more treatment or continue whatever treatment etc. This won't happen if the specialty team has to manage their own patients or has to see other referals. Thus you need more doctors (not just in ED) but also to help the specialty team. You can do this by having extra doctors on the specialty team, or even better have a second doctor to help out which ever team is admitting. Again this requires funding.

Sorry, yes, I really misunderstood you. I get the point now.

I am not sure what you are getting at here, however
1) there is really not such thing as an urgent colonoscopy according gastroenterologists, although surgeons will tell you differently. Thus its unlikely the need it "right now"

This was just me trying to be sarcastic, because I thought your point was "doctors have to treat other patients besides emergencies".

4) The thrust of my argument was not so much refering to emergencies, but patients who will need a few days in hospital. Like the smoker who comes in confused, with calcium levels sky high and a white mass on the chest x-ray which shouldn't be there. I wonder what he could have, although its most probably cancer. The way to manage this man is going to take time.

That's assuming that all people just go to the hospital without seeing their physician first, isn't it? I know that there are people who just walk into hospitals demanding to be admitted, but at least to my knowledge, everyone who isn't a real emergency will be sent away and told to go see a physician first, who will usually do a bunch of tests etc. before admitting patients to the hospital. At least that's standard practice in Germany, if it is not in Australia, well then my point is moot, too.

[JCady]

Unlike private organisations, generally hospitals don't have the ability to increase fees, thus they rely on government funding to sustain their operations. Moreover hospitals under a socialised medical system have to see everyone. So not only can they not compensate by increasing fees, they can't just refuse to see patients who don't have the cash. How inconsiderate.

This is actually an even bigger problem for U.S. hospitals, which under federal law (EMTALA) must provide free ER care to anyone who walks through the door out of their own pocket.

[PainRack]

And place a patient suffering from eg DVT in a stressful environment, just the noise alone would cause his pain perception to increase. Whereas if you get him into a ward, in "theory", the more relaxed environment might do wonders for alleviating discomfort, even if that clexane and tramalaldol hasn't started working yet.

A lot of the times we don't even admit DVT any more. Its cheaper to get either let them administer their own drugs at home or get someone to come over and do it for them (if they don't want to or unable to inject themselves) than keeping them in hospital. Only if they have a host of other medical issues or the DVT is too painful for them to walk, move, function at home would we consider admitting them.

Its the same here, except for one issue. There is a financial issue here as duplex scan can be charged to Medisave, a government mandated Health Savings account but an outpatient scan can't. Perhaps that and the hassle of asking patients in pain for follow up treatment when they're already in the A&E is why doctors admit them?

That's assuming that all people just go to the hospital without seeing their physician first, isn't it? I know that there are people who just walk into hospitals demanding to be admitted, but at least to my knowledge, everyone who isn't a real emergency will be sent away and told to go see a physician first, who will usually do a bunch of tests etc. before admitting patients to the hospital. At least that's standard practice in Germany, if it is not in Australia, well then my point is moot, too.

The guy came in confused. Furthermore, hypercalcaemia can be an emergency.

This is actually an even bigger problem for U.S. hospitals, which under federal law (EMTALA) must provide free ER care to anyone who walks through the door out of their own pocket.

Close. The law is that you must stabilise everyone regardless of their ability to pay. However, fees can be recovered, including bankruptcy proceedings. And of course, unlike Australia, the hospital simply increase fees elsewhere

[mr friendly guy]

That's assuming that all people just go to the hospital without seeing their physician first, isn't it? I know that there are people who just walk into hospitals demanding to be admitted, but at least to my knowledge, everyone who isn't a real emergency will be sent away and told to go see a physician first, who will usually do a bunch of tests etc. before admitting patients to the hospital. At least that's standard practice in Germany, if it is not in Australia, well then my point is moot, too.

Ignoring for a moment that this patient most probably should have come in sooner, given his deterioration in his mental state had been occuring for some time (his work place screened him for drugs and when they didn't find any they sent him to his GP, and he only came in when his physical state starting deteriorating as well) you do raise some good points.

Patients coming into hospital instead of their family doctor is a problem and will continue for two reasons.

1) Lack of after hours General Practioner (GPs) - thus patients come to hospitals after hours
2) The gap - generally the difference between what GPs charge and what the government reimburses. Once upon a time most GPs bulk billed medicare, that is patients ended up not paying. There are still a lot that do, however they are becoming rarer, and rather than seek GP help, some people just turn up to hospitals since they get free consultation. Now personally I find this reason about difficult to afford GPs weak since we give generous welfare, but I am not going to go into that rant right now.

Even if they don't require admission, they still need to be assessed by ED (hence this type of patient strains ED more than the other specialties), however if they take up a cubicle, there is one less cubicle for a patient who may end up being admitted. This in turn causes "ramping" (where ambulances wait outside until a cubicle or a place in the corridor is available), and of course it delays admission since the specialty team can't see them (well I supposed you could theoretically see them, if they want to be examined without the privacy of a curtain and to let everyone else hear them answering personal questions).

This is actually one area the government has moved to tackle, by providing after hours GP, sometimes very close to the hospital, so if the patient turns out to be sick and requiring admission, its a short distance to the Emergency Department.

Unlike private organisations, generally hospitals don't have the ability to increase fees, thus they rely on government funding to sustain their operations. Moreover hospitals under a socialised medical system have to see everyone. So not only can they not compensate by increasing fees, they can't just refuse to see patients who don't have the cash. How inconsiderate.

This is actually an even bigger problem for U.S. hospitals, which under federal law (EMTALA) must provide free ER care to anyone who walks through the door out of their own pocket.

Really? From what I understand such patients (ie ones who can't pay) aren't followed up in outpatient clinics, whilst in Australia its standard practice. Wouldn't the US hospitals save money that way?

Another problem is the blatant two-tiered system between state-funded insurance companies and private insurance companies.

I see our private hospitals as a way to help take the load of the public system for people who can afford to pay. In Australia due to idealogical reasons the previous government encouraged people to take out private health. To facilitate this, they simply exempted you from an extra tax on people who earn over a certain amount. This medicare surcharge tax could be avoided all together if you simply take out private health insurance. Hey this was the reason I took out private health, tax benefits, because its actually cheaper for me to pay the minimum coverage, since I am still young than pay the medicare surcharge.

From what I can see, private hospitals have nicer rooms, I am sure better amenities and some services are quicker, eg non emergency surgeries. However I doubt the level of care can match a public hospital as a) there are less doctors in private (ie less after hours care, less able to perform resuscitations) b) the specialists in private also work in the public system. In this case, its only favours the rich (ie those that will have private health) in terms of elective procedures. Plus if they get their procedures done in private hospitals, it doesn't strain the public system (which by far sees most of the patients).

The other thing about private health insurance is that if they come into a public hospital (say it just happens to be the nearest hospital or private hospitals are full), their insurance can be used to pay the bills saving the public system money. Although the way its structured seems to be that insurance companies can still charge a gap, thus we have people take out private health insurance for tax purposes but refuse to use it when they come into public hospital, which just defeats the purpose of it.

[Darth Wong]

If there was to be a private/public system, I would demand one caveat: that elected politicians and their families all be forced to use the public system. Otherwise, it would be all too easy for politicians to let the public system wither on the vine when they need to trim the budget and win elections, since they would never use it.

[MKSheppard]

If there was to be a private/public system, I would demand one caveat: that elected politicians and their families all be forced to use the public system. Otherwise, it would be all too easy for politicians to let the public system wither on the vine when they need to trim the budget and win elections, since they would never use it.

You mean like how Politicans here in the States talk all about the need to improve our public schools, and then do an about face and put their children in private schools?

[Darth Wong]

If there was to be a private/public system, I would demand one caveat: that elected politicians and their families all be forced to use the public system. Otherwise, it would be all too easy for politicians to let the public system wither on the vine when they need to trim the budget and win elections, since they would never use it.

You mean like how Politicans here in the States talk all about the need to improve our public schools, and then do an about face and put their children in private schools?

Pretty much. It's easy to create a two-tiered society when you're in the top tier. Having said that, schools are a special case, because of the obvious security issues around the children of prominent politicians.

[Axiomatic]

I can never quite comprehend people who consider that a national health service would allow everyone to get the medical attention they need, rather than just some of the people, to be a bug rather than a feature.

[Xon]

Patients coming into hospital instead of their family doctor is a problem and will continue for two reasons.

Another issue is the utter lack of unified record keeping and almost zero interoperability between GPs, public hospital and private hospitals for records. This is before you even touch the issue of a national wide scheme.

There is some movement to a unified medical record keeping but it isn't going to be implemented and up & running any time soon for a host of reasons. I want my universal ID damnit, carrying half a dozen cards & IDs is a PITA.