Thursday, 28 November 2013

NHS employment figures in perspective

We are well aware, see e.g. here, that the NHS employs about 1.4 million people, including "146,075 doctors, 369,868 qualified nursing staff and 37,314 managers".

It has a budget of "£105.254bn in 2012/13".

Just for fun, we can multiply up the doctors by £100,000 a year each (£15 billion), the nurses and managers by £40,000 a year each (£16 billion) and the other 850,000 by £20,000 a year each (£17 billion) and tot that up to £48 billion, half the NHS budget.

We are also well aware, from personal experience as patients, that you get treated a lot better/quicker in European countries. This is partly because of the best-of-both worlds taxpayer-funded (with small personal additional charges), patient-driven, competing-providers model.

But it's the money as well.

UPDATE: Kj in the comments links to this and this showing that the UK spends 9.3% of GDP and Germany (I'll take Germany because I used to live there) spends 11.1%. The taxpayer/government-funded portion is UK 7.7% of GDP and Germany 8.4%.

So what do they get extra for their money? There are some stat's on the numbers employed in healthcare in Germany here.

See if you can guess the total before you follow the link!

If your German's a bit rusty, click and highlight below to reveal the official total:

Four (4) million! Jeez!!

NB, I've adjusted that figure down to exclude people working in health-related sectors, i.e. pharmaceuticals and dispensing chemists, who would not show up in NHS figures either. If we scale that down for Germany's larger population, this gives us three (3) million, which means that Germans spend 20% more than we do but get 100% more out of it.


Bayard said...

As DBCR pointed out, once upon a time we had a public service ethos in this country. It still exists, but far too many see institutions like the NHS as an opportunity to take the state for as much as they can. The problem with the NHS and other institutions like it is that they were set up to operate in a world where by and large people behaved decently, but now they are struggling to survive in a world where most people are simply out for what they can get. What started out as a public service has become a goldmine for the unscrupulous.

Kj said...

MW: Here and here are the most relevant indicators:
Health expenditures in Germany is 11% of GDP, where around 75% is public spending. In the UK it´s 9,3% of GDP, where 83% is public. All 2011-figures. Might have changed a bit since then.

It´s quite predictable actually. We know that the public sector inefficiency adds some costs and annoyances in the UK, and we also know there is some transaction costs, potential for excess use in the public/private system of Germany. But all in all, seems like the benefits outweigh the advantages with systems like Germany, Switzerland, France etc..

Personally, I also live under a public provision system. But I´m largely satisfied. It´s just that people´s expectations are so much bigger than it´s ever possible to deliver in such a system.
But the thing is that the private system, if allowed, can wrap around that model pretty good. I can get everything from a hernia-surgery to gastric bypass at a local private clinic, and I can travel a couple of hours for a good cancer center. This will cost me big ofcourse, but there are several insurance options. I can either buy a regular insurance that keeps me out of the public system for any non-acute service, and I can even get an insurance that kicks in if the waiting-lists exceed a certain treshold in the public system.

Yes, that´s what they call two tier, big deal.

Kj said...

- benefits outweigh the costs... hehe

Mark Wadsworth said...

B, do you think NHS is overstaffed or the German health system?

Kj, thanks for the link to the spending statistics. So the Germans don't spend much more than we do.

That must mean that either salaries for German doctors and nurses are lower, or they spend a lot less on crap.

Lola said...

And I have read that between 1999 and now, spending on the NHS doubled whereas there was no increase in productivity (however that's measured)

Kj said...

MW: there are major caveats as to what counts as government spending though. AFAIU, Germany has public long-term-care insurance, which is a big ticket item, does it count as public or private? Stuff like that.

I think I´ve heard that doctor salaries in Germany are quite low actually. See this forum:

Lots of nagging about salaries, contemplating where to move for the best salaries. Like you´d expect for any ol "professional".

Kj said...

Here is also an interesting article about cost containment in the German system. It also contains a little gem with regards to the last topic:

The Quarterly: Outside these experiments with integrated care, how much success has Germany had with disease prevention?

Franz Knieps: Unfortunately, Germany has not yet had much success. Our constitution gives responsibility for public health to the 16 federal states—the Länder—and there is little coordination among them, or between them and the federal government, on preventive health initiatives or laws to promote public health—antismoking legislation, for example. Compared with some other countries, we need to develop our skills in this area.

Excellent. You see they think like all the other authoritarians, they just haven´t got the wherewithall to implement stupid measures to "promote public health" in the new, extended sense.

Kj said...

Also another great quote:

I think there are no new, revolutionary ideas in health care policy, but there are some old ideas that are still worth thinking about. When I was a young man, I met Brian Abel-Smith, an influential health economist at the London School of Economics, and I asked him what the major idea in health care policy was. His reply, in essence, was this: “My dear young friend, the only way to organize and pay for health services well is to change the system every second year so that nobody feels comfortable in it.” He meant that every so often you have to rearrange the coalition of stakeholders within that system so that nobody feels complacent, nobody feels safe.

It seems like at least the UK is doing this right.

Bayard said...

Mark, the NHS, but it wasn't just staffing I was thinking about, but everything else the NHS pays for.

Mark Wadsworth said...

Kj, your assumptions about Germany (lower salaries) are correct AFAIAA.

I think the World Bank counts the long-term care insurance, which is a compulsory deduction from salary, as a tax and hence as "government spending".

That list of health workers I linked to includes people working in long-term care for e.g. the elderly.

B, yes, most of the other half is pissed up the wall. And doctors are vastly overpaid in the UK.

paulc156 said...

Specialists in Germany earn significantly less than in the UK but GP's earn a similar amount and nurses slightly less than here, at least as of 2008 according to the OECD.

@MW "We are also well aware, from personal experience as patients, that you get treated a lot better/quicker in European countries."

Anecdotes [albeit three of them]are all well and good but no substitute for proper investigation, obviously.

Looking at the Commonwealth Funds comparisons between 11 health systems [Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, UK, and US] involving thousands of subjects/respondents carried out in 2010 [pre UK 'reform' bill]. 1,511 respondents in the UK and 1,005 in Germany.

Some relevant metrics include the percentage of respondents with more or less confidence that they will be able to afford care in their respective countries if seriously ill. France and Germany in this respect do rather worse than the UK.

Also pertinent is the percentage of Doctors saying time constraints cause major problems in getting patients needed medications and treatment because of coverage restrictions. The percentage is lowest of all in the UK [amongst the 11] and highest in the US [no surprise there] but 2nd worst on this metric is... Germany.

On page 28 of the report [link to follow]where overall views are recorded. Respondents categorise their health systems in one of three ways.

1: Only minor change needed.
Germany 38%
UK 62%

2:Fundamental change needed.
Ger. 48%
UK. 34%

3: Total rebuild;
Ger. 14%
UK. 3%

The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries

In chart form even clearer:

Kj said...

PaulC: wow, people think they pay too much and doctors want less interference. Not exactly radical stuff, or powerful counterarguments to MWs "anecdotes".

Mark Wadsworth said...

PC, the problem with better health care is that people get spoiled, take it for granted etc.

And the better you care for marginal people, the worse the overall average health of the population gets, quite clearly, so costs go up and up.

Also, Germans are world champions at moaning, for them a one-month waiting list is abuse of human rights, for us Brits, a three-month waiting list is fairly good news.

So there is no point asking Germans about German system or Brits about British system - you have to ask people who have lived in both countries and experienced both and can do a fair comparison.

So that survey, is, I'm afraid to say, complete crap.

paulc156 said...

@ Kj

" wow, people think they pay too much and doctors want less interference. Not exactly radical stuff, or powerful counterarguments to MWs "anecdotes"

Comprehension check. Whats' to counter? Anecdotal evidence by a 'handful' of anti state obsessives on a blog[excluding MW fwiw] combined with asinine interpretation of data by cheerleader doesn't constitute much of an argument in the first place...shock!

Germans have have far less faith they can afford to be seriously ill than Brits regards their health provision. Sounds rather like the insecurity felt by Americans who presumably are also just being silly people who don't want to pay up. sigh...

Furthermore, to underline the inadequacy of your response; In the report it makes plain that Germans were three times more likely to not fill a prescription or skip doses due to financial constraints than UK respondents. Eight times as many of them 'had a medical problem' but did not visit a doctor and over three times as many of them skipped a test, treatment, or follow-up, ALL FOR reasons of cost.

Just to add,quite apart from the fact that the 'Commonwealth' data casts clear doubt that the German health system in total is even as good as the NHS system, [never mind superior] it is a damn site more expensive [over a thousand dollars per capita per annum] even though it pays its specialists far less than we do and it's nurses somewhat less.

We should of course emulate them though, poor Germans [over a thousand of them] that took part in the survey must need re educating.Perhaps you need to get more people to listen to more of your anecdotes? :)

paulc156 said...

@MW "So that survey, is, I'm afraid to say, complete crap."

And so was that! LOL.

'how dare you' [pompous imitation] denigrate Germans as if they didn't know whether they had skipped tests, missed doctors appointments, follow ups, left prescriptions unfilled for real reasons of cost or just imagined. If only they were more stoic like us Brits.

Should the German authorities wish to examine the performance and appreciation of their health system they can rest assured that German citizens do not have a clue, but the YPP have several [3 or 4] highly valid [sic] opinions which will be of inestimable value.

Kj said...

PaulC: But you are predictably just looking at one factor, equity. Ofcourse paying co-pays is a strain on the financial situation on those with low incomes, no doubt. But your whole premise is that the UK system needs to be defended on this account alone. The study you cite is not a study of actual outcomes, it´s a study of perceptions, particulary that of equity. Actual health indicators, although difficult to measure, puts countries like Germany and France slightly above the UK:

This report also shows that cost growth in the UK has been higher than the central-european Bismarckian-type countries.
Welfare benefits are usually higher in non-anglophone countries that do not have the free-ATPOU principle of the NHS. There´s a tradeoff involved in that, where costs are not hidden from health consumers. That might very well be a perception of having to consider use of health services. And that´s how you can afford have a system that allows what is anectdotally described; less feeling of being subject to bureacracy and gatekeepers, more direct access to services and shorter waits (less non-financial rationing).

Bayard said...

P156, the survey to which you link Calls itself the "The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries" but in fact has nothing to do with policy and is simply the results of a "Telephone survey, conducted from March to June 2010, of adults ages 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.", i.e. it's entirely about people's attitudes to the health system and does not deal with policy or even purport to deal with expenditure and outcome statistics (apart from the first chart published) and, as Mark pointed out, that depends on what people are used to and what they expect.
The only really informative graphs are the ones showing expenditure per head, as it seems to show the UK amongst the lowest (although, without knowing what "expenditure per head" includes and excludes, it is difficult to be certain about this either), but New Zealand, who scored the same as the UK by and large in the survey (apart from the totally subjective "is it broken?" survey at the end) is even lower.

Bayard said...

Mark, I wouldn't say that the CF survey is complete crap, it is a useful survey of how people in different countries feel about their healthcare system, but it is not useful in comparing the benefits of one system to another. After all, if the UK has the highest satisfaction with their healthcare system for the almost the lowest per capita spending (and I'm not saying that it has), then that is some sort of achievement, even it it still doesn't mean that the system isn't crap in some ways and badly in need of improvement. Just because you're the best doesn't mean that you are necessarily any good.

Mark Wadsworth said...

Kj, "equity" is good, but we can do that on the "funding" side, there is no need for the state to control the "provision" side as well.

It's like cash welfare, everybody gets their unemployment benefit or pension, that is the "funding" and "equity" side dealt with. But they can spend their money on stuff "provided" by the private sector/competing bodies.

It is only hard-core Authoritarians who say that we should scrap cash welfare and the state should provide unemployed and pensioners with free food from its own farms and shops etc.

B: "if the UK has the highest satisfaction with their healthcare system for the almost the lowest per capita spending (and I'm not saying that it has), then that is some sort of achievement"

Yes, that is a great achievement and in some ways, the NHS scores very well.

"Just because you're the best doesn't mean that you are necessarily any good"


Kj said...

MW: I've not said equity is not important. But the commonwealth survey falls short of measuring anything but perceived equity. Say you make people go from free at the point of use to fees with a cap of 500 quid a year, and then give everyone 500 quid. You get the same equity, a welfare gain and more efficient use of resources.