Moral hazard in a failing service

I go to see a woman on the ward to tell her that, again, her procedure is cancelled. I see, written in the resigned expression on her face, the effort and emotional energy it has taken to get herself here: arrangements she made about the care of her household, relatives providing transport from her home over 70 miles away and now unexpectedly called to pick her up. A day waiting, the anxiety building as a 9am appointment became 10, then lunchtime, then afternoon. The tedious arrangements to be necessarily repeated: COVID swabs, blood tests, anticoagulation bridging. All wasted.

She smiles at me as I apologise. She is kind, rather than angry, understanding rather than belligerent. And yet she has every right to be furious. This is, after all, the second time this has happened. And she knows as well as I do that my attempts at assurance that we will prioritise her bed for the next appointment she is offered are as empty and meaningless as they were last time she heard them.

Such stories are the everyday reality for patients and clinicians within the NHS, repeated thousands of times a day across the country, each one a small quantum of misery. At least my patient got an appointment. Some don’t. Ask anyone with a condition that is not life threatening or somehow subject to media scrutiny or an arbitrary governmental target about their access to planned hospital care and you will likely get a snort of derision or a sob of hopelessness. Benign gynaecological conditions (for example) can be debilitating but frequently slip to the bottom of the priority list, suffered in private silence, without advocates able to leverage the rhetorical and emotional weight of a cancer diagnosis.

This is not all COVID related. Yes, COVID has made things worse but really all the pandemic has done is cruelly reveal the structural inadequacies that we have been working around in the NHS for years and years. ‘Winter pressures’ have reliably and predictably closed planned care services even if it took until winter 2017 for the NHS to officially recognise this and cancel all elective surgery for weeks. Estate is often old and not fit for purpose. Departmental and ward geography does not allow for the patient separation and flow demanded by modern healthcare. Staffing rotas are stretched to the limit with no redundancy for absence. Old infrastructure and equipment requires inefficient workarounds. Increasing effort goes into Byzantine plans for ‘service continuity’ to deal with operational risks, while the fundamentals remain unaddressed.

Efficiency requires investment. You cannot move from a production line using humans to one using robots without investing in the robots to do the work and the skilled people to run them. You cannot move from an inpatient to an outpatient model of care for a condition without investing in the infrastructure and people to oversee that pathway. You cannot manage planned and unplanned care via a single resource without adversely affecting the efficiency of both. You cannot expect a hugely expensive operating theatre or interventional radiology suite to function productively if the personnel tasked with running it spend a significant proportion of their day juggling cases and staff in an (often vain) attempt to get at least a few patients ready and through the department. Modern healthcare requires many systems to function optimally (or at least adequately) before anything can be done. Expensive resources frequently lie idle when a failure in one process results in the entire patient pathway collapsing.

The moral hazard encountered by people working in this creaking system is huge. How can we feel proud of the service we offer when failure is a daily occurrence? When we, the patient facing front-of-house, are routinely embarrassed by – or apologetic for – the system which we represent. We can retreat into the daily small victories: a patient treated well, with compassion, leaving satisfied; an emergency expertly, efficiently and speedily dealt with; teamwork. But these small victories seem to be less and less consoling as the failures mount. Eventually staff (people after all) lose belief, drive and motivation. Disillusionment breeds diffidence, apathy and disengagement. The service, reliant on motivated and culturally engaged teams, becomes less safe, less caring, less personal and even more inefficient as staff are no longer inclined to work occasionally over and above their job planned activity. A bureaucracy of resource management develops and teams become splintered. Process replaces culture and a credentialed skill-mix replaces trusted professional relationships.

The moral hazard is compounded by the seemingly wilful blindness of our political masters, the holders of the purse strings, to comprehend the size of the problem. Absent any real prospect of improvement, we learn to accept the status-quo, the cancellations, the delay, the waiting lists. And our patients accept this too: how else does one explain their weary stoicism. Meanwhile our leaders cajole us to be more efficient, to embrace new ways of working, to do a lot more with a bit more money. It remains politically expedient to disguise a few percent increase in healthcare revenue spending as ‘record investment’ but I argue that most people working at all levels in the NHS recognise the need for transformative generational investment on a level not seen since the inception of the service. Such investment requires money and money means taxation.

More than that, there needs to be the political bravery to open a considered debate about what we mean by healthcare, where our money is most efficiently targeted and what we, as a society can (or are willing to) afford in amongst other priorities for governmental spending. Shiny new hospitals providing state-of-the-art treatment may make good PR but are meaningless without functional well funded primary care. Investment in complex clinical technologies will not improve our nation’s health if the social determinants of this (poverty, smoking, diet, housing, education, joblessness, social exclusion) remain unaddressed. Such a discourse seems anathema to our current politics with its emphasis on the individual, on technocratic solutions and on the empty promise of being able to have everything we want at minimal personal, environmental or societal cost.

Until our leaders start this debate, and until we, as members of society, understand the arguments and elect politicians to enact its conclusions, ‘our NHS’ will continue to provide sometimes substandard and inefficient care in a service defined by its own introspection rather than by the needs of the community it should serve. Our healthcare metrics will continue to lag behind those of comparator nations. And I will continue to find myself, late in the afternoon, apologising to women and men for the inconvenience and anxiety as I speak to them about cancelling their procedure, hating myself for it but helpless to offer any solution or solace.

COVID: time to debate our values

For my first post, I’m adding to the thousands of column inches devoted to the COVID19 pandemic. I’m not an epidemiologist, a virologist, a public health expert or even someone whose practice has been substantially affected by COVID19, other than being unable to treat the patients I would otherwise treat, so I don’t claim any particular expertise. But ever since the pandemic hit the UK in earnest, I have felt a nagging doubt that to find the answers to how to deal with it, we are looking in the wrong place.

Two recent publications offer very different visions of the way government and society should respond to the challenges of Coronavirus.

The Great Barrington Declaration emphasises the harms associated with lockdown, for physical and mental health, for jobs and for the economy. It argues for an opening up of society to allow people at low risk of harm to live normally while shielding the vulnerable. The declaration has attracted vehement criticism, not only for its “libertarian agenda” but also for its unreferenced assertions and (the critics say) lack of scientific validity. Is it possible to shield the vulnerable? Is herd immunity possible?

The John Snow Memorandum presents a more conventional and mainstream view. It summarises (and references) what we can be sure about. It argues against allowing an uncontrolled outbreak in those at low risk, emphasising the challenges of shielding (sometimes large) vulnerable groups and the likely human cost in lives lost to COVID. But critically, it too makes unreferenced assertions about, in particular, the socioeconomic effects of an uncontrolled outbreak.

How do we reconcile the differing visions offered in these 2 statements? The evidence about COVID19’s biology only seems to get us so far. We know how it’s spread, we know it is highly transmissible, we know it is an order of magnitude more lethal that flu for some identifiable groups, and we know some of the mitigations we need to put in place to reduce its transmission, therefore the number of lives (or years of life) lost. We count in minute detail the infections, admissions and deaths attributable to the virus and we can see the effect of some lockdown policies on these numbers. But there is much we don’t know, in particular about the effects of our response. What is the effect of lockdown on the health, wellbeing, education and socioeconomic status of the population of people who, critically, would otherwise be unaffected by the virus and who therefore only experience the harms of the remedy? These effects are more difficult to measure and are therefore relatively invisible. They may arise distant from current events and be subject to many confounders though some assessments of health-economic impact of both COVID and lockdown have been attempted. Critics of lockdown suggest that its cost is orders of magnitude more than current ‘willingness to pay’ thresholds and that it is therefore not justifiable on this basis. Others argue that more effective lockdowns mitigate the economic effects of the virus and (in effect) that things could be much worse. A meaningful reckoning is impossible in the short term and both sides of the argument are complicit in extrapolating beyond the evidence in suggesting the balances of benefits and harms of differing strategies favour one argument or another.

Perhaps an examination of our values can help? Maybe our attitudes to the huge changes in society imposed by governments worldwide can be better explained by what we consider important, rather than by the imperfect and incomplete biological and economic science we have on COVID19. Here are a few questions:

  • Do we have a moral obligation to protect the vulnerable?
  • If we do is this absolute, or are there circumstances where this might be negotiable? How long does this obligation last? Are there sacrifices that we are willing to make in the short term that become unbearable longer term?
  • Even if it were possible, would an accurate accounting of the benefits and harms of lockdown policies be sufficient for definitively choosing a (least worst) policy, or are there reasons to override such an analysis?
  • Should individual liberty and autonomy be subordinated to an externally identified collective good?
  • Should we allow story and narrative to play a role in determining policy?
  • Is it reasonable to ask front-line staff to implement, at scale, generic policy when faced with decisions about individual people? Who is responsible for the individual and personal moral hazard associated with a policy decision being implemented in practice? 

These are not new questions. The broad concepts of utilitarianism, libertarianism and egalitarianism have been argued over for centuries by moral philosophers. There will never be a right answer, but unless science comes to the rescue in the form of a vaccine, these questions will need exploring anew in the context of COVID, especially in the worst-case scenario of short-lasting immunity and the virus becoming endemic. Can we stay locked down forever, unable to socialise, meet friends, work or travel? Such a prospect seems intolerable in the long-term but this position reflects my personal values, rather than a dispassionate scientific analysis. Ultimately it is our value judgements about these moral questions, as much as the science, that should determine our response.

We should discuss these issues alongside the emerging scientific evidence, but this discourse seems surprisingly absent.

This is not an argument for procrastination to allow a few more centuries of academic moral philosophical debate about the choices on offer. Decisions need to be made now by us, or rather by our leaders. But if we understand the values on which they base their decisions we will find it easier to follow.