Monday, 6 April 2009

Fact-checking Dan Hannan on the NHS

Daniel Hannan is brazenly going on the offensive to continue his attack on the NHS.

Brave man. I think my money's on Prezza.

But do Hannan's facts stack up? He sounds awfully confident, as usual. So let's take a closer look.

1. Does Britain have the worst health outcomes in the west?

Hannan: "the NHS produces some of the worst health outcomes in the industrialised world. Britain is the Western state where you'd least want to have cancer or a stroke or heart disease". He's pretty confident!

Hannan's evidence? A link to a right-wing think-tank with the misleading name "Progressive Vision", founded 18 months ago by a couple of communications professionals and which "is beginning more detailed research in this area" which it already knows will show why Singapore's health outcomes could be replicated in Britain if we ditched the NHS. Interesting methodology. (Lancet and BMJ papers are mentioned, but no references are cited). (Indeed, Progressive Vision's website rather suggests it may be seeking to test the old canard that a buzzy think-tank does not really need any research or publications to back up press releases and media advocacy. It has sections on "views", "media releases" and "media coverage" but no "publications" nor "research". Perhaps they will get round to some, but then perhaps they won't).

Fact check: But shall we perhaps also check against something cited and peer reviewed? Choose your weapon, Mr Hannan. We shall make this a home fixture for your Fox News friends by deploying The Journal of the American Medical Association. This 2006 article looks rather relevant. The authors are a pretty credible crew, from University College London and Institute for Fiscal Studies (Dr Banks), Department of Epidemiology, University College London (Dr Marmot) and Institute for Fiscal Studies (Ms Oldfield), London, England; and RAND Corp, Santa Monica, Calif (Dr Smith). I think it is reasonable to regard Professor Marmot as trumps in the international health evidence field.

So is Dan Hannan right? Sadly, they conclude exactly the opposite. (Perhaps Hannan would offer us his critique of their evidence?)

US residents are much less healthy than their English counterparts and these differences exist at all points of the SES distribution ... The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer ... These differences are not solely driven by the bottom of the SES distribution. In many diseases, the top of the SES distribution is less healthy in the United States as well.

And it gets more interesting than that.

With the sole exception of cancer, there exists a sharp negative gradient across both education and income groups in both countries ... As a result, country differences are larger and tend to be more statistically different at the bottom of the social hierarchy than at the top. Level differences between countries are sufficiently large that individuals in the top of the education and income strata in the United States have comparable rates of diabetes and heart disease as those in the bottom of the income and education strata in England."

Given that we are factual Fabian types, looking for the evidence rather than just promoting our own prejudices like Mr Hannan, let me note that there is also some evidence from the US which the NHS should learn from. There has been a lot of interest within the NHS since 2002 of studies in the BMJ of how the Kaiser Permanente model in California provides very good outcomes for the resources put in, particularly because of its model of integrated and preventive care.

This evidence was used in Dr Howard Stoate's Challenging the Citadel to call for a shift to a much more preventive health system, much less focused on acute care. Breaking public and political focus on the District General Hospital model is one key to this. Populist local campaigning to save every hospital may be tempting, but it is a barrier to using health resources more effectively. Conservative party please note!

Chris Ham summarises some of that evidence in this Nuffield Trust paper on Clinically Integrated Systems (pages 9-10). That this is not incompatible with the principles of the NHS can be seen impressive innovation lessons come from the public, socialised and successful part of US healthcare: the Veterans Health Administration. This must create a bit of cognitive dissonance at Fox News: Veterans (v.good); public socialised healthcare (v.bad). But the evidence shows that even the US might be able to develop patriotic pride in collective health provision after all! Indeed, my favourite US health wonk, Ezra Klein, produced a useful survey of the health of nations for the American Prospect in 2007. He isn't massively sold on the UK system, compared to that in France: what he could say for the NHS was that it offers universal coverage and better health outcomes than the US system while spending 41% per capita of what Americans spend. Though the cumulative funding gap between UK and leading European systems over the last three decades has been enormous, though the last decade has narrowed (but not eliminated) that gap.

2. Public opposition to the NHS

Hannan: "Outside Westminster, the old incantations are losing their magic. ... Yes, all three parties are committed to the NHS ... I wonder whether, as on tax and borrowing, public opinion hasn't overtaken the Westminster consensus".

Hannan's evidence? Who knows. Hunch? Unique ability of the right-wing populist to intuit beliefs of the British people? Talking to his ex-colleagues on the Telegraph leader writing desk?

Fact check: Who is right? Dan Hannan or John Prescott. Hmm ... Tricky. I know: what about asking people what they think? It turns out that YouGov have done exactly that. Hurrah!

OK, they were commissioned by the pesky fact-finding Fabian Society, but they did poll 3000 people. And the options put were a pretty fair way to find out whether Hannan's idle musings are shared by people in the real world. Look, we even gave people the "full Hannan" - terrible mistake for 60 years - as well as the "gradualist Hannan" of getting rid of the NHS by stealth.

The NHS is sixty years old this year. Which of the following best describes your attitude to it?
(a) Whatever problems the NHS may have, its commitment to free treatment for everyone means it is still one of our great national symbols: 70%
(b) The NHS was a good idea for its time but we now need a different way of running modern healthcare provision: 25%
(c) The NHS was a bad idea from the start and it should be abolished and replaced with something different: 1%
(d) Don't know: 3%

Labour voters were 80-15-1-4.

Conservative voters were 56-39-3-2.

LibDems were 79-13-3-5.

So Dan Hannan is wrong again. But there is some pressure within the Tory party and, more weakly, among Tory voters for rethinking and even scrapping the NHS.

Is the NHS safe in their hands? Not if Hannan gets his way. He notes that he is a humble backbench MEP, but he is developing quite a profile as the hero of the grassroots and has been given a keynote slot at the Spring conference to rally the troops.

While Michael Howard quickly sacked Howard Flight, David Cameron hasn't even asked Mr Hannan to stop shouting his mouth off about why the NHS should be scrapped a few weeks before he tops the Tory candidates list in a national election. And what does it tell us about the modern Conservative party that a candidate who rejects the party's policy of staying in the European Union, and rejects the party's professed support for the NHS gets to be top of his regional list for the European elections?

My view of progressive Conservatism has been that it would be nice if it were true. The evidence is increasingly strong that the Tory party doesn't agree with that.


DavidBrede said...

And as long as they refuse to denounce him the more they are tied to his views?

Mark M said...

So your 'fact checking' is to quote from a 3 year old article that says nothing at all about the NHS or American healthcare, let alone the quality of care, and to state figures from a 19 month old poll.

Even Gordon Brown was popular 19 months ago.

C+ (must try harder)

Shafiq said...

He said we spend too much money on the NHS, yet we spend the least per Capita in the developed world (less than even the US).

He also says that we have a shortage of doctors, yet in 2003, we had 2.2 doctors per thousand people, compared to 2.34 in the US - Not much difference I say.

At least in the UK, we don't have to choose between homelessness and health.

Sunder Katwala said...

Mark M

1. Hannan claimed we have got "iller" and we have some of the "worst health outcomes". If you have a more recent peer reviewed piece of comparative evidence, do supply it.

2. Those studying public opinion distinguish between attitudes, beliefs and values. These have different degrees of volatility. Opinions about individuals, parties, etc are more volatile than underlying opinions about institutions and the values and principles beneath them. The long-running British Social Attitudes dataset shows how underlying beliefs and values can tend to be very stable over long periods.

For example, views about the performance of a Health Secretary or government will often fluctuate with events and media coverage. There can be spikes and troughs in attitudes towards the NHS itself: the coverage of the 50th anniversary saw a 10 point rise in support for it, for example. But Hannan is clearly facing an uphill task to undermine support for the NHS.

Again, if there is evidence to counter mine, please supply it.

Mark M said...

1. Taking cases of MRSA, from Oct 04 - Mar 05 there were 3,689 reported cases (

In 2007, there were nearly 5,000 reported cases (

I'm sure you will accuse me of cherry picking figures but, to me, those MRSA numbers are going the wrong way.

2. You say yourself the NHS got a 10pt boost on it's 50th aniversary. There was even more positive coverage on it's 60th. Added to the fact that it is a highly loaded question (even someone massively anti-NHS will struggle to disagree with "Whatever problems the NHS may have, its commitment to free treatment for everyone means it is still one of our great national symbols") and the poll is pretty much meaningless now.

A fair question would have been 'What do you think of the NHS?'
a) I am happy with it, keep it
b) I am happy with it, but I feel there may be a better solution
c) I am unhappy with it, but do not feel there is a better solution
d) I am unhappy with it and it needs changing

I suspect you wouldn't get 70% picking a) from that list.

Shafiq said...

Mark M

Last month, it was reported that MRSA rates have been dropping for four consecutive quarters. In other words the number of cases in 2008 was less than in 2007 - I say that is the right direction.

As for your question: What do you think of the NHS, I very much doubt you'd get many people picking D, which is what Mr Hannan is calling for.

Chirimolla said...

Mark M

You're right, those MRSA figures from 2007 are cherry picked.

How is one disease representative of all health outcomes?

The trouble with using reported figures for just one disease is that they are susceptible to reporting bias. i.e. the rate of MRSA infection may have remained the same, but reporting standards toughened.

Go on - try and meet Sunder's challenge of finding some representative peer reviewed data to support your view.

Mark M said...

You must have missed the point of my first post.

Sunder's evidence is also cherry picked and barely supports his view anyway. He tries to put down Hannan's view that "Britain has the worst health outcomes in the west" by quoting from a journal that doesn't once use the words 'healthcare' or 'NHS'. Hardly supporting evidence when it's 3 years old and doesn't even mention your subject matter.

holgate said...

I'd always wondered what happened to that grandstanding OUCA hack. He's really just trolling for attention, though.

I'm reminded of the post-2001 Tory policy review, which involved a tour of various countries to see how they did healthcare, and notably did not include the US. When Britons visit the US and see that their travel insurance covers $10m in emergency coverage, they remember it.

At the same time, whatever comes out of Obama's push for healthcare reform will not resemble the NHS. Nor will it resemble the Canadian provincial system. Which makes Hannan an excellent slayer of strawmen.

(Still, I'll point to the Commonwealth Fund's ongoing comparative study.)

As for Mark M, I'm not sure if it's worth waiting for him to come up with a coherent rebuttal, after three attempts that will be scored as "played and missed".

Mark M said...

Perhaps then Sunder would like to spell out exactly where it is in these journals that counter's Hannan's point of "Britain is the Western state where you'd least want to have cancer or a stroke or heart disease".

He emboldens a passage that says "The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer".

What relevance does that have to the quality of care available? At what point in these journals does it says "Thanks to their nationalised system, Britons enjoy a much greater quality of care than the US" or equivalent?

Of course, if you knew anything about Hannan you'd know he isn't proposing we adopt the American system. He would rather than Singapore system. What he is actually doing is saying to America "you don't solve your healthcare problems by nationalising it". Sound advice really.

x said...

"1. Does Britain have the worst health outcomes in the west?"

The problem with this is that Hannan didn't actually write this, so this is a strawman argument -- your own quote of him reads "some of the worst health outcomes in the industrialised world". Your question changes "some of the worst" to "the worst", and also changes "industrialised world" to the west, perhaps you could explain what you think the two terms mean, or if you think they mean the same thing?

You comment that "Progressive Vision"'s is beginning research that "it already knows will show why Singapore's health outcomes could be replicated in Britain if we ditched the NHS", however I see no indication of this in the referenced page -- they say it is worth serious investigation and research but I don't see them saying that their outcomes could be replicated in Britain (or that they already 'know' this).

Your other comments on "Progressive Vision"'s website that it does not have a publications or research section are strange -- if they say they are only "beginning more detailed research" how would they have something to publish or research to show?

In my opinion, the section regarding "Progressive Vision" contains a number of loaded words designed to attack what they say by attacking them (a fallacious argument).

You go on to use data from the Journal of the AMA, writing a number of paragraphs on this subject as part of the "Fact check", however the AMA article is referring to health incidents, and says nothing about survival rates, treatment, etc. From the context within Hannan's article it appears he was referring to what happens after you've got cancer or heart disease, which renders pretty much your whole "Fact check" point moot.

Regardless, whether the UK is better than the US (or worse, and of course it depends on how you define "worse" and "better"), is utterly irrelevant without any other information -- the UK could be ten times as good as the US, but it would be meaningless if most other countries were twenty times better (obviously I've picked some random numbers there).

"2. Public opposition to the NHS"

I'm not sure what you're actually trying to fact check here -- Hannan said that he "wonders", implying he doesn't actually know, so you can't be fact checking that.

It's also not clear that the YouGov poll is asking the same question Hannan is asking (I'll set aside for the moment that I think the YouGov question is a loaded question).

Even with that, I think drawing the conclusion that there's pressure for "scrapping the NHS" is a difficult one -- is this what the people polled actually meant, or were they just picking something from the limited options? Were they asked about scrapping the NHS?

Of course, using the exact same logic, you could just as easily have written "But there is some pressure among Labour voters for rethinking and even scrapping the NHS."

You write "Is the NHS safe in their hands? Not if Hannan gets his way." But it isn't clear what you mean by "safe", or what Hannan thinks should be done with the NHS either (or what you think should be done with it for that matter).

You even go on to say that he is a backbench MP (so his views are not necessarily that of the party), but then imply that because he is developing a profile as a hero of the grassroots (which is an unsupported claim) he will have a better chance of getting his way; he can be a hero and not get his way of course. Nor is it uncommon for members of the same party to disagree, sometimes radically. You also mention his keynote speech, but it's difficult to make any judgement on this as I don't know what it will be about, do you? Does it have anything to do with the NHS at all?

Your second to last paragraph repeats the claim that Hannan wants the NHS to be scrapped -- could you direct me to a source for this claim? Note that saying something has failed is not the same as saying it should be scrapped.

According to the OECD, the UK rates as follows in 2005 (only data I have access to), I've included data from the US since you've used them in your post and Germany and France as a comparison with two randomly picked (read: I saw them in the list) European countries :

Death from heart disease per 100,000 population (23 listed): 13th 49.3; France 2nd 22.5, Germany 12th 48.3; US 7th 40.3; Japan 1st 18.4; Hungary 23rd 71.7

Death from cancer per 100,000 population (24 listed): 18th 175.6; France 15th 166.2; Germany 11th 161.2; US 10th 159.8; Mexico 1st 96.8; Hungary 24th 242.0

Data from the ONS for 2005 (most recent report I could find) shows:

Death from cancer per 100,000 population (19 listed): 8th 216.9; Germany 4th 215.3; Cyprus 1st 149.6; Hungary 19th 330.8

Death from heart disease per 100,000 population (19 listed): 10th 141.5; Germany 8th 150.4; Portugal 1st 71.9; Lithuania 19th 490.6

holgate said...

At what point in these journals does it says "Thanks to their nationalised system, Britons enjoy a much greater quality of care than the US" or equivalent?

Try the Commonwealth Fund study for size.

The problem that you and Hannan face is that you're treating the set of those who lack access to healthcare in the US as though they don't need healthcare.

To return to his contention: there are western states where cancer, a stroke or heart disease might leave you dead sooner than others, but there's only one that regularly bankrupts those afflicted.

What he is actually doing is saying to America "you don't solve your healthcare problems by nationalising it". Sound advice really.

Oh, whack that scarecrow, Mark M! Kick old Wurzel in the nads!

What he's doing is wilfully reinforcing a bullshit Fox News narrative about scary, scary "socialized medicine" that few people will see back in the UK. You know that, I know that, he knows that. Perhaps he's thinking about parlaying it into a cushy US think-tank gig alongside Iain Murray and the other Thatcherites-in-exile: people over here will swallow any old bollocks delivered with that accent.

Rathfelder said...

Arguments about how many people die from which diseases don't get us very far. Life expectancy is a better measure. Wilkinson and Pickett provide convincing evidence that in developed countries inequality is a key determinant of this. The USA is amazingly worse than almost all developed countries, despite spending much more on health care than any of them.

Richard said...

Thanks for this. I guess Hannan is letting the cat out of the bag. These comments from him are not just his personal opinions but are core Conservative opinions from Central Office. Cameron says he wants to roll back the state, but he cannot do that when the state runs the health system. The NHS is a fifth of government public spending, so if he is shrinking government he cannot ignore that fifth. The Conservative party are using Hannan to test the water to see if the public could stomach the sorts of cuts that he's planning for the NHS.

Bob Piper said...

So, Mark M's 'fact checking' involves 'facts' from an article in the Telegraph which are two years old. Well, here's an article with 'facts' from the Telegraph from 2 months ago which disprove his 'facts'.

mr-money said...

Daniel Hannan is correct. All you have to do is walk into an NHS hospital and see for yourself.

It will take hours before you are treated. In fact, it's almost certainly days. It happens to me every time I use the damn system. The system that Hannan promotes is vastly superior.

And by the way, old people have paid for this system their entire lives. They deserve to be treated, yet a lot of the time, old people will be denied treatment.

voyou said...

Mark, your numbers show that the incidence of MRSA went down from 2004 to 2007. 3,689 cases over a six month period is equivalent to 7,378 cases over a 12 month period, which is greater than the 5,000 cases in the 12 months that make up 2007.

Shafiq said...

Mr. Money,

I don't know about you, but the last couple of times I've been to an NHS hospital, I've been really impressed. I was dealt with straight away and had a choice of 3 GPs surgeries, two healthcare centres and a hospital to go to (all within a mile radius of my house).

I'd rather have our NHS than the US system, any day. Ideally, we'd have a Singaporean system but all experts have concluded that such a healthcare system is impossible to reproduce.

Old people aren't denied treatment because it costs too much, that's ridiculous - but if a certain treatment is going to extend their lives for a bit without improving the quality or the comfort of it, then it makes no sense to use the treatment.