Healthcare, Pensions & Ageing Populations

[Jubal]

(Split from World Politics and Elections)

France meanwhile is somewhat a little bit on fire due to Emmanuel Macron's attempts to reform the pension system to cut its costs. My sympathies tend to lie with people who want good pensions, though I'm not sure a lot of people on the left have really gone out and outlined reasonably just how much taxes are going to need to go up in the coming years, especially on businesses and the middle classes, to support the vastly larger pension population Europe now has. I suspect more and more countries will end up relying on a UBI-style state backed pension, because private pension systems just have too many holes in them now, but that may lead to worse outcomes for a lot of middle class pensioners (who will pay more tax and get less pension, in order to support working class pensioners - which is a necessary and morally decent thing, but may nonetheless go down like a cup of cold sick among sections of the electorate with high propensities to vote). The other thing I think is terribly urgent is some pretty radical rethinks of how we do healthcare: we really need to shift to a place where we refocus on trying to give people fifteen healthy years after retiring rather than thirty increasingly frail ones, but some of the things needed for that, like more early-intervention care on what people see as "minor" issues that affect quality of life at the probable expense of spending as much on e.g. continually improving cancer or heart care to keep people's bodies physically technically functioning for longer, are again quite possibly likely to be unpopular. It's a hugely difficult area & set of issues.

[Pentagathus]

Re the healthcare issue, it's already been recognised by governments but the issues are far deeper than just politics. The NHS has been focused on these long term interventions for a while now, but on top of long waiting lists, staff and resource shortages (which have been massively exacerbated by Covid) there's also the fact that these interventions require patients to take the responsibility for their own health. There isn't any easy solution to that, education is crucial, and funding for grass roots sports, having more PE in schools (ideally alongside education on why we do PE), workplace health interventions etc would help, but the fact is a lot of people just don't really think about their health until they're feeling the effects of their life long habits. Quite often it's already too late to avoid complications at that stage, although we do focus on exercise and education based rehab alongside medical management for cardiac and pulmonary issues, which can be very effective if the pre-existing damage isn't too severe or isn't degenerative.
For certain health risks like smoking we've seen a good long term decline in smoking rates, however someone who's spent 30 years heavily smoking before quitting at 55 has already done a lot of damage to their lungs, brain and body, even if they haven't developed emphysema. Likewise, even though resistance training is beneficial at any age, if you are taking it up at 65 because you've developed osteoporosis, then the fact is you're a few decades too late to develop much bone density. And again, this is all assuming that we can convince these older populations that they need to change their life long habits and develop healthy ones.

Whatever political changes we make, providing health and social care for an aging population is going to be extremely expensive, and is going to strain the current working age populations. Political changes are obviously still required, our rates of childhood obesity are still rising (there was a big spike during the pandemic thanks to lockdowns) and we can't afford to abandon the health of our younger populations just to focus on keeping old folks going.

On the brightside, I have seen a lot more young people (even including school kids) going to my local gym, and in general there does seem to be more awareness and general debate on these issues, so hopefully this is a real trend that we'll see evidence of in the next few years.

[dubsartur]

The other thing I think is terribly urgent is some pretty radical rethinks of how we do healthcare: we really need to shift to a place where we refocus on trying to give people fifteen healthy years after retiring rather than thirty increasingly frail ones, but some of the things needed for that, like more early-intervention care on what people see as "minor" issues that affect quality of life at the probable expense of spending as much on e.g. continually improving cancer or heart care to keep people's bodies physically technically functioning for longer, are again quite possibly likely to be unpopular. It's a hugely difficult area & set of issues.

Chopping 15 years off national life expectancy seems like a pretty drastic step, even by Boris Johnson and the Great Barrington Declaration's standards.  Could you explain further?

Edit: the ONS in the UK says that "Life expectancy at age 65 years was 18.5 years for males and 21.0 years for females"

In the USA, a big problem is that many poor people have no access to fresh food, and many middle- and upper-class people live places where walking or hiking is useless and dangerous.  This leads to bad health because people who can only buy processed food and have no reason to walk or bike an hour a day are unhealthy (and to fix it you need to change zoning laws, policies around roads bike lanes and sidewalks, and subsidies for different kinds of food).  Likewise if the local fast food joint is the only clean, bright, orderly space in a neighbourhood that poor people are allowed to hang out in (and if the only things for the underemployed to do are sports, smoking, and drinking).  There are also specific issues like food stamps in the USA covering groceries but not pots and pans to cook them in or crockery and cutlery to eat them with (a formerly homeless woman from California who I know got caught by that one).

How do things compare in the UK?  I get the impression that many former industrial cities such as Leeds are terribly bleak.

[Jubal]

So, I don't think by "refocus" I meant we should try and cut life expectancies, I was rather more talking about priorities and shifting to take comparatively minor quality of life stuff more seriously. I'm not saying that we should cut life to 65, I am saying our priority and success criterion should more be focused on good health until the current life expectancy of eightyish over and above trying to reach a life expectancy of 95+. I do take both your points - healthcare has managed to shift focus on some elements, but it's held back by several factors. Staffing is a really major issue, as is people being in environments and financial conditions that are better suited to exercise etc. The cost of living crisis will definitely not have been good for diets etc, I guess.

I do think that at the research and treatments end there's still an actual gap: knowing family members with (and myself having a condition highly likely to turn into) arthritis, it's extremely frustrating seeing people's capabilities to do longer walks or crafts etc visibly decline, they can't get GP appointments and if they did then these things get basically shrugged off more often than not because they're chronic rather than acute. Treatments are advancing in some of these sorts of areas, but slowly given how common these illnesses are. A quick google (for example these UK figures from a few years ago) suggests that we're still spending on cancer research several times more than on arthritis or gastrointestinal issues or indeed most other disease areas: not that I think we shouldn't be trying to cure cancer, obviously, but I do think there's an imbalance at the R&D end where widespread, chronic, non life threatening diseases lose out badly for research funds.

Also, topic split as we're not really on World Politics and Elections any more and this is an interesting and deserving discussion in its own right.

[Pentagathus]

There's also currently a shortage of placement opportunities for healthcare students (or at least for Physios, can't speak to other professions but I think other AHPs are also facing this issue) in the UK and apparently out of the UK too. Not really sure why this is, perhaps because of high demand for workers to be working and not having time to act as educators on placement right now, I think this was happening to some extent before covid (I was told it was by Edinburgh Napier back in 2019 or 2018, but I don't know if that was actually true or if it was just a problem facing them since their physio course was quite new), and like everything else the pandemic has worsened it.
Quite worrying considering that healthcare degrees really can't produce effective healthcare professionals if they don't also have good quality placements. I suspect we really need to rethink how AHPs are trained, there is currently an apprenticeship route in the UK but it's very difficult to find a trust that will sponsor you since they have to pay you at a band 4 level and pay your tuition fees (which I think are the full 9,250 a year despite the university not being even close to providing full time tuition in this case). My experience as a current physio student is that the degree course is very lacking and seems to heavily rely on the placement component, but whether that's just because my university is failing or if this is the national standard I don't know.

[dubsartur]

In Canada, like the USA, the doctors' professional associations limit intake of medical students (and limit what anyone without a MD can do) to keep their incomes high and total spending on doctors' wages under control.  Is it the same in the UK?

Very tired.  It seems like people's experiences with doctors is not useful in an analytical / policy discussion because they are so individualistic (and depend so much on individual people's ability to prod doctors into doing their job, which grows out of sex, ethnicity, class, etc. but is also a skill and a personality trait).  They are useful in a 'listening to a friend gripe' conversation, or maybe a conversation with local friends and relatives, but not an analytical / policy discussion between people in different countries.

It also seems like there is a basic difference between older people, working-age people, and youth.  Among Brits from say ages 18 to 60, what are the typical characteristics of someone who is physically inactive, has a diet heavy in processed foods and alcohol, and abuses substances such as weed, alcohol, or tobacco?

[Pentagathus]

In Canada, like the USA, the doctors' professional associations limit intake of medical students (and limit what anyone without a MD can do) to keep their incomes high and total spending on doctors' wages under control.  Is it the same in the UK?

Not as far as I know, I'm pretty sure the number of available educators would be the main limiting factor here. I don't think many doctors see training more doctors as a professional competition, there's clearly a shortage in most areas. IDK about the politics behind it but many GPs use physician's associates, nurses and AHP's to offload much of their work. It also seems that AHPs and nurses are more commonly being trained to be able to prescribe medication here too. So if the doctor's associations are aiming to limit all this they are not being very successful.
With physiotherapy I get the feeling that many current physios (particularly university educators I expect) feel that a university degree route is the necessary route, and that an apprenticeship route (even though it also necessitates studying at university) is not sufficient. But I would say that's from a kind of professional snobbery/elitism more than wanting to reduce competition.

Among Brits from say ages 18 to 60, what are the typical characteristics of someone who is physically inactive, has a diet heavy in processed foods and alcohol, and abuses substances such as weed, alcohol, or tobacco?

I'm not sure if there are typical characteristics, that's a very broad population unfortunately. It's probably most of the population, iirc it's something like 50% of men and 66% of women don't meet the national minimum exercise targets (which is only about 150 minutes a week of low intensity activity like walking).

[dubsartur]

The ways I have seen it explained are that it is to protect each individual's access to the doctors' share of overall healthcare spending.  For a particular healthcare budget, the more medical doctors, the less each of them can be paid (especially in the USA with its crazy income inequality and expensive tuition fees).  My province is starting to work around this by empowering pharmacists to proscribe medication for more conditions.

In my province another problem is that the GPs have the same voice in salary negotiations with the government as say the plastic surgeons.  Each specialty gets one vote on the negotiating committee.  So general practitioners and family doctors don't get paid enough to cover the overhead and stress of running a business and dealing with a wide range of conditions, because if they got paid more some other specialties would have to get paid less (and they are the biggest specialty, but that does not give them more votes).  So they leave the specialty and put more strain on the remainder.  This is also something I have heard, but from more credible sources than the people interpreting how medical doctors lobby the government on medical school admissions.

[Pentagathus]

I know here most (if not all?) GP practices are privately owned, not entirely sure how the funding works out but I think they have a separate pay negotiations from the NHS staff pay. NHS pay is a bit weird, most medical staff are on banded pay but at some point doctors get a separate pay scale, not sure at what level. Having set paybands for each level is presumably to prevent nepotism and whatnot, but unfortunately it also means you can't offer more pay for the armadilloty jobs that people don't want to do (like discharge coordination ewww), so those armadilloty jobs tend to stay understaffed or (sometimes) staffed by armadilloty staff.

[dubsartur]

Humh ...

In a case I know better, tenured and tenure-track university faculty in Canada form a powerful union.  But eg. graduate students and sessional instructors are not members, and as tenured faculty win generous wage increases, administrators try to hire as many non-union members as possible because if the budget for tenured faculty goes up in constant dollars every year something else has to go down or the government has to keep increasing the real value of payments to universities (Baumol's Cost Disease).  I see tricks like forcing small (= weak) departments to merge so the university can lay off a department secretary.  If the tenured faculty worked in solidarity with other teaching and research workers, they would probably have to accept lower starting wages and lower annual increases.

So the claim about medical school admissions in Canada was plausible to me when I heard it.

Running a private practice in Canada has a lot of administration and costs (eg. hiring an admin assistant and renting space) which not all specialists face.

[dubsartur]

Treatments are advancing in some of these sorts of areas, but slowly given how common these illnesses are. A quick google (for example these UK figures from a few years ago) suggests that we're still spending on cancer research several times more than on arthritis or gastrointestinal issues or indeed most other disease areas: not that I think we shouldn't be trying to cure cancer, obviously, but I do think there's an imbalance at the R&D end where widespread, chronic, non life threatening diseases lose out badly for research funds.

I have been reading up on some things and cancer jumps out as a common cause of death in the North Atlantic, from 30-somethings with their first child on the way, to people in their 60s and older.  Its also an extremely complicated family of diseases and has obviously miserable consequences.  So I think a major reason why cancer gets a lot of funding is that it kills and maims a lot of people.

In addition, the health problems of sedentary life and substance use are not problems that benefit from high-budget industrial research.  Changing people's behaviour is hard and so is rebuilding cities so people find it natural to move under their own power, buy lots of fresh food, and limit their alcohol, tobacco, etc. consumption.

Derek Lowe has a blog about why drug discovery is costing more and more per useful drug, similar to Sabine Hosenfelder's writings on why spending on theoretical and particle physics is not producing major breakthroughs https://www.science.org/blogs/pipeline

[Jubal]

I broadly agree that's why cancer gets a lot of funding: it's scary and deadly! But my original case was just that, precisely because of that, funding may consequently be overbalanced towards deadly things as compared to not-deadly-but-reduces-quality-of-life things. And I think lifestyle related problems are only one part of the puzzle here: certainly for the sorts of physical health conditions I have, they're not fundamentally lifestyle related and it kind of feels most of the time like society pre-emptively has given up on trying to improve the damage they do to my productivity or quality of life. And that seems an inefficient plan, on the whole.

[dubsartur]

Scientific medicine has always been good at acute conditions and prevention (the late lamented public health movement, killed because applying its principles to COVID as to cholera would have been inconvenient) but not chronic conditions for reasons which people with a background in systems, causation, or Seeing like a State could say a lot about. That seems like a different issue to which acute conditons get research funds though?

Edit: I am told that ME/CFS are good examples of how this works, neglected because they are chronic conditions which are hard to define let alone cure, then COVID arrives, lots of people know someone who was disabled with ME/CFS like symptoms after a viral infection, and suddenly research speeds up because "post-viral infection syndrome" is much more addressable than "vague symptoms of tiredness and sensory sensitivity with unknown causes."

[dubsartur]

pterry agreed with you that chronic conditions like Alzheimer's and dementia are underfunded relative to cancer https://en.wikipedia.org/wiki/Terry_Pratchett  I don't really have any expertise in this area though.

Biomedical researchers such as Derek Lowe seem to think that a lot of medical research funds are not spent very effectively https://www.science.org/blogs/pipeline

[Jubal]

Interesting side note to this: a scientist looking at extreme high ages (100+) thinks that most of the "data" on where people are very old has holes in. Like "no birth certificates, no death certificates, and is probably mostly identifying hotspots of pension fraud" levels of holes:

https://theconversation.com/the-data-on-extreme-human-ageing-is-rotten-from-the-inside-out-ig-nobel-winner-saul-justin-newman-239023