Why Rudy Giuliani was right about the NHS

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Rudy Giuliani has been in a spot of hot water with his claims about prostate cancer survival being better in the US than in the UK

Even over here. The Health Secretary has been defending the record of the NHS, arguing that Rudy's attack on "socialized" healthcare is wrong and the NHS record on prostate cancer is good.

Now David Gratzer, the man whose article gave Rudy Giuliani his cancer survival data, has waded into the controversy on the Mayor's side. And I'd say his points were pretty strong:

Let me be very clear about why the Giuliani campaign is correct: the percentage of people diagnosed with prostate cancer who die from it is much higher in Britain than in the United States. The Organisation for Economic Co-operation and Development reports on both the incidence of prostate cancer in member nations and the number of resultant deaths.

According to OECD data published in 2000, 49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and, consequently, that just 43 percent survived. Economist John Goodman, in Lives at Risk, arrives at precisely the same conclusion: “In the United States, slightly less than one in five people diagnosed with prostate cancer dies of the disease. In the United Kingdom, 57 percent die.”

None of this is surprising: in the UK, only about 40 percent of cancer patients see an oncologist, and historically, the government has been reluctant to fund new (and often better) cancer drugs.

Here is Gratzer's explanation of the error made by the critics:

So why do the critics think that Britain’s survival rates are as high as America’s? The main reason is that they are citing overall mortality rates, which are indeed, as Ezra Klein writes, similar across various countries.

That is, the percentage of all Americans who die from prostate cancer is similar to the percentage of all Britons who do. But this misses the point, since a much higher percentage of Americans than Britons are diagnosed with prostate cancer in the first place. If you are a patient already diagnosed with prostate cancer, like Rudy Giuliani, your chances of survival—as Giuliani correctly said—are far higher in the United States.

So Gratzer is arguing that people in the UK are dying of undiagnosed prostate cancer and are not counted at all. Perfectly possible.

And this makes sense as an explanation given that, as Clive Crook points out, the UK does much worse on cancer overall than the US. Why, apart from the Gratzer argument, would prostate cancer be an exception?

Giuliani's US critics are missing the point about the British healthcare system.

First, we spend much less money per head than in the US. This is a deliberate feature of a "socialized" system. If everyone in the UK bought as much healthcare as they wanted given their income, spending would be greater than it will ever be under a taxpayer funded system.

The US spends $5274 per head and we spend $2164. The NHS aims to use its monopoly buying power to achieve greater value for money, although there is some evidence that it doesn't succeed as well as it thinks it does. But even if it did brilliantly in achieving efficiency gains it would be surprising if that disparity in spending did not produce some difference in outcomes.

Second, the UK system is not designed to produce optimal outcomes. Who would design a monopoly system, centrally managed with almost no market incentives, if optimal outcomes was the aim?

No, the UK system is aimed at something else - equity. It's main objective is to ensure universal and equal coverage of healthcare to all and this is achieved (or, at least, an attempt is made to achieve it) by sacrificing efficiency and suppressing professional wages to make the service free at the point of use to all residents.

Rudy Giuliani's point was surely, precisely that. That he prefers the outcome of private medicine to that of a socialised one.

It is perfectly reasonable to argue that the US system is unfair to the uninsured, or that the wages of medical staff should be suppressed to keep down costs. But these arguments should be made explicitly if they are going to be made at all.

To argue that the two systems achieve the same outcomes for someone like Rudy Giuliani and his prostate cancer is frankly ridiculous.

Comments

[Bill]

The ideological necessity to defend the NHS with invalid data is almost as tragic as the higher incidence of prostate death, under the NHS, in the UK.

[Chris]

What an ideological piece.
1) The point of the NHS is to subsidize people who can't afford private healthcare - not to equalize all treatment.
2) To judge an entire health system based on prostate cancer is absurd. 3) We know the UK does not have the best publicly funded health system. Maybe there is a reason Guiliani didn't compare with outcomes in France or Germany or Scandinavia?

[Dave Parker]

Giuliani could afford the best healthcare available - so he received the benefits of a prostrate treatment regime developed under socialised medicine in Europe. Millions of his fellow Americans can't afford even the most basic treatment. They die even more frequently from undiagnosed prostate cancer - one reason why life expectancy over much of the US is significantly lower than in the UK. Infant mortality rates are much higher as well. In the US rich people do fine and doctors are very well paid - I know which system I prefer, and only the selfish, the greedy and the brainwashed could defend the gross inequalities in the US.

[Richard Mann]

One must presume that the actual incidence of prostate cancer is comparable in both countries. Therefore if the mortality rate is the same, the higher survival rate in the US after diagnosis can only be because many of those extra diagnoses are younger people, i.e. the more easily treatable, caught by an aggressive screening programme. Therefore, once diagnosed the chance of survival once again becomes roughly equal. Indeed, if the mortality rate in the US is equal to Britain despite these early diagnoses then it implies the subsequent standard of care is worse. For the record I would advocate private medicine on the principle of individual choice. But it seems the Americans do not get twice the standard of health care for twice the cost.

[Andrew O'Neill]

This reinforces the case for a French style middle way between private insurance and government owned health system. The french system involves personal health insurance policies paid for by the tax payer but the policy holder has the choice of which hospital to use, encouraging competition between hospitals to achieve 'optimum' service.

[NMapstone]

These figures are all misleading.
Prostatic carcinoma is not far off ubiquitous in the elderly male if you look hard enough for it.
So we could institute a screening program in elderly males and diagnose lots of cancer. The elderly males would die of something else and instantaneously our figures are improved - without treating a single patient!

[Pete]

I wonder how high the effective cost-per-head of healthcare in the UK is when you factor in, for example, all of the extra days of work lost to inadequately treated illnesses and longer waiting lists?

The budget option (i.e. the NHS) may well turn out to be more expensive when one considers the many consequences of second rate healthcare provision.

[Nick Strong]

It is a pity that Mr Finklestein did not consult a doctor before jumping to his conclusions.

The hypothesis that patients are dying in the UK of undiagnosed prostate cancer is ridiculous. Patients do not die of prostate cancer unrecognised. If the disease has advanced sufficiently to cause death the signs are obvious and would be cited as the cause of death. So there is not an epidemic of undiagnosed prostate cancer deaths in the UK. It remains the case that the statistics show that prostate cancer death rates are approximately equal in the two countries.

So why might a larger proportion of patients diagnosed with prostate cancer die of it in the UK that in the US? To understand this one has to understand the nature of the disease and the different approaches of the health systems of the two countries.

Prostate cancer is very common among older men. At post mortem examination of patients dying of other causes an incidental finding of symptomless prostate cancer occurs frequently - as many as 80% of men over 80 . Hence the saying about prostate cancer that goes "you are much more likely to die with it than of it". In the UK most patients with prostate cancer do not have the condition diagnosed prior to dying, and the cancer has no bearing on the cause of death.

On the other hand in the US there is a vast industry of early cancer diagnosis, hence your chance of being diagnosed with early symptomless prostate cancer before you die - of something else - is much higher in the US that in the UK. So as a result it is true to say that a smaller proportion of all patients known to have a diagnosis of prostate cancer during life will die of it in the US than in the UK. But it is not true to say that if you have prostate cancer - either diagnosed or unknown - that your chance of dying of it differs between the two countries. In fact the similar death rates per head of population strongly suggest that there is little difference.

The likelihood of developing prostate cancer is the same in the US as in the UK. The rate of diagnosis is higher in the US but the death rate is the same. So the only conclusion that can be drawn from these facts is that the US health system spends a lot more money than the UK in the diagnosis of early prostate cancer without any demonstrable benefit.

[Doug]

You argue that the undiagnosed who are not counted in the statistics skew the statistics but exactly the same argument can be made of the uninsured who never show up in doctor's clinics. Currently estimated at around 45 million though some independent investigators (Families USA) think it might be as high as 90 million. How do you think that skews the US numbers?

[Hermann Burchard]

Dan, may I propose "equalization". not "equity" were you write "No, the UK system is aimed at something else - equity." Equity in English common law is basic justice or fairness. It's not unfair if industrious people afford better lives than laid back bums (like myself). The idea that all get the same health care regardless of effort to pay for it or effort to stay well is not what equity used to mean but new-speak. spin dogmatism, or demagogery.

[joel]

If the American model is so good, why is it that 18,000 die each year because of lack of resources (money) to get to a doctor.
Over 50 million Americans lack health care insurance and suffer the consequences. The US is the only "first" world country without humane universal health coverage.
There are many nations' health care systems that are worth looking into so as to craft a decent system, learned from others' experiences.

[ellen]

it seems unlikely that people would be dying in large numbers of undiagnosed prostate cancer. much more likely, given these statistics that the current treatment is pretty ineffective - that those who get fast-growing forms of cancer die of it, those who get slower cancers tend to die of something else first, and that the british system is working more efficiently by spending fewer resources diagnosing an illness where treatment makes little difference...

[Benedict White]

The problem here is not the difference between a socialised system, and an insurance based one, but the difference between one where the "customer" can kick the system and one where they can't.

The problem of course is that one where the customer can kick the system will favour those who either know and/or care over those that don't. This produces inequality as people who could survive were they both willing and able to use the system don't because they don't.

Labour tend to solve the inequality problem by making the system rubbish for everyone, whereas they could allow the inequality to develop and use that to educate those who would otherwise remain ignorant.

[Anthony NYC]

Hi Daniel - take a look at the excellent Associated Press fact check of the entire Rudy argument.

The main point is:

"Doctors in the two countries have different approaches. That's because while aggressive prostate cancer can kill, it often grows so slowly, and is found when it's so small, that men die of something else before it ever threatens their lives or even causes symptoms.

So there is disagreement — and studies conflict — over whether the chances of survival for men with low-risk tumors really improve with aggressive treatment, or if they can be closely monitored and treated only if their tumors grow, thereby avoiding side effects such as impotence and incontinence."

http://ap.google.com/article/ALeqM5jTQuw866PTaudC0CeXN-518klm1gD8SLRU080

The claims also won a maximum 'four pinocchios' from the Washington Post.

I think you may struggle to use this to advance a pro-free market approach to healthcare.

[Bay Given]

Surely all that these numbers say is that the US diagnoses a higher proportion of prostate cancer sufferers whose illness turns out not to be fatal...

Good news if you're already diagnosed, but of no import to the population at large. BUT does this mean Americans have a far greater incidence of PC but treat it better? Or that their PC is less deadly? Something vital is missing here.

From Finkelstein:

"So Gratzer is arguing that people in the UK are dying of undiagnosed prostate cancer and are not counted at all. Perfectly possible."

The figures don't support this at all. At least, not the ones we've been given. The numbers in the papers show that roughly the same proportion of people (men) die from PC in both societies.

[stephen s]

"But this misses the point, since a much higher percentage of Americans than Britons are diagnosed with prostate cancer in the first place."

Incredible. Best you think about that some more.

How gullible are you? Truly?

[Ian]

An important point missed is that in the US recovery rates are better because they treat cancer more agressively. This holds true not just for comparisons with the UK but also with other developed nations e.g. Canada. This may, as in all things, have an economic facet but it is mainly a clinical practice issue.

It is also interesting to note that the commentator also passes by the point that more Americans get prostate cancer and all cancers for that matter. Does this not suggest that a National Health Service is actually doing an overall better job in keeping its citizens/customers healthy to start with. Or perhaps Americans are more stressed about keeping their jobs so that they can pay their medical bills.

[Stuart]

OK, but the main criticism of the numbers is that in the US there is a screening programme for prostate cancer (like we have here for breast and cervical cancer) that picks up more cases, earlier and less severe. We all know that survival chances are related to how early it is picked up. To truly compare like with like we need to see how many cases as severe as those diagnosed here are treated successfully, not all cases.

More importantly Giuliani has probably made an eloquent case for comprehensive screening for prostate cancer. And who knows, maybe if we did have such a programme the NHS could even beat the inefficient and unfair US system...

[william]

One way you could increase both survival rate and diagnosis rate for prostate cancer is simply to mistakenly diagnose a large number of people as having prostate cancer when they don't actually have it. Tests for prostate cancer do have rather higher false-alarm rates than you'd like, and economic forces in America do encourage diagnostic false alarms via a "better safe than sorry" attitude to avoiding litigation.

Those falsely diagnosed people will then survive because they never had prostate cancer in the first place. It's a big win for the medical profession, and the statistics, but not so great for the patients.

[Dectora]

Is record collecting identical in both countries? A very interesting article was published in The Guardian by a Great Ormond Street consultant which detailed his astonishment at the very high survival rates of children suffering from certain cancers in a US hospital, which used methods identical to those in his own Hospital. He was allowed to see full medical records of all children treated and discovered the magic formula; exclude on no reasonable grounds many children for whom treatment has failed. Easy when you know how , isn't it?

[chris lee]

Finkelstein is lying with his stats here, he's not comparing like with like.
The portion of Americans who can afford to be diagnosed with Prostate Cancer are the same group of people who can afford the best treatment. The portion of Americans with Prostate cancer who are not diagnosed with it, contain that group who cannot afford to go to the doctor in the first place. Nor can they afford treatment. So they don't show up in Finkelsteins figures at all!
In the UK that is not the case, access to the diagnosis is more or less equally available to all.
This is schoolboy stuff, Finkelstein should do better.

[Steve]

I think thus piece shows why a little knowledge is a dangerous thing.

Mr. Finklestein's ability with statistics may be just about adequate, but his appreciation of comparative context appears to be totally absent, as others have observed.

What a shame that an able man let's himself down so badly.

[Mike]

I have lived in the USA for 20 yrs. I now spend several month a year in my home in the UK and I am happy to pay taxes in the UK. I am lucky to be healthy, but believe me, Britain does not want to go the US way in medicine. The British spend about 30% compared to the USA, per capita on health care, yet everyone can get treatment. About 40% of US don't get on a waiting list and 60% are under insured, so the stats are a joke. Sure, people like Giuliani are in fine shape in the US system, he probably doesn't pay himself and has the money in any case. Giuliani is trying to undermine the system in the UK and open the door to big US med business to sweep in. Sadly, the Brits seem gullible and buy into US garbage. Or do the Brits want to spend $700 (£350) for a 12 mile ambulance ride and about £2000 (£1000) a night just for a hospital bed, not including extra for any treatment? And that's the cheap part! Wake up Britain get business like; hammer the over charging pharmaceuticals, charge none Brits for treatment at the rate we pay in their countries, stop the waste of Dr's running budgets and get them back to being physicians only and double the NI contributions, we would still be paying 30% less than the US. The NHS is great value for money if run right.

[JOHN CHUCKMAN]

Daniel is so keen to make his right-wing point, he has done a second column on exactly the same subject, only this time more assertive in his lack of knowledge.

The fact is that US healthcare costs per capita are ridiculously high, half again as much as in many other Western countries.

And yet for this avalanche of money, more than forty million are left without coverage, perhaps a hundred million have poor coverage, and the county's vital statistics are not impressive in terms of life expectancy and infant mortality.

It's the world's most idiotic and chaotic system.

[Marcus Cotswell]

Well, he *might* be saying that, I suppose, but what I think he is saying is that more people get prostate cancer in the US. So that even if more of those who are diagnosed surive, overall a similar proportion will die.

So there is an issue for preventive care in the States maybe. But your main point stands - palliative care is better in the States and Giuliani and Gratzer are pretty much spot on.

[Alan D. James]

I recall that Giuliani's comments was a knee-jerk reaction to Michael Moore's film "sicko". I think it would be a good idea to remember - as the Canadian politician Tommy Douglas did (he introduced a free public medical in Saskatchewan, the first province in North America to do so) that privatised medicine will cost at least what a free public medical service would cost - and then add on a bit extra for corporate profits

[Stephen Garramone(Col, USAF, Ret), Melbourne, FL]

Giuliani is wrong. A person diagnosed with prostate cancer in the UK at the same stage as a person with prostate cancer in the US such as with Giuliani himself will have the same survival chances. The treatment regimens and options are basically the same in the Western world. My personal opinion on one of these options "watchful waiting" is that this would be insane. I hope this option is not pushed in the UK.

I think there should be private (or private insurance) medicine in addition to government funded medicine but government medicine should be available with no out-of-pocket expenses for anyone in the country with NO MEANS TEST. It is unfair to have to lose all you have worked for first before you qualify for free medical care (Medicaid). This would cover the people in between jobs, etc.

I do believe in stratification, though. I think the rich who have one way or another gotten an economic advantage or entitled to medical care with frills. That's one of the perks for getting lots of money. Greed is a great motivator in ingenuity (albeit sometimes ingenuity in illegal methods) and must not be discounted. However, the level of availability and competence of care to those without should be on a par with those who have.

I am a physician in the USA and I would like to combine the maintenance of independence of physicians with the guarantee of availability of medical care for everyone without the prospect of losing one's savings or house or whatever.

Stephen M. Garramone, M.D.

[Sue]

Unless an international mandate were instituted for a 100% autopsy rate on all deaths, its impossible to determine what caused a death and what co-morbidities did or did not contribute to their deaths. So, all of this is speculative.

This discussion is pointless medically and politically.

[Corrine]

Great article.

As someone living in both the US and the UK I find the differences interesting.

One one hand, in the US you have to pay for your healthcare by choosing an insurance provider, or if you are benefited as an employee, then you on average pay much less for your healthcare. My monthly un-benefited insurance was about £125-150 in the US. And then there were 'deductibles' and 'copay' which lowered my prescriptions and tests. Still expensive. The idea is that people are made responsible to allocate their funds for healthcare themselves, which doesn't always work, or is always available.

But then in the UK everything is 'free'. But what people don't mention is the fact that the government takes around 12% of each paycheque for many of us for the free healthcare. So we are still paying for it, we just don't have the opportunity to do it ourselves.

Add up your NHS portion of your paycheques and decide how close that amount is to 'free'. I think you'll find you are paying the same if not more than in the U.S. And, that insurance doesn't cover much outside of the country.

There are good and bad things to both systems, for instance it's no one's fault if you have cancer. But in the U.S. if you have an expensive disease you are hit hard financially (unless you are on the dole). Here you don't feel the financial drain as much but the decisions you can make about your healthcare are more limited, which is a whole other cost to consider.

[Alexandra]

I'm an American with great insurance--lucky me. But it is sickening to me that so many people go without insurance, and also that you never know what insurance will pay for and what it won't. You could go bankrupt over the nitpicking that insurance companies get out of paying. I know one woman with cancer who has insurance, but has still had to pay more than $100,000 in out-of-pocket costs. How does this happen? One example: Maybe she has a doctor who is in network, so she thinks she'll be okay. But the radiologist who reads her mammogram is not in network, so she has to pay hundreds of dollars for that doctor's fee. And on and on it goes. It isn't just the actual cost of the services, it's the stress that wears on people of not knowing what their insurance covers. I think the British system is better.

[Eric]

A little sanity please! As an American, let me assure Times readers that the streets here are not filled with the bodies of poor souls dead from lack of health insurance (live 'homeless' bodies with mental and chemical problems- that's another matter!).

Statistics re: the uninsured in the US are often misleading because health insurance is often tied to employment. Americans tend to change employers with some frequency and are not required to buy health insurance between jobs. So 'uninsured' often means not having insurance at sometime in the study period, perhaps due to job change.

The system has many quirks, gross failings, and occassional Michael-Moore-ish nightmares. But it would be better to think of it as different rather than inferior to the British, French, etc. systems.

[DaveOner]

Guys, guys. You're falling into the "cowboys'n'indians" debate trap.

While I, as an American, don't like Rudy at all it would be stupid to say that he (or most candidates these days) are trying to keep healthcare the same.

The debate here is HOW to fix the US system, not if it's better than your's or not. The general Republican debate is against state-run health care and he used your system as an example since most democrats point to EU healthcare as a great model. Whether the statistics brought up are accurate or not is another issue as is how great of a model it actually is.

This debate is actually irrelevant when you look at the whole picture. It's all posturing. Thanks for giving that jerk more press!

[Michael McGowan]

Reading these comments, the most depressing thing to US readers must be the closed mindset of those who reflexively defend the NHS. It is a crude, topdown, politicised, over-bureaucratised rationing system. Its stalinist idea of "equity" is very expensive second-rate care for all... unless you live in Scotland when you get free eye tests and access to cancer drugs unavailable elsewhere in the UK. It is the worst form of publicly-provided healthcare with demoralised staff and negligible accountability to patients. Cross the Channel to see how much better things could be while preserving universal access. The standard "defence" of the NHS never involves pointing out what it does well compared to its European peers because it is manifestly inferior to them. Instead it always defaults to arcane debate about statistics coupled with lots of rubbishing of the Aunt Sally of the US healthcare system. This is not rational debate. It is the hysterical invective of people whose left-wing gods have failed them.

[Dectora]

Daniel, as cancer of the Prostate is close to your heart, may I suggest that you order a copy of Sandra Gilbert's 'Unlawful death' from Amazon. She and her late husband were both full Professors at UCLA when she and her husband made (or were sold) by a colleague at UCLA)the wrong choice. I suggest that you might like to have a stiff martini by your side when you read it.

[James]

The actual title of that book is "Wrongful death" but it certainly seems worth a read!!

And Daniel, really, I expected better of you.

You are usually very convincing but backing a neo-fascists mangling of statistics is really not your style. He misrepresented the data, the organisation which -collected- it admits as much. This is exactly the sort of thing a rationalist such as yourself ought to be opposing. For an ultra-moderniser this smacks of an "Old School" approach to facts and figures.

[Matt]

Gratzer says "In the US ... [about 20% of] people diagnosed with prostate cancer dies of the disease. In the United Kingdom, 57 percent die."

Then he says "the percentage of all Americans who die from prostate cancer is similar to the percentage of all Britons who do."

So is he saying that the UK only diagnoses those with particularly severe/obvious prostate cancer? Because, by his own admission, the overall mortality rate is almost equivalent.

This isn't an argument that says that the UK health system is worse at treating the cancer, it is an argument that says the US is better at checking to see whether men have the cancer (so that their figures of 'diagnosed with cancer' include more men who 'have the cancer and do not happen to die from it'). Even though that's, overall, irrelevant, since Gratzer's own statistics say that the overall mortality rate is the same (ie, the average man with prostate cancer is no better off).

Alternatively, the argument could be that American men are more likely to go to the doctor for vague checks, than UK men.

Is the real message that the (twice the health care spending per head) of the US, compared to the UK, is useless, and hence, the cost of medical care is needlessly inflated in the United States? Is that what Giuliani was arguing?

[alkali]

Daniel Finkelstein writes:

"So Gratzer is arguing that people in the UK are dying of undiagnosed prostate cancer and are not counted at all. Perfectly possible."

Nick Strong writes:

"The hypothesis that patients are dying in the UK of undiagnosed prostate cancer is ridiculous. Patients do not die of prostate cancer unrecognised. If the disease has advanced sufficiently to cause death the signs are obvious and would be cited as the cause of death."

This is the core of the dispute, and it is plain that Strong is right. The symptoms of advanced prostate cancer are unmistakable: painful urination, blood in the urine and (after metastasis) bone pain. It is absurd to imagine that lots and lots of British men are dying of prostate cancer that is never diagnosed, even post mortem.

[bupalos]

Most of the posters here have figured out that the bottom line is the bottom line. The same percentage of people die of PC in both countries. All the rest is political window dressing, the obvious implied difference being that many more people are diagnosed in the U.S. (at great cost), probably with asymptomatic PC that never amounts to anything regardless of the treatment regimine.

Having been around PC most of my adult life, I feel that the "aggressive" approach is pretty stupid. Incontinence, sexual disfunction, and hormone imbalance in my opinion becomes a much greater contributor to the ultimate cause of death than a mild, untreated PC, which is present in 80% (!!!) of elderly men anyway. I know my dad lost a lot of his will when the diapers came. Of course, you never know...but we should at least entertain the notion that many of those who undergo prostate removal and then die of something else may have lived longer without the surgery. Prostate surgery Is one of those typical medical "successes" that may lead to failure elsewhere. This is the kind of error of commission to which the incentive laden US system is prone.

In the UK you spend WAY less and live longer, healthier lives. Parse it however you want, to me, that's the end of the story.

[Paul]

Interesting isn't it that in the UK anyone can have access to treatment, there may be some delays but in the US there is a two tier system of health care. Those that have and those that don't.
Given the choice after experiencing both health care in the UK and abroad where normally good health care is very expensive I'll take the UK.