Editor's blog 17th September 2008: Moral hazard in healthcare

Standing in the Halifax today, waiting to pay in a cheque (I love to swim against the tide), I was reflecting on the current havoc of the financial markets and some things that it means for healthcare.

One thing that it means is that a lot of highly numerate graduate calibre people will be looking for jobs due to the contraction of the investment banking and private equity businesses.

Not all will be suitable for repurposing into the healthcare world, but a few may. They may have some of the skill set that is required to develop commissioning from a theoretical prospect, as it largely remains, into a reality.

Another thing it means is that there is going to be a significant inflation in the running costs of healthcare institutions. There already has been in food and fuel prices.

How strong will the bargaining power of the trades unions (medical and otherwise) prove to be? Will the recent three-year pay deals be re-opened in the light of rising prices?

Another is that commissioners should be looking at previous recessions, and determining the kinds of health needs that grow during such times. Depression is the blindingly obvious one, but there will be others.

The language of finance
Among the striking aspects of the current situation is some of the language that has emerged, blinking into the daylight from the financial netherworld.

The most evocative phrase is 'moral hazard' - which put basically, means that by reducing a party's exposure to a known risk and so protecting it from the consequences of its actions, that party's behaviour is changed to the detriment of the community, since others must pick up the bill or the pieces.

In finance, a government bail-out of an over-extended or under-capitalised bank is deemed to be a moral hazard as it will encourage such risky practice in the future.

Wikipedia adds that "Moral hazard is related to asymmetric information, a situation in which one party in a transaction has more information than another. The party that is insulated from risk generally has more information about its actions and intentions than the party paying for the negative consequences of the risk.

"A special case of moral hazard is called a principal-agent problem, where one party, called an agent, acts on behalf of another party, called the principal. The agent usually has more information about her or his actions or intentions than the principal does, because the principal usually cannot perfectly monitor the agent. The agent may have an incentive to act inappropriately (from the view of the principal) if the interests of the agent and the principal are not aligned".

The Economist

'Moral hazard' derives from the insurance industry, where it was thought that if people with insurance will take more risks than the uninsured, so leaving the insurer open to more claims that it had calculated.

The Economist defines moral hazard as "one of two main sorts of market failure often associated with the provision of insurance. The other is adverse selection."

Moral hazard in healthcare
The insurance references instantly lead consideration of moral hazard in healthcare towards the political right. 'Socialised medicine' such as the NHS is thus viewed as intrinsically wrong and unsustainable, as it leads to moral hazard for those who will be treated anyway by an egalitarian system even if their behaviours (such as smoking, drinking, over-eating or failing to take exercise) cause ill-health to them and costs to the exchequer.

The grain of truth around personal responsibility for avoidable ill-health is usually surrounded by an unpalatable husk of entitlement in this argument. It is undoubtedly better for healthy people to remain that way, and so avoid healthcare wherever it is possible and sensible to do so. Most of us do this most of the time. It is why the system has not fallen apart.

Living in avoidable ill-health is quite disagreeable enough a hazard. The low level of health knowledge and understanding of consequences in a significant cohort of the population, plus the immediate gratification of various unhealthy activities, play their parts.

Yet as society has got wealthier, more people's health has improved more. The myth of the ageing population that would bankrupt the NHS has, thus far, proven unfounded. Ever since the Guillebaud Committee of Enquiry started its work in 1953.

There remain grave problems with health inequalities, which are exacerbated because the health of the wealthiest parts of the population is improving so fast. Where I live, we tend to think of people who die before they are 80 as dying early. There are parts of Blackpool where 60 is considered "a good innings".

There are also clear signs in some poor areas, such as parts of Glasgow, that the health and life expectancy of the poorest is stagnating or actively worsening.

This is not a new problem.

There is another view to be taken of moral hazard in healthcare, and it would be to look at the moral hazard of commissioners towards the poorer parts of the population. It would involve taking a genuinely hard look at the reasons why, despite a massive increase in spending on healthcare, the progress with addressing health inequalities has been slow.

It would involve looking at what evidence-based interventions produce the maximum return on commissioning investment. It would involve a multidisciplinary effort across and beyond the public sector - as many of the key determinants of health (such as housing, employment, family) are not provided by the NHS.

Bad education leaves the poor with asymetric information about health. To borrow the economic analogy, commissioners at whatever level, from GP to PBC to PCT are the agent, and the population are the principal.

Agency is a great and grave responsibility. To act in a moral way involves assessing the needs and sharing out the available resources as evenly and fairly as we can.