No 12 - The cost of doing bloods
Tldr
Healthcare is incredibly variable and it is very difficult to work out the cost of anything.
Even estimating how much a simple blood test cost can show a huge potential range.
If more people don’t start to think about this problem it will start to put increasing pressure on the NHS.
Why should we care about the costs of doing bloods?
Currently, there is a global shortage of EDTA blood bottles - the yellow ones. Now this is not just an NHS crisis, it really is global and it is having a quite dramatic effect on the health service.
Why do we need to care about this? Partly because modern doctors and nurses have become so used to relying on blood tests to back up our clinical judgements that having to practice in a “more austere environment” without the blood test feels very new and uncomfortable.
It also means that for the first time in years, clinicians need to start rationing what tests they order and actually think about “will this change my decision, my diagnosis or my management of this patient?” - scary stuff!
It may also put some patients at greater risk of harm because we actually can’t afford to check if our clinical judgement was correct.
So, why is this related to the cost?
While I have been practicing medicine there have only been a few “common” investigations that have been limited due to costs, mostly: CRP; MRI and other imaging tests.
As a junior doctor I could order almost any test I fancied for most patients but for some reason all of the more senior doctors used to get really worked up about ordering CRP. A consultant (resident) once bollocked all of the junior doctors on my team for ordering CRP “too often” and wasting “£30 a go, every day”.
The UK also rationalises our imaging tests - ultrasound scans, CT and MRI because the machines cost quite a lot of money and the radiographers cost quite a lot of money and no one pays any extra for them. Whereas in other countries like France, Italy or America these scans are far more available because anyone can pay for one whenever they like, which means that they aren’t rationed as much as they are in the UK. I’m not saying that is better, but it is a different model of healthcare that allows clinicians to work differently, and some would say more efficiently.
How much does CRP really cost?
CRP is one of the many blood tests that junior doctors love. If its high, something bad is probably going on. If its low, then hopefully nothing too bad is going on … but we all know it isn’t that simple.
CRP requires a blood sample to be taken in a yellow tube - one of the ones that is currently a bit rare.
The price of CRP is: £30; $12-16; £2; £35; $1; Rs. 265.00 - hang on, this is a wide range isn’t it? (See the below references for the range of costs):
https://www.health.harvard.edu/heart-health/c-reactive-protein-test-to-screen-for-heart-disease
https://labtestsonline.org.uk/news/CRP-testing
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311066/
https://doctap.co.uk/blood-test/esr-crp/
https://www.nice.org.uk/advice/mib78/resources/quikread-go-for-creactive-protein-testing-in-primary-care-pdf-63499354178245
https://bmjopenquality.bmj.com/content/bmjqir/2/2/u204012.w1749.full.pdf
https://aricjournal.biomedcentral.com/articles/10.1186/s13756-018-0414-1
https://www.medifee.com/tests/crp-cost/
The costs of healthcare are really complicated
Partly, this is because it is not really a free market, so the price signal doesn’t work properly. In the UK the person at the Department of health who decides how much money hospitals get each year doesn’t really understand the cost of each individual drug or procedure. The manager of the hospital doesn’t really understand either. THey have a pot of money to spend and they will buy what they guess to be the best use of the money.
The person who organises the logistics and orders all of the kit doesn’t really understand either. They don’t really know what all of the kit is used for. They are probably just working off a guesstimate of what was bought last quarter.
Likewise, the clinician at the front end doesn’t really understand the cost of the kit they are using and quite frankly doesn’t care either. The kit doesn’t even have any prices on it, so even if the clinician was interested they wouldn’t easily be able to find out what each of the different pieces of kit cost.
The patient doesn’t know or care because they have paid their taxes and expect their blood to be taken.
The companies that make all the kit don’t really care how much it costs to make the kit as long as they can persuade the government and the NHS to buy the kit with a decent profit. The person buying the kit isn’t using their own money and isn’t going to use the kit and so really doesn’t care how much profit the company is making. All in all, hardly anyone in the system has an incentive to actually understand the cost and use of anything within the health service. (I must point out that I said “hardly anyone”, I am sure there are quite a few experts who do actually know this stuff but you don’t hear from them very often).
So, that is partly why its difficult to know what something actually costs but the other major complication is that healthcare is incredibly variable.
Let’s use the case of taking a blood sample as the example.
Firstly, the patient. If they are a healthy young fit rugby player who has just drunk 5 pints of water then its really easy to find a vein or take blood. If the patient is a tiny, old lady who hasn’t been able to drink for 3 days, then it can be almost impossible to find any veins. This can be the difference between getting the blood samples in 2 minutes or 62 minutes.
Next, the clinician. There are people of various levels of experience from brand new nursing student to phlebotomist of 30 years to consultant anaesthetist of 25 years. This has two impacts - the time it takes for an experience person to get the blood and their cost per hour.
Lastly, you have the cost of all the kit itself: tourniquet; gauze; tape; alcohol wipes; needle; syringe; vacuum continental; blood bottles; VBG syringe; cannula; saline; stickers; tray; sharps box; storage cupboard; collection system; porters; lab forms; pen; lab staff; analysing machines; technicians; biomedical scientists; computer systems etc etc etc.
So, if the sample is taken on a young, fit patient by a young phlebotomist being paid £12/h and it takes 2 minutes. Then the cost of that blood test might be £0.40 (staff cost) plus £5 (all of the kit), plus £2 (lab costs). £7.40.
Alternatively, if its a difficult patient that requires multiple attempts to get blood then it might cost:
15 minutes of an Emergency Department Technician £16/hour = £4
15 minutes of a junior doctors time £32/h = £8
15 minutes of a consultants time £100/h = £25
Each of these individuals might have 3 or 4 attempts to find blood, so that 12 kits costing £60 and then the lab cost on top £2. Totalling £99. For exactly the same blood sample and results but on a different patient.
Healthcare = complex, variable and expensive
This variability really does make paying for healthcare difficult and it makes estimating the cost of healthcare difficult and researching the costs of healthcare difficult. Especially, in a tax payer funded, top down system where nothing is really tracked and logged per patient.
And just to ram the point home further, this example with a cost range of nearly x12 was for one of the most simple procedures in modern medicine - taking blood for a test. I can’t even imagine how difficult it is to work out the range of costs involved in a renal transplant or heart bypass.
In the near future, the costs of healthcare are going to become larger and this will have an impact on the ability of frontline staff to deliver the care to their patients. Some clinicians may not find this stuff interesting but personally, I find it fascinating. Especially, when there is a global shortage of blood test tubes and it is already starting to impact patient care now, and that’s before everything gets more expensive and even more complicated in the coming years!