I haven’t written a blog for a while. My excuses range from being too busy, to feeling that I haven’t got much to say any more. The message that I and people like me have been putting out, about the need for healthcare to be effective and not to harm people, seemed to have been generally accepted.
It seems so obvious to me that healthcare should only be available if it is effective and can be proved to improve outcomes, and that only the interventions that are value for money should be provided by a universal health service.
But do most people wanting treatment really think like this? Well, it seems they don’t.
I was jolted out of my complacency yesterday when I read a blog by John Appleby, from the think-tank The Kings Fund, which looked at a survey done in 2012, the British Social Attitudes survey.1 It had asked the public a simple question, what treatments should be available on the NHS in times of austerity?
The questions were as follows:
1. The NHS should provide all treatments regardless of cost or whether they provide proven health benefits
2. Or should it provide only those services that provide proven benefits, regardless of cost
3. Or only those that provide proven health benefits and good value for money.
To me, the answer should undoubtedly be number 3. Why should anybody, whether they are paying for their treatment or not, ever want treatment which does not work? And in a cash limited service, which is free at the point of need, should not the money you have be spent on the most cost effective treatments?
Yet 31% of respondents answered yes to question 1 – they thought that they should have all treatments whether effective or not and regardless of costs. This is almost unbelievable. 3 out of 10 people would like our NHS, funded out of taxation, in other words, by all of us, to provide treatments that either have been proved to be ineffective, or harmful, and also to spend an unlimited amount on them. How do these people think this can be afforded? And what do they really understand about outcomes of operations and treatments? Do they think that they should have the right to any treatment that some one somewhere, whether qualified or not, has decided to offer to the general public? Going further – do they think that they should have whatever they want, for free, AND if it doesn’t work they should then be able to sue for compensation?
I can understand the public’s lack of trust in evidence provided by medical researchers. In general the principles of scientific evidence have not been taught in schools or anywhere, and people are much more likely to believe in something if someone has told them that they have benefited from it themselves, or it has been advertised cleverly. I know that treatments such as homeopathy, vitamin cures, and other complementary therapies, are incredibly popular despite there being no evidence to support them. But people do pay for them, and sometimes the fact that they do so sometimes makes them seem more effective. But for these treatments to be free would mean that other treatments which do work would not be available, or not in sufficient amounts for those that need them.
In fact, only 28% of respondents came up with the answer I think is correct – no 3, only those treatments that provide proven health benefits and good value for money should be provided. And the largest number, 42%, 4 out of 10, picked number 2 – while treatments should have proven benefits, cost should not be considered as part of a decision about what treatments the NHS should provide.
I think this explains why politicians are so scared of saying anything about what should not be available on the NHS. They cannot rely on the general public thinking logically at all. If any party proposes to cut out treatments, either because they are ineffective or too expensive, they will immediately risk 30% of the vote.
Recently I was asked by someone from the Department of Health to give ideas on how to reduce referrals from general practice to hospital, because I had written a paper on it.2
I made a few suggestions of things that had worked in my experience, things like providing services for the less complicated treatments out of hospital, such as extended role physiotherapists doing joint injections, nurses doing complex investigations such as endoscopy, bunions operated on in podiatry clinics) so that patient still get the treatment but nearer to home and less expensively). And I also suggested that the NHS should make sure that treatments definitely proved to be ineffective should be stopped – like arthroscopy for arthritis of the knee, coronary artery bypass graft surgery for those suffering from chronic angina which is not getting worse (it is no more effective than taking tablets), and most tonsillectomies. But the lady on the other end of the phone cut me short –she wasn’t interested in stopping people getting anything. She wanted me to say something that would magically stop these pesky GPs referring patients to hospital at all. I tried to say it doesn’t work like that – if a patient has a problem as a GP you have to try to do something about it. If there is effective treatment you have to refer. That is your job, but if no treatment is needed you have to say so. And you need to be backed up by health service managers and politicians when you say it.

But this is too politically dangerous. So we are going to have to go on expecting the NHS to provide everything, and so in a cash limited environment what will happen is that people for whom there is effective treatment and who really need it, are not going to be able to get it. We are not very good at planning for the future, whether planning to keep healthcare costs affordable, or using contraception to stop the world running out of resources, it seems.
So what can be done about it?
I think people need to be confronted with the logic of the situation, and politicians need to understand that they have to give meaningful choices to the electorate. After all, people now accept that we have to some austerity – we cannot just spend our way out of our financial difficulties. So why should health be any different? How to do we convince the general public that they can only have cost-effective treatments on the NHS, or it will collapse?
What do you think?

References

http://www.kingsfund.org.uk/blog/2014/12/public-view-which-treatments-should-be-available-nhs
Evans E, Aiking H, Edwards A. Reducing variation in general practitioner referral rates through clinical engagement. Quality in Primary Care; 2011;19(4):263–72