Following my previous blog on people wanting it all, I think we have to ask why the British public thinks it can have everything it wants. When I started out as a GP in 1970, people did not think like this at all. I remember an eighty year old lady who called me out at 3 am because she was short of breath. She was in heart failure, and as I treated her I asked whether it had happened before. “Oh yes”, she said, “several times. I thought each time that someone would find me dead in the morning. But that is what happens when you are old doesn’t it?” She said it calmly, not complaining in any way. Expectations were low, and there weren’t so many things that could be done. Now people don’t think they should ever die. Some new treatment will always come along to prolong life, and of course they should have it regardless of cost. The change in attitude has come about because of the success of the business model of medicine. Doctors, pharmaceutical companies, and private investors all make money out of new treatments and the media and politicians whip up the frenzy of more, more, more. It is this ethos, part and parcel of the marketization of healthcare coming ultimately from America, which has made the NHS unsustainable.
I occasionally like to read the Economist, a right wing publication which comes into the house through my dear husband, on health matters. As an incorrigible left leaning GP, brought up in Aneurin Bevan’s home town, it reminds me of what those in more exalted circles and now those in power in Westminster think about health and what to do about it in these challenging times.
The Economist’s columnist is knowledgeable and fair in his (or her) analysis, but always comes to the same conclusion. Given that the NHS needs vastly more money spent on it, and the general public so far, at least in England, has voted for the party which is very keen on balancing the books, it seems that the NHS is unlikely to get this money and therefore will become unsustainable. The solution therefore would be to go towards an insurance type of system as is common on the continent, with people paying their own insurance at a level they can afford, for the benefits they want. In the latest article1 he acknowledges that this is not the most efficient or effective way of providing universal coverage for health, but it accords with the conservative way of thinking about an individual’s choices and autonomy as opposed to the idea that the state tells you what you can have for free.
For me, this is not the way forward. We know the UK spends far less on health care compared to other similar countries, and experts tell us that there is a £30 billion gap between what is needed and what the NHS gets at the moment, because of population increase, people living longer, and poor lifestyle choices leading to obesity, degenerative diseases and lack of fitness. So, what to do?
One choice would be to pay the £30 billion, getting it from taxation, probably a hypothecated tax which can only be spent on healthcare. Would people vote for this? They might; people do value the NHS very highly. However it is likely that this would not be enough in the long term without other changes.
So, if we are to balance the books, what would be needed?
The article points to the changes promoted by Simon Stevens, the CEO of NHS England, and most commentators agree that these reforms are sensible and should make the NHS much more efficient. They focus on making the Health Service more productive; improving the quality of the product – for example, not just more hip replacements, but hip replacements with reduced recovery times, using hips that last longer and produce bigger improvements in patients’ self-assessed health status. They also centre on treating people in more local, low tech settings whenever possible to prevent them coming into hospital, and lifestyle measures which would try to prevent people getting ill in the first place.
To be honest though, there is nothing new in these proposals. These are measures which have been tried for years, and when I was a medical manager in a Welsh Health Board from 2006 to 2010 this is what we were all trying to do. We put an enormous amount of time and effort into it, but it never worked. Not because the ideas themselves were impractical, but because in order to implement the changes you had to invest in new efficient services first before being able to disinvest in the old expensive and inefficient ones. We thought money was short then, but it was goldrush time compared to the austerity we have now, but the necessary money was never forthcoming.
And as I wrote in my previous blog,2 the great British public expects every healthcare intervention to be available when they want it regardless of the cost.
One woman in her forties wanted a small red spot (haemiangoma) removed from the side of her nose, and asked me to refer her. Even at that time, in our locality, this sort of cosmetic benign lesion was not supposed to be referred, so I suggested she go privately. She got very angry, and insisted on me referring. So perhaps rather cowardly, I gave in, and referred to the plastic surgeon. He refused to do it on the NHS, whereupon the woman’s husband, who was a solicitor, started writing some very forceful letters saying it was her right to have it done on the NHS. After a bit of this, it was referred to the local Health Bard, whose policy it was not to do these operations, but after a while I heard that she had it done after all. It is hard to keep to the policy when people get so angry and threaten to go to the papers. Anything for a quiet life, and indeed to involve legal action is much more expensive than doing the treatment. This happened time and time gain, and I don’t suppose it is much different now. And this was something very clear cut – cosmetic surgery – so how it will go down when it is a heart operation (where the evidence is not at all clear cut as to whether it would work for many people) or something life threatening?
So, yes, we could go for an insurance based system, whereby you get what you pay for, the poorest getting only the basics and the wealthy getting what they want. It would be far more expensive for the individual , so that even poor people would have to pay something for the lowest level of care for themselves, and the middle income groups paying a lot. Even so the government would have to pay for those unemployed, elderly or very sick who could not pay anything.
I don’t think such an insurance system is necessary or advisable. I agree with Simon Stevens that we should concentrate on public health initiatives to improve activity and prevent obesity. We should also improve contraception and drive forward an expectation that two children per couple is plenty, with no exceptions for religions where fecundity is prized, – the world, let alone the NHS, cannot take the increase in population that is happening now. Keep the NHS as it is, but provide only well-tested, cost effective treatments we know work well. Concentrate on providing these efficiently and safely, in the public sector, making sure that the private market does not come anywhere near them, and drawing on best practice from over the world to make sure the methods are tried and tested. Innovation should come slowly and carefully, with continuous audit to make sure it is safe and value for money. Organizations like NICE would be tasked with preventing many more expensive treatments being done than at present. So no, you won’t get your knee replacement until you have lost weight, reduced smoking and become more active, and you won’t be offered expensive and maybe harmful new painkillers at all. You won’t get a caesarian section unless it is essential, and you won’t get that expensive cancer drug at eye-watering prices. What you will get is effective, tried and tested treatment in centres as near to you as possible, keeping hi-tech hospitals for those that really need them. All this would still be provided free, and yes, you may well have to wait for some treatments. But in my world diagnostic tests and diagnosis should be prioritised so that everybody starts treatment sooner, preventing the waste that goes with late diagnosis. Cutting out treatments of dubious merit (apparently the NHS still spends millions on homeopathic treatment) would save a lot of money which could then be invested into improved diagnostics and effective local treatments.
This would be called rationing, but rationing on rational grounds. It seems self-evident but is unlikely to happen. The biggest obstacles are the press and media which know that health stories sell newspapers, and the best stories are when things go wrong. It seems to me very unfair that they should always blame politicians (usually those on the left) and the management of the service, just because we have a very respected and cost effective service. In other countries this just does not happen – when things go wrong the hospital or the doctor may be blamed, but it will just be a local story. They can’t blame the service as a whole because it is so fragmented and each patient has signed up for different things.
Not even I think that you can take consumerism out of the equation altogether. It is a basic human trait to want things regardless of need, and people could still insure themselves (as they do now) to get these extras, to buy time or get a more personal service. The private sector will undoubtedly persuade many to have these non-essential treatments, which indeed may well help some people. and many people will get top up insurance. Possibly the new experimental treatments would be tried ut in the private sector, which may well get bigger and more important. But the basic NHS would remain, albeit with more caveats and restrictions than before, giving world class treatment to those that need it, and we would be able to afford it.
2 https://scepticalgp.wordpress.com/2014/12/24/we-want-it-all-dont-we/
Elen Samuel, doctor and writer 