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The nasty choices needed to save the NHS
July 5 this year will be the 60th birthday of the National Health Service. The NHS has come to occupy a place in the national psyche that is almost religious: every politician has to declaim, sooner or later, and often, “I believe in the NHS”, or face electoral limbo. Anyone putting forward serious criticism or suggesting change risks heartfelt disapproval, as if both our sole article of national faith and our most powerful repository of identity were being desecrated.
So it is hardly surprising that almost before the new year had begun both Gordon Brown and David Cameron had come forth with statements of impassioned commitment to the NHS. Brown got in first but his effort backfired hilariously with his comments about the rights and responsibilities of NHS patients seeking treatment; the media, in the absence of much news, headlined this as a threat to deny treatment to fatties and smokers � something that is often done already, but at which the prime minister was unwise to hint.
Cameron followed with his tribute to its founding idea of fairness for all. And tomorrow Brown is going to deliver what is inevitably called a “keynote speech”, rousingly entitled The Future of our NHS: Personal and Preventative. Since it can no longer be denied that all is not well with the NHS, both men are calling for something that their parties have discussed for several years � an NHS constitution.
Oddly enough it doesn’t have one; it has been the typical British muddle, based on a noble and impossible idea � comprehensive and equal treatment for all, free at the point of need.
I suppose a constitution might be a good idea, although personally I wouldn’t start from there. But the point is surely that any constitution will be quite useless unless those who write it are prepared to grasp several nettles which politicians have for decades found too painful to touch.
First is rationing. Nearly all of us now know that the NHS � the taxpayer � cannot afford to pay for all the treatments and drugs that are already available, still less for those that will be developed in the future.
The demand is going to be almost infinite; tax receipts are not. As more conditions become treatable and patients’ demands become more sophisticated, this problem will soon be a great deal worse.
Everyone knows this and most people admit it, except for politicians. Doctors and think tanks have been pressing the government to recognise it for years. The Institute for Public Policy Research reported in 2000 that the public would lose confidence in the NHS unless the government admitted that state healthcare must be rationed. Indeed it already is, one way and another.
For instance, Saga magazine and Populus have published a survey suggesting that one in six people over 50 had been denied treatment on grounds of cost. More than half the doctors replying to a survey in Doctor magazine said patients were suffering as a result of being denied treatments on grounds of cost. The chairman of NHS Alliance, which represents NHS trusts, commented that “rationing is the great unspoken reality”.
The other nettle that nobody wants to grasp is fairness, or to use that infuriating cant word, “equity”, which seems to conflate fairness and equality. Equal treatment for all is a first article of faith. However, it never has existed and never could, simply because doctors and nurses vary hugely in their abilities and experience. Even in the same hospital, two surgeons will have very different death rates, particularly in certain specialities. Patients, too, vary hugely in their ability to make the best use of services, right down to taking their medicine properly. All this is unfair, but unavoidably so.
Fairness and equality are at odds with what both Brown and Cameron say they want � local power, professional autonomy, devolution and diversity. That inevitably means having the notorious postcode lottery: one GP surgery or one hospital will do things differently from another. I am in favour of breaking up the monolithic power of the NHS altogether and having services offered by autonomous providers. But if you want a unitary NHS, it cannot be both localised and centralised. All this falls firmly into the category of “no easy answers”. That is precisely why it is high time to reconsider what exactly a National Health Service can realistically provide: most of the assumptions of 1948 are no longer relevant.
The idea of a free and universal service has been abandoned with the introduction of charges for dentistry, glasses and prescription. So has the principle that everyone is entitled to the same care � smokers, fat people, old people and heavy drinkers are already denied treatment and some candidates for dialysis or organ transplants inevitably find themselves at the bottom of the list.
If politicians were prepared to face these intractable problems, they might come up with unpleasant suggestions for rationing. I would start with the beginning and the end of life. It does not seem right to me that hugely expensive efforts are made to keep very premature babies alive only to lead a life of severe disability. Nor do I think it is right to strive to keep very old people alive; there was something to be said for pneumonia, “the old man’s friend”.
In the “national conversation” that Brown will undoubtedly call for tomorrow, I would mention that nearly half the NHS budget is spent on people aged over 64 and nearly a third on those over 74. These proportions are rising, according to Department of Health statistics for 2002-03 which I got in 2005; last week the department told me it could not give me updated figures as it does not keep them. I wonder why not. Are they considered too disturbing?
If I were elderly I hope I would consider my need for expensive cancer drugs less important than a young mother’s. Equally, although my default response is always for the freedom to smoke or hang-glide, I am entitled to feel differently if your freedom to give yourself coronary artery disease and diabetes competes with my child’s medical treatment. I regret to say Brown is right about that. These are all nasty thoughts, but without thinking them through the NHS will not survive many more birthdays.
The Sunday Times | Sunday, January 06, 2008
Comments:
NHS rationing.
Hi.
I have read your column, ‘The nasty choices needed to save the NHS’, in the Sunday Times of January 6, 2008.
You make the assertion that ‘…. the NHS – the taxpayer - cannot afford to pay for all the treatments and drugs…….’.
I have heard/read that (or a similar) assertion on a number of occasions, but it has only ever been an assertion. It seems to be made mainly by those who have a vested interest in the NHS not being successful and/or those who do not need to depend on the (bog standard) services of the NHS for themselves. I have yet to see any substantial evidence to support the assertion that the present or some predicted future NHS is or will be unaffordable.
(However, I have seen a great deal of evidence of insufficient funds, incompetence and waste).
There are ample resources in the world’s fifth largest economy (we were the fourth largest in 1997, but that’s another point!) to adequately fund a high quality, free-at-the-point-of-delivery waiting-list-free responsive national healthcare service from public funds. There is a lack of will to prioritise the allocation of resources (i.e. give the money available to the NHS rather than, say football or the arts or whatever).
It is the bizarre decisions on how available resources are allocated, together with wasteful and grossly incompetent management, combined with, it seems, an underlying lack of desire to change the situation, that cause repeated failure to meet the real needs.
I have a considerable amount of material on the incompetence of management, on waste and on the ‘unusual’ allocation of public funds, but will give only one example of each here.
Incompetence – can any management that has had its budget doubled with little discernible difference in service delivery be described as competent?
Waste - You mentioned the Bumper Book of Government Waste in your excellent column of last week. The government itself recently identified waste totalling £23 billion. Need I say more?
Bizarre allocation decisions – Virtually every week I see an example of millions (sometimes billions) of public money being spent on things that in any truly civilised society would be way, way down the priorities as compared with caring for our fellow human beings. That makes it difficult to choose one, so how about a proposal to spend £17m on nine sculptures around the borders of Wales?
You touched on such bizarre decisions in your excellent column of last week. Unfortunately, those who allocate the money collected in taxes do actually choose to allocate the money to ‘gender awareness outreach co-ordination work’ rather than to ‘looking after the sick and the needy and the disabled, ….’.
Properly consulted the public take a very different view.
For example: The question ‘Should the nation spend £25 million to prevent a national treasure being exported?’ may produce a fair proportion in favour. The question ‘Should the nation spend £25 million to prevent a national treasure being exported or should the money be spent on preventing people going blind, giving deaf people digital hearing aids, etc?’ (which is the real question if resources are so scarce we cannot afford the NHS) would produce a very different result.
So long as people like you are prepared to contemplate publicly the concept of rationing then it will be extremely difficult to achieve the improvements needed in the NHS. It is demoralising for management to be told that it can never meet demand, and experience shows that in the public sector the management often does not even bother to try.
The proposals for NHS rationing have their origin in an unsupported assertion that the NHS cannot ever meet the demands placed upon it.
A properly organised and resourced NHS could meet the nation’s needs for healthcare.
We need a different approach to the present one to allocating funding to, and the management of, the NHS, but here is not the place to propose solutions.
I have a lot of material on these topics too!
And I have a robust response to the oft-repeated lie of ‘There’s no money in the budget’.
Incidentally, if anyone tells you that contracting out public services was/is a bad idea, I’ll happily give you some interesting facts on that too.
As politicians and supporters of the status quo these days seem to prefer to attack the man rather than debate the issue I would prefer to remain anonymous should you decide to publish this letter.
Regards.
P.S. If you do wish to pursue the idea of NHS rationing I have some really interesting suggestions on the design and implementation of a ‘fair and equitable’ scheme!
P.P.S. When thinking about public sector services it can be useful to bear in mind the answers to questions like: ‘Where do many ministers, MPs, senior civil servants and public sector managers get their healthcare and educate their children?’
Posted by: anonymous | 12 Jan 2008 22:01:38
