Stop, think, rebuild; a prescription for the NHS

Two years ago few would have predicted that the centre of gravity of the health debate would move so quickly towards reform and value for money and away from higher spending. Yet on Sunday Sir Derek Wanless, the author of the landmark report on NHS financing used to justify higher spending, cautioned that all the extra money (in fact "slightly more" than all the money) has already been spent. Yesterday Aidan Halligan, the former Deputy Chief Medical Officer, commented: "We have learnt that throwing money at the problem only allows us to do more of what we have always done." The service has lurched from a deficit of 200 million pounds before Christmas to 800 million now, losing a chief executive and a head of human resources along the way.

The scale of the extra resources is not in doubt. After inflation, annual spending has increased by four-fifths since 1999-2000, taking spending beyond the European average. The increased spending per year amounts to an extra 120 billion pounds in total. But it is equally clear that the extra resources have not created a service of the standard of continental countries. Certainly some areas of the service have improved. The longest waiting times have been reduced, but improvements have tended to fall in areas of narrowly focused political pressure or where reforms, such as patient choice, have been implemented. Other areas of the service have been neglected.

The public is clear that spending has risen sharply but expectations have risen just as quickly. But the majority of extra resources has been absorbed in higher costs rather than being used to expand access or develop new services. As a result there is a widening gap between supply and demand. The reduction in the rate of spending increases after 2008, already announced by the Government, will only make the situation worse.

This raises the prospect of much greater rationing and longer waiting times that will come as a very unpleasant surprise to patients. It will also increase suffering, as a high proportion of patients' conditions deteriorate further while on waiting lists.

All the political parties need to undertake an urgent review of NHS aspirations in the future. We need a debate to identify which services should remain in a taxpayer-funded core and which areas are appropriate for a new partnership between the individual and the State. The latter areas will include the services where the NHS has failed to deliver on its guarantee of care. Despite the highest possible funding increases, the service as currently constructed does not deliver on its guarantee of universal care. For example, the British Society of Hearing Aid Audiologists showed last year that waiting lists for NHS hearing aids can reach up to three years. The National Audit Office has reported that only half of stroke patients receive proper rehabilitation in the crucial months after suffering a stroke.

Worse, the fiction that the NHS covers these areas of illness prevents new forms of funding and new providers from emerging. Where the NHS has recognised the limits of its coverage, such as in ophthalmology, a successful market has been allowed to develop. Standards of eye care have risen and - with several opticians on every high street - choice and access for patients have been transformed.

As well as supply and demand, the other fundamental divide is between consumer demand and society's need. As medicine advances and the population ages, consumers will inevitably want to spend more than society wishes to fund. In coming years numbers of young taxpayers will fall relative to the older generations. Will the young taxpayers of 2016 or 2026 wish to fund the health wishes of a much greater number of non-taxpayers? The days of an exclusively tax-funded health service are numbered.

The great prize of a reformed and balanced funding system is that the gaps in today's service could be filled and a modern, truly comprehensive service could emerge. People could be freed to put additional resources of their own into healthcare, as they increasingly will wish to do.

This new system will look and feel different. Alongside a new funding model will come new forms of provision based on out-of-hospital care much closer to people's homes. Pluralism - with private and voluntary sector providers delivering care on equal terms with the NHS - will be taken for granted. The gains to innovation will be immense. Co-payments and health insurance will be the new vocabulary of healthcare financing.

The review of NHS aspirations should be undertaken without political prejudices in any direction. We must certainly guarantee equitable access for healthcare for all in society. Healthcare free at the point of use is a cornerstone of the British system. But, as the Prime Minister himself said in 2003, the 1945 model of healthcare has never delivered equal access for people on low incomes. Equity is the first thing to go when healthcare is rationed by waiting lists because the better-off can push their way to the queue or jump it altogether by going private. If rationing does start to bite and waiting lists lengthen after 2008, equity and fairness will suffer.

Despite admitting the need for reform, politicians remain unwilling to face up to the debate on financing. The medical profession and their patients are all too aware of the need. Two thirds of the electorate agree that the NHS is unlikely to meet patient expectations, no matter how much is spent on it. The parties will find considerable support for some boldness.

(Article above by Dr. Karol Sikora of "Doctors for Reform")






MORE ON NHS REFORM

Doctors for Reform has a point. The NHS, as elegantly argued by Professor Karol Sikora, a leading Doctor for Reform, on this page yesterday, is going to face a widening gap between supply and demand and will have to choose which services to provide and which to leave to the open market, ie, for the rich.

Look at the pressures that will be wrought by an ageing population: in 1950, with the NHS barely a year old, there were more than five people of working age for every pensioner. By 2050 there will be just two. Then look at the potential (and cost) of new genetic technology. If a genetic test, for instance, could show that I have a 4 per cent higher than average chance of developing Columnist Repetitive Argument Pharyngitis, and should therefore, for my health, avoid opinionating in newspapers regularly, ought I to be allowed to have the tests to discover that on the NHS?

Say that a test, for which you may have to pay yourself, shows that you have a 15 per cent chance of developing a particular cancer, where the norm would be 3 per cent - should the NHS give you preventive treatment that would reduce your probability of contracting the disease to the 3 per cent average? Even if it costs tens of thousands of pounds?

When David Cameron declared in January that the Conservative Party now believes in a taxpayer-funded NHS free at the point of need, he embraced the cost of new genetic treatments as well as new cancer drugs. "The NHS can no longer ration these treatments as it used to," he declared. Really? Who is going to pay for them? With both main parties playing politics for idiots - you ask, we give - there is no check on consumer demand for the NHS. And consumer demand is limitless: it started with basic healthcare, grew to embrace mental health and fertility and now slimness, and would, given half a chance, stretch to beauty and energy as well. Permanent blondeness? Why not? Look at the expensive things people are prepared to pay for privately with only a slim chance that they might make a difference to their health - from reflexology to cutting-edge cancer drugs - and then ask yourself whether you want to fund all this on the NHS.

So, yes, Professor Sikora is right: the days of an exclusively tax-funded health service are numbered. But then they always were. What the NHS provides was limited from Day 1, and demand has always outstripped expectations. In its first year of operation, 1949, Bevan estimated that the NHS would cost 176 million pounds; it actually cost 437 million. A year after its launch, a shilling prescription charge was introduced, both to raise money and to reduce the "cascades of medicine pouring down British throats", in Bevan's words. Two years later, dental and optical charges had to be introduced. The rich always have and always will be able to buy a more expensive range of healthcare.

What Doctors for Reform seem to be demanding (it isn't entirely clear) is a completely different European-style funding system for the NHS, and it isn't necessary. What we do need is greater realism from politicians about the limits of the system, less encouragement from populist ministers to act like children demanding more sweets from the sweetie shop, and a serious attempt instead to decide where the lines should be drawn in future.

More here

***************************

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

***************************