The NHS needs its Reformation
The government has promised that from next year everyone aged between 40 and 75 will be offered an ‘MOT’ of their health. The patient most in need of a health check, however, was 60 this week: the NHS itself. To a limited extent the government has recognised the inadequacies of what for its first three or so decades tended to be called ‘the envy of the world’ by using the anniversary to publish the NHS Next Stage Review, written by Lord Darzi, a junior health minister and eminent surgeon. The document is less celebratory than defensive, effectively admitting that the patient has often become lost in an organisation which is one of the world’s largest employers after China’s Red Army. Sadly, much of what it goes on to propose will, in fact, entrench that very bureaucracy.
At the outset, one should recognise what is good about the NHS. The principle of universal healthcare for all, regardless of the patient’s ability to pay, caught the public’s imagination in the 1940s, gave institutional expression to the social solidarity of the war years, and remains dear to patients to this day. While Britain had some excellent hospitals in 1948, many founded with generous benefactions, getting into them was not easy for all. The foundation of the NHS happened to coincide with the introduction of antibiotics, which, combined with improvements in hygiene, sent infectious diseases in Britain into rapid decline.
It is no accident that the NHS survived the privatisations of the 1980s and is still supported by the Conservatives today. Nigel Lawson’s famous remark that the health service was the closest thing the English had to a religion was correct. Yet — to extend the metaphor — the flock is growing querulous at the management of the church. According to a YouGov poll in the Daily Telegraph this week, only 21 per cent look forward to any real improvement in the NHS; 78 per cent think there are too many managers; and 82 per cent believe that ‘a great deal’ or a ‘fair amount’ of money is wasted in the health service. If the NHS is a religion, it is badly in need of a Martin Luther figure and a root-and-branch Reformation.
The principle of universal, state-funded healthcare remains more or less sacrosanct. It does not follow that the state should be the monopoly-provider. Rightly, if belatedly, the government has experimented with making the NHS a buyer of private services. Unfortunately, not all these experiments have been a success, often because of bureaucratic ineptitude or cultural hostility towards the private sector within the NHS: private companies offering hernia treatments, for example, have been given contracts ensuring they were paid no matter how few patients chose their services. And why is that? All too frequently because GPs have been reluctant to make referrals to private treatment centres.
Lord Darzi now proposes that hospitals be penalised financially for failing their patients. Fine in theory, but we know what happens in practice when public bodies are fined for transgressions: the taxpayer merely ends up paying the fine. More promising is a proposal to give patients an individual budget for their treatment — which they can spend in different ways. For the first time, then, NHS patients will be able to appreciate the real cost of their treatment — and perhaps be disabused of the delusion that state services are ‘free’. As the state of the public finances deteriorates and taxpayers feel the pinch, it is more important than ever that the public debate about taxand-spend rise above its present infantilised level. Voters and politicians need to hold a mature dialogue about value for money and the proper limits of public expenditure: this dialogue has been scandalously postponed by New Labour’s pretence that its so-called ‘investment’ in the public services has been a ‘gift’ from government to people, rather than a drain on the public’s own resources.
Along with the rise in hospital infections, the lack of cost control within the NHS is this government’s biggest failure in health policy. In 2002, Gordon Brown, then Chancellor, accepted a proposal from Sir Derek Wanless that healthcare spending be doubled by 2022 to bring it in line with health spending in other European countries — putting a penny on National Insurance in order to pay for it. What he didn’t say was what he intended to achieve with the money; rather, spending was adjudged to be a good in itself, intrinsically virtuous. Small wonder, then, that of the extra £5 billion put into the NHS in 2004/05 alone a mere 2.4 per cent went on operations and new beds — while 27 per cent went on pay rises and 29 per cent on pensions.
Left to its own devices, the NHS would quite happily grow into a monster which would consume all Britain’s wealth. As John Appleby, chief economist of the healthcare think-tank the King’s Fund, points out: at current rates of expansion by 2046 the NHS would account for one in every two pounds spent in the Britain. And yet — even then — we would not be assured of better healthcare: spending in this area is subject to a law of diminishing returns, where huge sums are spent extending the lives of terminally ill patients by a few days.
The biggest failure of the Attlee government when constituting the NHS in 1948 was to detach healthcare from economic reality and to fail to give the new service any defined boundaries. It is about time such limits were honestly discussed. Rationing is a daily reality in the NHS, but not one that is properly acknowledged. And how are we to reconcile the public’s desire for the devolution of control to communities and individuals with its equal distaste for the ‘postcode lottery’? Everyone says they want to move beyond the ‘one-size-fits-all’ ethos of the NHS to a structure of greater diversity and variety; and yet there is still an insistence upon uniform standards. Clearly, this debate is in its very infancy.
Of all nationalised institutions, the NHS looks the safest: no party has the slightest intention of dismantling it or privatising it. We regret that the Conservative party’s position on healthcare is so timid. Lord Darzi is not the Martin Luther-style reformer that the health service needs; but nor, on present evidence, is David Cameron.
Previous page
