A visitor from Mars, struck down by some Earthly bug as he circles in his space ship, couldn’t fail to appreciate how popular is our National Health Service. Let’s hope that this would give him some confidence, as he waits in A&E for four hours to be treated!
But he might also wonder about two other things: how can an institution already older than most of its patients still be fit for purpose? And if it’s so good, how come almost no other country in the world has copied it?
It almost feels unpatriotic to question the NHS, but it’s sometimes good to do so, if we are to keep it fresh. So what’s the case for the prosecution: why might the NHS be ready for retirement?
Let’s look at three of the more serious arguments.
Who wants one-size-fits-all?
First, you might wonder whether a service created by Aneurin Bevan in post-War, rationed Britain, can hope to satisfy the wishes of the richer, better educated, internet-hungry consumer of the 21st century? Who, for example, would want to do the weekly shopping in a 1940s-style shop?
It’s obviously true that we now expect more information, control and convenience in every aspect of our lives. It’s also clear that the NHS is struggling to keep up in this area. There is much more to be done in tailoring services to individual patients’ differing needs, and in forging a genuine partnership between patients and those who treat them.
And in some aspects of healthcare, choice is important. Not when you’re knocked over in the street and need emergency care. But when you’re coping with the long-term impact of diabetes, or when thinking about how you want to give birth, personal choices are a vital part of good healthcare.
However, deep down, the NHS also means something else. Fundamentally, it’s an expression of a set of values, which don’t date. It’s about compassion and fairness. There’s just something plain WRONG about people suffering needlessly because they are too poor to afford good healthcare.
And it’s also about security and selfishness. None of us can be sure that we won’t need help when we are vulnerable, frail or dependent, so we all have a personal interest in good, universal healthcare.
Perhaps Bevan tapped into something timeless here. We have a shared need for the NHS, and hopefully our shared needs are not incompatible with our differences.
Who wants a monopoly?
Second, why would we rely on a monopoly provider of healthcare, when in almost every other aspect of our lives (retail, telecommunications, transport, most professional services, energy, even higher education) we have competition and choice?
Well, there are governance arguments– the NHS is democratically-controlled, so not a monopoly in the conventional sense. There may also be efficiency arguments – competition and choice are expensive, because they rely on maintaining surplus capacity.
There are certainly good arguments about the nature of healthcare itself. For those who need the health service most – for example, those with long-term conditions – good healthcare is about coordination and following good practice. Patients often need help from several different professions, using different sets of technology and skills, doing what the evidence shows is required. What they don’t need is this being disrupted by competing healthcare organisations more concerned with their own survival than giving the right care when it’s needed.
The great enemy, of course, is complacency and provider-capture – the NHS doing what it finds easiest, not what the patient really needs. We need to ensure that, in the place of market mechanisms, we have something even more effective to keep the NHS’s toes to the fire.
Who wants higher taxes?
And third, we simply can’t afford Bevan’s NHS. Relying solely on the taxpayer doesn’t work any more, because people want to pay less tax not more. Within two years, a gap of more than £250m per year will have opened up between what the NHS in Wales needs simply to stand still, and what it will actually be receiving. The NHS’s chare of GDP will need to increase from 8.0% in 2009/10 to 10.2% in 2039/40, just to cope with increasing numbers of older people. Will (mainly young) tax payers find an extra quarter in the share of national wealth taken by the NHS?
This problem isn’t unique to the NHS, of course. Healthcare systems across the developed world all face the problem of rising healthcare costs, whatever their funding system. You might well argue that the NHS is inherently more efficient than many, so will cope better.
But actually, the resolution of this dilemma lies not so much in the funding system or finding another percentage or two of GDP for the NHS. It actually lies in keeping ourselves healthier for longer – forging a partnership between the NHS and every one of us. But, as obesity and the other conditions of affluence go on rising, we don’t yet seem to have found out how to do this.
What’s our Martian friend to tell his mates when he gets back to the red planet? He might talk about the NHS as an expression of our national values; he might talk about the uniqueness of healthcare. He might talk about the unresolved problems of a human race living longer than it ever has done.
What I hope he’s seen is an NHS fiercely determined to change how it works for the better, while sticking doggedly to the eternal values of compassion, fairness and solidarity.
Written by Marcus Longley, Professor of Applied Health Policy and Director of the Welsh Institute for Health and Social Care
He will be giving a public lecture on the issues raised here at 5.30pm on Monday 26th March 2012 in the Cochrane Building, University Hospital of Wales, Cardiff. Free admission. For further information or to book a place contact the University of Glamorgan Centre for Lifelong Learning on 01443 482567.
This blog is reproduced from an article in the Western Mail on Monday 26th March.