Sunday, May 22, 2011

Where now for the NHS?

When the NHS began it used to give away free hot water bottles. Things have changed. As people live longer they make more demands on health care. As technology improves health care becomes more expensive. This would not matter if growth of GDP was buoyant, but growth is sluggish. The NHS is being asked to make do within its existing budget, but to take account of demographic changes and health-specific inflation it has to make major savings elsewhere.

The last government threw huge amounts of money at the NHS, but productivity reduced. This means that doctors and nurses each saw relatively fewer patients. Part of this was the result of the European Working Time Directive which stopped junior doctors from working more than 48 hours a week, but more than that was a change from a professional contract, whereby doctors and nurses stayed working until the work was done, to a sessional contract whereby they engaged in a certain number of 3.5 hour sessions a week. Since their sessions included periods for administration, continued professional development, research and perhaps other non-clinical time, less time was spent at the coal face. The consequence was more doctors and nurses had to be employed to complete the work.

The option of throwing yet more money at the problem is not available. The new government has agreed to ring-fence the NHS budget, sparing it from the austerity package, but even with a standstill budget it has to make savings. Are there things that it is doing that it could stop doing?

One way of reducing the work in the NHS would be to encourage private practice. After all in many countries patients find that when people pay for services directly they get better results. There is no way that the NHS with its intrinsic rationing will be able to pay for the hotel services and promptness that middle class people are going to demand. These are not medical but social standards and there is no reason that they should not be paid for. Some ways that this could be done would be to give tax breaks for private health insurance, and to allow waiting lists for elective surgery on the NHS to drift. far from diminishing the NHS this would allow the national service to do what it is best at.

There are undoubtedly some health services that are best provided by the community. Even the United States recognizes this. No-one would suggest that the CDC was run as a private firm. Or the Walter Reed. There is no call to privatize the VA. I am content to let the British Public Health Service be run by the NHS. The epidemiology is best done by someone with statutory access to the data. In the UK family doctors are all independent contractors. They work for the NHS and are paid for out of general taxation, but they are effectively small businessmen. Not so the hospitals which are owned and paid for by the government and all employ thousands of health workers. But even here they have been separated into independent Trusts and are no longer one great monolith.

Still, I would have the NHS doing less. What I would concentrate on are the things that people cannot do for themselves. Lots of medical time is taken up with the trivial that does not need expensive time spent on it. Most virus infections cannot be treated (herpes is the exception) so there is no point going to the doctors with colds and flu. Many medical interventions are of unproven value. I see no reason why patients should not be allowed to purchase these as long as they don't use my money to do so. I am thinking of homeopathy especially, but there are many other 'treatments'.

A few years ago it was estimated that ten times as much money was paid by the NHS on indigestion remedies than on the whole of cancer chemotherapy. Surely this cannot be the correct priority. It is expensive treatments like cancer chemotherapy and cardiac surgery that we need help to pay for, not the provision of statins in the hope that they may prolong life. I think that NICE has things the wrong way round. Rather than setting a threshold for treatments yielding less than 1 QALY per £30,000, they should be seeking out the cheap treatments and recommending that people pay for them themselves.

The other area I find odd is to use the NHS budget for social engineering. Many illnesses are self inflicted. They are caused by smoking, drinking, eating unsuitable foods, not taking exercise, taking class A and class B drugs. Much mental illness is so engendered and much is simply unhappiness. To cram this degree of social problem into a medical model seems to me to be unwarranted. The remedy for many of these ills is not a medical one. Better housing, schooling, conditions of employment and environment may all have a part to play. Antidepressants are not the answer.

What is mainly wrong about the NHS is not poor quality medicine but its being used to answer questions it wasn’t designed to answer.


Burke said...

This reads like something out of Atlas Shrugged, although it has not yet reached the point of total collapse.

Essentially, there are people who can pay for the health services they need, and there are people who cannot. Socialized medicine is a way of forcing the able to provide for the latter, conceptually a kind of slave system.

Metaphorically, a kind of cannibalism.

Not hard to see why it is deteriorating everywhere it exists.

It's what happens when rights are sacrificed for need and charity becomes compulsory.

Anonymous said...

In the US those of Democratic persuasion want to add to our coming mess by refusing to acknowledge (as you alluded to) that our current Medicare system will choke on it's own growth unless we engage in responsible planning to deal with future obligations.

Markets are the only logical answer that will permit those less privileged to receive any (hopefully appropriate even if not convenient) care while allowing those who can afford more & who have the will to pay for it to receive what they want/need.

Mr. Obama's concept of an independent panel to control costs will never work. As a young physician trying to grow my practice I worked incessantly. If the government had controlled things then the way they seem intent upon doing my zeal would surely have waned.