The NHS now

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"12 months to save the NHS" was the election slogan used by Tony Blair. When Labor took over the running of the NHS in 1997 there was undoubtedly a problem. Doctors had been complaining for years about underfunding, but all their complaints had done was to trigger yet another reorganization. Make the pips squeak, said Tory Chancellor, Kenneth Clarke. It was felt that by increasing efficiency more could be obtained from the same amount of investment.

In fact, the NHS was very efficient indeed. The graphs demonstrate that health spending in the UK lagged far beyond similar spending in Europe and North America, yet the quality of care was not that different. At its best the NHS was the equal of any health care provider, and if you were acutely ill it pulled out all the stops. The major problem was waiting. You could get everything for free, but you had to wait for it. At one time a hip replacement meant a 5 year wait. A prostate operation might mean an indefinite wait unless the whole thing seized up, in which case you would be in as an emergency and operated on the next day. In 1997 there were over a million people waiting for operations. Of course as my son has pointed out, it's not how many who are waiting that matters but how long they wait. Ten million waiting for two weeks is not a problem; 100,000 waiting for ten years is. Nevertheless, a million waiting for operations is a powerful political slogan and the government targeted this. A lot more money went into health care, but if you pay a lot more you will need to make sure that the money is well spent. Hence a massive increase in bureaucracy.

What started out as an attempt to remedy a political slogan ended up a bureaucratic nightmare and more and more targets accrued. It's not just the total wait that matters, but how long you wait in the ER to get seen, how long for an outpatient appointment, how long an ambulance takes to get to the scene of an accident. And cancer patients are a special case; they need to be sen quicker than someone with a hernia. So the targets multiply.

With more targets there is a diversion of resources from providing good health care to meeting targets. As in Education they teach to the exam rather than educate the child, so in medicine they respond to the target rather than the patient. Thus we see cancer specialists who must see a new patient with cancer within two weeks of a referral complaining that their clinics are full of patients with benign breast lumps (which might remotely be cancer) and patients with more serious non-cancer diagnoses being delayed.

Those who run services spend time gaming the system rather than improving the service. If patients in the ER must be admitted within 4 hours of being seen, it's quite simple, you rename a trolley a 'bed', and call a corridor a 'ward'. If an ambulance must be on the scene within eight minutes of receiving a call then you re-designate the time that the call was received to eight minutes before the ambulance arrives. The polite term is 'gaming'; the less polite is 'lying'.

In the days of the USSR nail factories had targets to produce a certain number of nails; they responded by producing millions of very small nails. When the target was changed to a certain weight of nails they responded by producing one very large nail. This analysis sees the problem as central direction. One solution sees the answer as introducing more competition. Let the market take care of the problem. The difficulty with this solution is that a free market depends on certain providers going out of business. Imagine no hospitals in Philadelphia; all the business has gone to Wilmington because the taxation scheme there is more favorable.

Then there is 'post-code prescribing'. Yesterday I emphasized the importance to our Lords and Masters of Equality. Despite all claims to the contrary, people are not equal. Some are more beautiful, some are more intelligent, some are richer, some are more athletic, some are fatter, some are predisposed to sickle cell disease, some to diabetes, some to certain types of cancer. Whatever health system is established, some will do better out of it than others. If you live in Bournemouth you will live longer than if you live in Middlesborough. Why? 1] You are likely to be richer. 2] You are likely to have had a less strenuous job. 3] You are less likely to have come into contact with toxic chemicals. 4]You are less likely to be a smoker 5] You are likely to drink less 6]You are likely to be in a higher social class. 7] You are likely to have a better doctor. (Doctors like to live in nice parts of the country too, so there is competition for jobs here. You have to be a saint or an immigrant or to have been born there to want to practise in Middlesborough.)

Allocation of funds for health care might be thought simple. Just divide the available money according to the number of people living there. But old people are much more likely to get ill, so there needs to be an age weighting. One in three living in Bournemouth is over 60 while it is one in six in the rest of the country. But then other factors are relevant. Some ethnic communities have a greater need - sickle cell disease and thalassemia. Poor people use the health service more. Do you compensate for that by putting in more health care money or deal with the social factors separately?

I have mentioned all these drawbacks, not because I think that the NHS is a bad thing, quite the reverse. But Sicko makes it sound like paradise, which it is not. Don't think that the ills of the American health care system can be remedied just by changing to a single purchaser or (heaven forefend) asking for advice from Fidel Castro. Every country is going to have difficulties providing health care for its citizens and there are problems and solutions that are common to all.

Tony Blair has put billions more into the NHS yet funding still lagsfar behaind that of other countries. Tomorrow I will discuss why health care keeps costing more.