by Lynda Goetz
The UK’s National Health Service (N.H.S.) is not fit for purpose. It does not work for those it is supposed to work for and it does not work for those who work for it (unless perhaps you are one of those 2,000-odd highly paid bureaucrats earning over £100,000pa). This much has become increasingly apparent since Covid, but the seeds of this failure are, some would say, inherent in the model which this country, and this country alone, has chosen for its health service. For many years, the British people appear to have treated the NHS as akin to some sort of religion. No Prime Minister, politician or party has dared to mess with the ‘principle’ that it is ‘free at the point of delivery’, or, in other words, paid entirely out of taxation. This ‘sacred cow’ has become a monster, devouring all the money which many governments over many years have been forced to throw at it. It has gobbled up the latest billions, but outcomes are no better, indeed, are worse, than they were before. Why is this?
Some people attribute the problem to increased population; others to increased technology and improving pharmacology; others to the ballooning bureaucracy; yet others to the shortage of doctors and nurses or to health tourism and nearly always, of course, to lack of money. All of these things play a part. The problem, like all modern problems, is complex. No single solution can possibly present itself. All aspects need to be tackled and no political party or party leader wishes to be the one to do so. The NHS is political dynamite. Tinkering around the edges of this system is not going to solve the issue (as has been shown with changes made in the past), and no new system is ever going to be perfect, (apparently, even Germany, that country so often held up as a model of efficiency, is currently encountering problems with its health service; problems, not as grave as our own, but problems none the less) but total reform is imperative. Where then to start in resolving these issues? It is all very well identifying the difficulties, but as with all areas of concern, having once identified them, we need ideas to provide solutions.
The biggest problem is the principle of ‘free at the point of delivery’. Even back in 1948 when the model was created it was appreciated that the demand for healthcare was nearly unlimited. Aneurin Bevan, the Labour Health Minister at the time, made the mistake of insisting, therefore, that it must not be limited by price or Treasury restrictions. When the governing Labour party introduced charges for spectacles and false teeth in 1951, he resigned. However, from the outset, some members of his party and his government disagreed with his approach (including, according to Professor Vernon Bogdanor, somewhat surprisingly, Tony Benn) and time has proved those original doubters right. Population increases and immigration, combined with an ageing population and increased expectations resulting from scientific and technological progress have massively increased demand. Healthcare is now effectively rationed through shortages of staff and waiting lists. (The Single Point of Access ‘SPA’ referral system, run by most health trusts, which denies GPs the chance to refer directly, seems specifically designed for this purpose – and of course employs more staff to manage it).
‘Free at the point of delivery’ has resulted in a supreme lack of awareness in the general population of the cost of anything. Because it is a public service and ‘free’ many assume they have a ‘right’ to demand and lack any understanding of relative costs. For example, it is not as expensive to get an X-ray done as it is to get a CT scan, which in turn is not as expensive as an MRI scan. Some tests are much more expensive than others, as are some procedures. Certain tests may be essential to diagnose a particular condition, others may be useful, but not essential and others may be pointless. With the rise of the internet and ‘Dr Google’, there are patients who consider their knowledge to be as valuable, if not as extensive, as that of the medics and feel they have been ‘short-changed’ if some tests or procedures have not been carried out (“What, they didn’t do an MRI?!”). Many also have little or no clue as to whether or not they should be calling an ambulance. Some may make the mistake of feeling a situation is ‘not serious enough’ when it is and yet others will call 999 for a non-life-threatening situation. Few will have any idea of the cost of doing so.
Under our ‘free’ system, choice is limited. For example, if you require a cataract operation, you are limited to the lenses available to the NHS. You cannot ‘top up’ by paying the small difference in price of the lenses but have instead to go entirely private at a cost of several thousand pounds. That may be fine if you already have private health insurance – otherwise it is money you need to have in savings. In countries where an insurance-based system exists (basically most of the Continent, Australia, Canada, etc) outcomes appear better and patient choice is more extensive, although some contribution from patients is, of course, required. In France, for example, state health insurance covers between 70-100% of costs for things such as doctor visits and hospital costs. Low income and long-term sick patients receive 100% coverage. Most private services are also available through the public healthcare system. Some people will take out supplementary insurance to cover the higher/extra costs.
In July the NHS had 6.8 million people on waiting lists for treatments. That is one in ten of our population, which is an extraordinarily high number. Apart from the individual misery of those involved, many of whom will be unable to continue with normal day-to-day life, this is surely an economically damaging statistic? A & E departments are overwhelmed; GPs are almost impossible to see or even talk to in some areas and many patients who are ready to be discharged from hospital cannot be because they have nowhere suitable to convalesce, thus taking up desperately needed beds. We need the re-establishment of cottage hospitals or their equivalents.
At the same time as the public are despairing about the ability of the NHS to offer appropriate and timely health care, its nurses, physiotherapists, midwives and doctors are equally despairing of its ability to offer them appropriate remuneration, respect and a reasonable work-life balance. The Royal College of Nursing (RCN) has recently voted to strike for a whopping 17%+ pay rise, even though they were awarded a pay rise of between 2.97% and 4% in August which was backdated to April this year. Many are leaving the profession and others are leaving the direct employment of the NHS to work for agencies which supply locum staff to the NHS – at considerable extra cost to the taxpayer. Junior doctors, particularly those who are not yet in specialist training posts, are doing the same. They may not get the holiday or sick pay to which they are entitled as employees of the NHS, but they have flexibility and freedom from the extremely rigid hierarchy and timetabling of the NHS.
A headline in one national newspaper over the weekend read “Every 1pc pay rise nursing union demands could fund 13,000 new nurses, says report”. The report in question was from the NHS Pay Review Body, but this quote surely completely misses the point. If 40,000 nurses left the profession in the year to June, the question which needs to be asked is ‘Why?’ If the answer to this question is a general feeling of dissatisfaction with pay and conditions, recruiting new nurses under the same pay and conditions is absolutely not going to solve the problem (unless, of course you take the morally questionable route of hiring them from countries where pay would be lower).
The same is true of doctors. Apart from those consultants at the top end who are leaving over dissatisfaction with curbs on their pensions, many at the bottom are leaving because of pay erosion and unsatisfactory working conditions. When HR departments are seemingly incapable (or too busy organising diversity training?) to manage to timetable the holidays of medical staff, it is unsurprising that those staff will look to work somewhere that not only pays more but does respect honeymoon or holiday arrangements requested six months or a year ahead. Doctors who have moved to Australia or New Zealand are consistently impressed by the way their time off is managed and respected. One young doctor who had moved with her doctor partner to Australia loved the way both their rotas were worked out to give them time off together. In NZ the exams, which doctors are obliged to take for their Continuing Professional Development (CPD) and which in this country cost the individual doctors thousands of pounds, are paid for by their employers, i.e by the health service.
These are the details which any reform of the NHS needs to consider. Without the medical staff we do not have any sort of health service, free at the point of delivery or otherwise. A system where those who can afford it are contributing even a small proportion would begin to deliver a system that worked, provided choice and possibly even provided some sort of accountability (both from the bureaucrats and from the patients). A health service is not a cult and should not be revered as one by the media, the politicians or the people it is supposed to serve.