Tag Archives: NHS

How do we decide what should be provided by the state?

 It is easy in principle to decide whether something should be left to private enterprise  or public service. Simply ask five questions:

 (1) Is the service or product generally considered to be a necessity?

 (2) Will profit compromise safety?

 (3) Is the service obviously inappropriate to be left in private hands, for example policing or defence?

 (4) Can the service be provided by private enterprise without subsidy?

 (5) Can free enterprise be reasonably expected to deliver the necessity universally?

 If the answer to any of (1)(2)(3) is YES or the answer to either (4) or (5) NO, then it should in principle be provided either directly or indirectly by the state.

Be anti-social; live to a ripe old age

An unpleasant mentality is  distorting the notion that the NHS is a national health service. Increasingly, politicians, the media and medics are taking the line that treatment can be legitimately withheld from people wicked enough to disobey the official disapproval of smoking, drinking, getting fat and so forth. For example, Norfolk Primary Care Trust has decided that confirmed smokers are to be taken off waiting lists for “all non-urgent operations such as hip replacements ….[because] Smokers have three times the complications as non-smokers”. (Metro 23 10 2006) I think anyone needing a hip replacement would dispute the operation’s definition as non-urgent. It is worth adding that the story mentions the Trust is “£50 million in the red” and an unkind soul might conclude that the withdrawal of treatment to smokers is connected to the debt. Nonetheless, the fact that smokers have been targeted speaks volumes for the ideologically driven mentality within the present day NHS. It is only activities which come within the ambit of official disapproval and moralising that are the subject of such withdrawal of treatment – it is noticeable that no politician or health trust has suggested that treatment for AIDs or HIV should be withheld because it is in most instances the consequence of the individual’s behaviour.

The moralising which bolsters the supposed clinical case for withdrawing treatment from certain groups runs along the lines that people are being selfish and irresponsible by smoking, drinking, getting fat etc. Wild claims are made for deaths supposedly due to such behaviour – any smoker who dies at a ripe old age is as likely as not to be classified as dying from a smoking related disease. All this supposedly self-inflicted illness is portrayed as being a massive burden on society and especially on the NHS.

Most absurdly and dishonestly, smokers are claimed to be a drain on the taxpayer despite the fact that tobacco taxes (excise duty and VAT) greatly exceed any additional costs smokers might place on the NHS. Ditto with alcohol and alcohol related illness.

But do smokers, drinkers and the fat, who on average die younger than those who do not display such traits, actually impose extra costs on the taxpayer? Writing in the Sunday Telegraph (22 1 2006) the historian Niall Ferguson baldly and erroneously claimed those who smoked, drank and got fat are being antisocial because they “tend to expire slowly and expensively”. Most do not and whatever cost to the taxpayer arises from such people it pales into insignificance compared with those who live to a ripe old age. Not only do the latter draw pensions and benefits for far longer than the shorter lived smokers, drinkers and the fat, but the most costly of NHS patients are those who live to extreme old age for they frequently end up in hospitals or nursing homes for months and years. The most antisocial thing a person can do from the taxpayers’ point of view is live to an extreme old age.

The road to NHS privatisation

The good news  first.  The NHS was founded in 1948 on the principle that all treatment should be free at the point of use regardless of income. 63 years after its foundation the principle is largely intact. We have prescription charges and fees  for dentistry and the work of opticians, although  even these charges for the poor, old age pensioners and children are either considerably mitigated or waived completely. For the vast majority of illnesses and injuries NHS treatment is available and no one who is entitled to it need fear that they will be bankrupted by the cost of the treatment and care, and for the vast majority of ailments  it is unlikely that  the NHS will say no to treatment because it is too expensive. There are increasing disputes over the funding of expensive treatment, especially cancer drugs, but these affect only a tiny  minority of patients and often a refusal to fund treatment stems from doubts over a drug’s efficacy rather than its cost. The sole major NHS blot is dentistry where it is difficult to find dentists to take NHS patients in many parts of the country.

Now for the bad news:  the  NHS  ethos is under severe attack, not by piecemeal reform but frontal assault.  The Coalition Government proposes to put 80% of the NHS budget into the hands of GPs and allow private health companies, many of them foreign,  to enter the NHS market by bidding for contracts to run groups of GPs.  They also intend to increase  the outsourcing of non-GP NHS work to private companies.  The clear intention is to destroy the NHS as we know it by making it predominantly a profit- driven service rather than one propelled by patient need.  It is the penultimate  act of a drama which has been playing out for 20 years.  If these changes are pushed through the final act is likely to be  outright  privatisation.  

The drama began in 1990 when the introduction of the “internal market”  through the  NHS and Community Care Act  was the first major thrust at the unified integrity of the NHS with health authorities (HAs) given their own budgets to buy care for local populations hospitals and GP fundholders to obtain faster hospital treatment for their patients than non-fundholders .  This not only caused a large increase in NHS administrators, but also  struck at the universality of the NHS by allowing HAs to make different judgements about treatments and patients to be at the mercy of whether or not their GP was a fundholder or not.  

Labour supposedly scrapped the internal market when it came to power in 1997, but this was more PR than reality because foundation trusts were established which led to  hospitals once again competing for business.  Blair also  left in place the purchaser-provider split between primary care organisations and hospitals by scrapping GP Fundholding but replacing it with Primary Care Trusts (PCTs) through which 80% of NHS funding is now channelled.   (think of PCTs as local area health managers funding GPs, dentists etc.)

The next breach in the integrity of the NHS was devolution (1999) which allowed Scotland, Wales and (eventually) Northern Ireland to manage their own health budgets.  This   caused substantial differences in funding between the four Home Countries, for example, prescription charges have been abolished in  Wales and Northern Ireland  but not in England and  Scotland, and  the  variations in treatment, especially in the provision of expensive drugs, which were already in evidence before devolution were magnified.  

 The creation of The National Institute for Health and Clinical Excellence (NICE)  in 1999 also  complicated the issue  of drug treatments after devolution. Amongst other duties,  NICE  investigates the efficacy of drugs and makes recommendations which NHS health providers do not have to abide by,  but which are generally followed.  After devolution Scotland had a separate version of NICE , which often makes different judgements about drugs from  the original NICE,   a body which covers only England and Wales.  All this fragmentation of the NHS  has resulted in some treatments being offered in Scotland and Wales but not in England, for example drugs such as Aricept, Reminyl and Exelon which are used to treat Alzheimer’s are being denied to early stage Alzheimer’s sufferers while it is available to such people in Scotland and Wales (Daily Telegraph 18 10 2006).

NHS  change under the Blair Government was  “continuous revolution” lines.  In 2002  Strategic Health Authorities (SHAs) – which complicated the administration even more –  were introduced followed by  in  2006 by Patient Choice, which allowed patients a choice of several hospitals if they needed to go into hospital. This meant more administrative work,  increased the competition between hospitals for patients  and,  because it was introduced only in England,  a further diminution  of  the universality of the service.

To these strikes against the public service ethos of the NHS can be added the creeping privatisation of the NHS which ranges from the logistical and administrative to the medical. Hospitals have and are being built under PFI and their maintenance placed in private hands. Hospital meals and cleaning  are provided by private contractors. (I was in a large London hospital in 2009 and it was chaos. There was a PFI contract for meals, a PFI contract for ward cleaning, a PFI contract for the multi-media installations (TV, internet etc). It was chaos because the ward sister had no authority over any of the contractors.)  Medical supplies to hospitals are distributed by the German firm DHL. Most disturbingly, private medical firms, often American,have been  granted massive contracts to take patients away from the NHS, a policy made all the more dangerous for the long-term security of the NHS because the treatments the private firms undertake are the simpler ones. The NHS are left with a reduced patient base for the simpler operations, which can result in the closure of NHS departments or even hospitals, and leaves the NHS with the more difficult and expensive cases to treat.

The present Coalition proposals are  to abolish the PCTs and transfer the 80% of the NHS budget they administer to GPs.  Apart from the question of practicality – doctors are trained to be doctors not businessmen and accountants  – this will open the opportunity  for private companies (especially American healthcare  ones) who are profit-driven  to take control of large sections of  primary care provision.  Even where that does not happen, GPs will be forced to work to a budget which means they will have to start  routinely thinking not of the clinical needs of patients but the cost of treatment. Not only that, but patients will know that it is the GP saying yes or no to treatment not some anonymous person at a local area health office as is currently the case.   This  will utterly alter the relationship  between patients and doctor.

What do we need to do to save the NHS? Apart from making private medicine pay its way, the NHS ideally needs to (1) not only stop further privatisation but to take back into its direct control that which has already been lost; (2) ensure that enough medical staff of all sorts are trained in this country and NHS posts reserved for them; (3) end the practice of money following patients; (4) fund NHS healthcare on the basis of an area’s population and demographic distribution; (5) retain and where necessary build new local hospitals; (6) restrict treatment to the hospital within a health authority area; (7) lay down a national schedule of treatments which must be offered throughout the NHS and (8) restrict NHS treatment other than emergency treatment to British citizens.

No 8 is necessary because a great part of the problem for the NHS in areas such as London is that it is being overwhelmed by the large number of foreigners who one way or the other either have a right to NHS treatment or who obtain it because NHS staff are unwilling to check whether someone is entitled to NHS treatment. Of course, there are supposedly reciprocal arrangements for Britons to obtain health treatment abroad but the balance of advantage is all against Britain because the range and quality of provision in many of the countries which provide supposedly reciprocal treatment is inferior to that of the NHS. There are also potentially vastly more foreigners eligible for NHS treatment than Britons eligible for treatment abroad, for example, 400 million non-British EU state citizens.

The NHS consultants would doubtless froth and whine about reduced private work opportunities and it might be necessary to give their NHS pay a very large boost. But there are not that many of them and the cost would not be vast in the context of total NHS spending.

That is the ideal. How much of it could be achieved as things stand is debatable because our EU membership and other treaties severely restrict control over both our borders and what any British government may do. For example, while we remain in the EU we cannot stop any person legally  resident in the EU from coming here (apart from special cases of crime or terrorism) and either working for the NHS or claiming NHS treatment. PFI contracts also presents a severe obstacle because of the cost of buying up the PFI contracts, many of which extend to 30 years or more. Nonetheless it can be done, viz:.

“The NHS body was due to pay £2m a year for the next two decades to the private firm that built West Park Hospital in Darlington, County Durham. But after reviewing the costs, Tees, Esk and Wear Valleys Mental Health Foundation Trust decided to take advantage of a break clause in the deal. It paid £18m upfront to get out of the PFI contract 23 years early, but it now owns the hospital outright and expects to save £14m over the course of the deal once maintenance and inflation is taken into account.”  http://www.telegraph.co.uk/health/healthnews/8296685/Hospital-saves-14m-by-getting-out-of-PFI-deal.html

Let the NHS become anything other than what it is, a national health service free at the point of use and you will never get it back. It was created in the extraordinary circumstances of the immediate post-war national solidarity when both the electors and the politicians were determined that Lloyd George’s boast of creating “A land fit for heroes” should not be mocked twice.

The NHS goes to the heart of what should be public and what should be private. The prime distinction is between service and profit. Public provision is the provision of necessary services to everyone, which private provision never has nor can supply: private provision is simply the provision of services to those who can pay. This has  been lost sight of by governments over the past 20 years.

So you think private healthcare would beat the NHS…

Anyone who has ever had private medical insurance will know how incomplete the cover is. Common exemption clauses are a two year waiting period for existing complaints to be covered, a complete exclusion of psychiatric treatment and severe restrictions on aftercare, which is frequently excluded when active medical treatment ends.

Those who have had chronic and serious illness soon discover that the amount of private active treatment and aftercare they can obtain is considerably less than they imagined. Many enter  courses of treatment which end before the utility of a treatment is exhausted. They then transfer to NHS care. Frequently operations are funded by their insurance but not the subsequent nursing which is undertaken by the NHS.

Those in Britain who laud the idea of private insurance as a substitute for taxpayer funded health service should examine the effects of such a system in the richest country in the world, the USA. Around 40% of the population have no health insurance. Even those with insurance find themselves left high and dry more often than not. Here are the words of a British journalist and novelist living in New York, Zoe Heller, from the Daily Telegraph London 6/5/2000:

One of my best friends was short of cash one month and let her insurance lapse. That same month, she was diagnosed with breast cancer. Seven years later, she is still paying off the credit card debts. Another uninsured friend was rushed to hospital for emergency intestinal surgery. She will be paying her bill on an instalment plan. She counts herself lucky that the hospital has a relatively liberal policy about treating uninsured patients…

A recent study established that one in four of every American declaring bankruptcy in 1999 cited illness or injury as the main reason for his financial problems and that of that group, roughly half were insured. In other words, paying extortionate sums to the insurance companies doesn’t protect you from financial ruin if you happen to fall ill with something serious and expensive enough.

Even the rich in the US find healthcare beyond their means if the treatment is long and serious. The Superman actor, Christopher Reeve, one of the highest paid Hollywood actors, had exhausted his savings within two years of the terrible injury which left him paralysed. Private medicine will guarantee virtually any treatment – if you can afford to pay for it. That is the long and short of it. The NHS provides a remarkably wide range of healthcare free at the point of use. It mitigates strongly against “unfairness”.

As far as private medicine in Britain is concerned,  it currently enjoys a great deal of unacknowledged  public subsidy. Private medicine in Britain is notoriously prone to pushing any bungled private treatments back on the NHS without compensation. It also makes little investment in private sector facilities because it can rent NHS facilities for more complicated treatments, facilities which are purchased at well below any realistic cost. Private medicine also makes no contribution towards the cost of training medical staff. In short, private medicine in the UK lives off the back of the NHS and the taxpayer.

The media which is only too willing to feed the public with NHS “horror stories”. A good example is one from the Sunday Telegraph. On 27 August 2006 their front page ran ‘Blunders by NHS kill thousands of patients a year”. Does anyone seriously imagine that any healthcare system in the advanced world does not suffer such casualties or that private medicine is generally more efficient or safer? Of course the NHS makes many mistakes and these add up to a sizeable bald global figure but when you are catering for a population of 60 million that is scarcely surprising.  As a public body the NHS also records its mistakes so that its overall perfomance can be measured. That does not happen with the private sector.   A public audit of the safety and efficiency of private medicine  would make interesting reading.  I would be willing to bet that it would show two things:  (1)  that clinical outcomes for similar treatment in the NHS and private medicine are poor l more often in private medicine than the NHS and  (2) that the range of treatment offered by private medicine would be both much narrower and less demanding than that undertaken by the NHS. It would also be interesting to know how many patients had to be treated by the NHS after private medicine had bodged treatments, procedures  or aftercare, the ailments  of the patients whose treatments had failed and the cost to the NHS of picking up the pieces.

The harmful effects of private medicine on the NHS go beyond inadequate payyment for NHS facilities, medical training, the rectification of bodged treatments and the cherry-picking of treatments and patients.  Even  if private medicine  paid for NHS resources in full, it does not follow that would be a good thing for the NHS because the money received might  not adequately compensate for the loss of the NHS facility during the time it is in private use. This is particularly the case where complex treatments, especially surgery, are concerned because the number of NHS facilities able to offer the treatment will be very limited. It is worth mentioning that a sizeable proportion of private medical treatments in the UK, especially the more demanding cases such as those of serious heart disease, involve the treatment of foreigners. It is morally indefensible to allow NHS resources to be hired to be used on a foreigner rather than used to treat a British citizen on the NHS. Where there is genuine spare capacity in the NHS, private medical providers should be charged a realistic price for it. In cases where private medical treatment goes wrong, the private medical provider should pay for the remedial NHS treatment.

It is vital that the NHS survives because even with present life expectancies, there are going to be an awful lot of people who will need intensive medical support in their extreme old age. The cost of that will almost certainly exhaust the resources of even those who have made seemingly substantial private provision for their old age.

The NHS has many faults, but for most of the population, it is a better and more complete supplier of medicine than private medicine will ever be or could be.


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