THE FUTURE OF THE NHS
By
Malcolm Morrison
__________
One cannot properly prognosticate about the future without examining, and
understanding, the past.
The NHS is revered, rightly, throughout the land. It was born out of a noble idea –
that no one should be denied treatment because of their inability to pay for it; but it
was based on a false premise – that, by treating those with disease, the nation would
become healthier and, so, the need for health care would diminish.
Britain in 1948, when the NHS came into being, was very different from the Britain of
today.
Prior to the NHS, people had to pay to see a doctor (except for those on ‘The Panel’
– workers, but not their families). Many postponed going to the doctor because they
could not afford the fee; so only presented when their disease was well advanced.
In hospitals, Lady Almoners enquired about the patient’s financial state and
‘suggested’ a suitable donation – though the poor were ‘allowed’ free treatment.
GPs relied on their fees from patients (though it is said that some waived their fees
for the poor and charged the ‘well off’ more!); and hospital consultants relied on their
fees from ‘private patients’ (though they were not so-called then) and ‘gave’ their
services to the ‘voluntary’ hospitals (sometimes getting a small ‘honorarium’ – they
were ‘honorary’ consultants). In some major teaching hospitals House Officers
(then, almost all ‘Housemen’!) were unpaid (their ‘reward’ being free board and
lodging!) and had little, if any, time off.
In those days the main diseases (infections (particularly TB), heart disease and
cancer) were all killers – or, as we would say today, ‘life-threatening’. There were
few drugs; they were not very effective but had few side-effects; and they were
cheap. Antibiotics were just coming in (anti-tuberculous drugs came a few years
later); digitalis was about the only ‘heart medicine’; and radical surgery was the
treatment for cancer (with some getting post-op radiotherapy) – but there was no
chemotherapy.
How times have changed! Today, most treatments are ‘life-enhancing’ rather than
‘life-saving’. There are myriads of medications for all manner of diseases; they are
very effective but have serious side-effects; and they are expensive. Most surgery is
aimed at preserving function; we now have joint replacements, arterial stents bypasses and grafts, organ transplants and various forms of ‘reconstructive’ surgery.
‘Oncology’ (a new specialty) now encompasses restricted surgery, reduced doses of
highly-focussed forms of radiotherapy and an ever-increasing variety of
chemotherapeutic agents – with gene therapy on the horizon.
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All this, together with better housing, better food and better hygiene, has led to
people living longer. But, the longer we live, the more likely it is that we will develop
a disease that can benefit from one (or more) of these truly ‘wonderful’ treatments –
and, so, enjoy a better ‘quality of life’.
BUT, the problem is that this ‘increased demand’ puts a strain on the NHS – and all
who work in it. The ‘cost’ of the NHS continues to rise; but the ‘resources’ (both of
manpower and money) are restricted – by the political decision of how much
‘Parliament’ chooses to spend on it by way of the NHS budget.
Of course, this is not new; it has been building up over the years - indeed since the
inception of the NHS.
One of the ‘founding principles’ of the NHS was that it should be ‘free at the point of
delivery’. However, it soon became apparent that treating the ‘pool of disease’ in the
population at the birth of the NHS did not reduce demand; it increased it! The fitter
people are, the less will they tolerate ‘minor ailments’ – especially when the
treatment is ‘free’! And so, in 1952, the first ‘charges’ were introduced – for dentistry,
spectacles and the prescription charge; and this led to the resignation of Nye Bevan
(the ‘founder’ of the NHS and then Secretary of State for Health) and Harold Wilson
(then a junior minister) because of the breach of this principle.
Over the years, successive governments, Secretaries of State, and all politicians
have buried their heads in the sand and refused to face up to the basic problem.
Instead of ‘dealing with the underlying disease’ they have applied ‘palliative
medicine’ (attempted to ‘treat the symptoms’) by a series of reorganisations! The
problem has become more acute in recent years due to the financial restraint
brought about by the banking crisis – together with the increased longevity of the
population and the proliferation of effective, but expensive, treatments.
The problem is simple – ‘demand exceeds supply’. Thus, there are only two
possible solutions – reduce demand or increase supply (or a mixture of both). These
are political (not medical) decisions; but it is our duty, as a profession, to ‘advise’
politicians of their options – but they must make the ‘choice’, even if politically
unpalatable!
Reducing demand would entail a form of ‘rationing’ (well understood in 1948!)
whereby certain conditions or treatments would not be available on the NHS (this
principle is already being applied, in minor form, by NICE). Increasing supply means
putting more money into the service – either by raising taxes or by imposing charges
for some (or all) forms of care/treatment (which is also being applied in the form of
the prescription charges and payment for some appliances).
Clearly such choices will be painful for all – but they are now necessary. It is
interesting that no other nation has copied our NHS in having everything ‘free at the
point of delivery’. We certainly do not want to return to the ‘bad old days’ of pre-NHS
when people ‘couldn’t afford’ to go to the doctor; but there are ways of protecting the
(really) poor from the effect of charges.
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I am sure there will be different opinions on the details of how to deal with the basic
problem. I believe the profession should be debating the issues; and the HCSA
should take the lead.
But I am equally sure that all doctors will wish to preserve the principle on which it
was founded – that no one should be denied treatment because of their inability to
pay for it.
__________
MCTM
15.5.14
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