Civitas: Background Analysis 1

Even if the sole concern of public policy were to provide the highest possible standard of care for the poorest people in society, a rational person would not choose the NHS. This claim may initially seem to be counter-intuitive but how successful has the NHS been in achieving its own objectives? Traditionally the NHS has aimed to be universal, comprehensive, high standard, equal and free at the time of use. In practice, it is not universally available, not comprehensive, not of a high standard, and not equal; but it is free at the time of use (mainly). The one thing it does - not to charge - has serious side effects. The obsession with free care partly explains why the NHS fails to be comprehensive and of a high standard. It also explains why it fails to be responsive to consumers - now an additional objective of the NHS. The Government itself has made some damning criticisms. For example:

"At its heart the problem for today's NHS is that it is not sufficiently designed around the convenience and concerns of the patient. The NHS provides many patients with a good and reliable service. But it is simply not responsive enough to their needs. Patients have to wait too long for treatment. Records get lost. Wards are not clean. Standards are too variable. Old-fashioned demarcations between staff, restricted opening and operating times, outdated systems, unnecessarily complex procedures and a lack of training all combine to create a culture where the convenience of the patient can come a poor second to the convenience of the system."

"The current system penalises success and rewards failure. A hospital which manages to treat all its patients within 9 or 12 months rather than 18 may be told that "over performance" means it has been getting too much money and can manage with less next year. By contrast, hospitals with long waiting lists and times may be rewarded with extra money to bail them out -- even though the root of the problem may be poor ways of working rather than lack of funding."

But, the Government has decided to persevere with the same structure at a time when many commentators, from all points of the political spectrum, are taking a serious look at overseas systems. Anthony Browne, for instance, became health editor of the Observer in 1999, on the very same day that Alan Milburn became Health Secretary. In the Observer of 7 October 2001, he says that: 'what I have learnt about the health service and its workings has appalled me and completely eroded my faith in the NHS.' He continues:

"I used to be a believer. I grew up cocooned in the affection and pride that the British public had in the NHS, the glorious creation of postwar Britain that offered free, modern health care to all. Poor and rich got equal treatment; no longer would health depend on wealth. It was the only institution, it was claimed, that worked on an ethical principle."

"Each year, thousands of British people - the young, the old, the rich, the poor - die unnecessarily from lack of diagnosis, lack of treatment and lack of drugs. They die and suffer unnecessarily for different reasons, but there is just one root cause: the blind faith the Government has in the ideology of the National Health Service, and our unwillingness to accept not just that it doesn't work, but that it can never work."

Some unavoidable conundrums have to be resolved by any health care system. The most pressing question is how best to reconcile the interests of two groups: (1) those who can afford to pay for their own health care and who want to exercise some choices when making their decision about who to pay and how much; and (2) people who cannot afford to pay but who must be provided with access to an agreed standard of care.

People who can afford to pay want, not only the power to choose how much to spend, but also an insurance policy which will give them the power to escape bad service and drive up standards. These same people will also have to pay for the poor. What standard of care should be provided for the poor and should it be lower than that enjoyed by the self-sufficient majority?

The NHS copes with this question by providing a (theoretically) uniform standard for everyone, so that it can be said that health care is provided according to clinical need not ability to pay. In effect, the two groups are treated as antagonists and the highest priority is attached to preventing the self-sufficient (usually called the rich) from getting more than anyone else. That is, under the NHS the conundrum is approached in a divisive spirit. Elsewhere in Europe, however - including countries which are socialist or social-democratic - a compromise has been sought which aims to serve both groups. The French, for example, speak of their system as a combination of la medicine liberale (based on choice) and solidarity. Similarly, the German system tries to blend choice with a high and universal guarantee of access.

Whatever the particular rights and wrongs of the German and French systems, their overall objective is more defensible than that of the NHS: namely to discover a system which serves everyone. They have found ways of making the market serve everyone. In particular, they have avoided the danger of deepening the division between the poor and the rest; and they have sought to apportion to the government only those tasks it can perform best.

In the months preceding the National Plan of July 2000, there had been much media discussion about the merits of alternative systems, including European social insurance schemes, but the Government's response was to devote a few paragraphs to their dismissal. However, elsewhere in the document the NHS is compared unfavourably with other European countries. The National Plan admitted, for example, that cancer survival was worse in the UK than in many European countries. There were too few hospital beds compared with most other health systems and too few doctors: 1.8 practising doctors per 1,000 population compared with the European Union average of 3.1. And the Government acknowledged that the NHS carried out too few operations in contrast to countries such as the Netherlands, where twice as many heart bypass operations were performed.

Background ANALYSIS

CONCISE ANALYSIS AND COMMENT: Online No. 1

What's Wrong With the NHS? David G. Green Even if the sole concern of public policy were to provide the highest possible standard of care for the poorest people in society, a rational person would not choose the NHS. This claim may initially seem to be counter-intuitive but how successful has the NHS been in achieving its own objectives? Traditionally the NHS has aimed to be universal, comprehensive, high standard, equal and free at the time of use. In practice, it is not universally available, not comprehensive, not of a high standard, and not equal; but it is free at the time of use (mainly). The one thing it does - not to charge - has serious side effects. The obsession with free care partly explains why the NHS fails to be comprehensive and of a high standard. It also explains why it fails to be responsive to consumers - now an additional objective of the NHS. The Government itself has made some damning criticisms. For example: "At its heart the problem for today's NHS is that it is not sufficiently designed around the convenience and concerns of the patient. The NHS provides many patients with a good and reliable service. But it is simply not responsive enough to their needs. Patients have to wait too long for treatment. Records get lost. Wards are not clean. Standards are too variable. Old-fashioned demarcations between staff, restricted opening and operating times, outdated systems, unnecessarily complex procedures and a lack of training all combine to create a culture where the convenience of the patient can come a poor second to the convenience of the system." Secretary of State for Health Introduction to the NHS Plan (July 2000, p. 15) "The current system penalises success and rewards failure. A hospital which manages to treat all its patients within 9 or 12 months rather than 18 may be told that "over performance" means it has been getting too much money and can manage with less next year. By contrast, hospitals with long waiting lists and times may be rewarded with extra money to bail them out -- even though the root of the problem may be poor ways of working rather than lack of funding." The NHS Plan (July 2000, p. 28.) But, the Government has decided to persevere with the same structure at a time when many commentators, from all points of the political spectrum, are taking a serious look at overseas systems. Anthony Browne, for instance, became health editor of the Observer in 1999, on the very same day that Alan Milburn became Health Secretary. In the Observer of 7 October 2001, he says that: 'what I have learnt about the health service and its workings has appalled me and completely eroded my faith in the NHS.' He continues: "I used to be a believer. I grew up cocooned in the affection and pride that the British public had in the NHS, the glorious creation of postwar Britain that offered free, modern health care to all. Poor and rich got equal treatment; no longer would health depend on wealth. It was the only institution, it was claimed, that worked on an ethical principle." "Each year, thousands of British people - the young, the old, the rich, the poor - die unnecessarily from lack of diagnosis, lack of treatment and lack of drugs. They die and suffer unnecessarily for different reasons, but there is just one root cause: the blind faith the Government has in the ideology of the National Health Service, and our unwillingness to accept not just that it doesn't work, but that it can never work." Click here for the Observer article. The Underlying Conundrum Some unavoidable conundrums have to be resolved by any health care system. The most pressing question is how best to reconcile the interests of two groups: (1) those who can afford to pay for their own health care and who want to exercise some choices when making their decision about who to pay and how much; and (2) people who cannot afford to pay but who must be provided with access to an agreed standard of care. People who can afford to pay want, not only the power to choose how much to spend, but also an insurance policy which will give them the power to escape bad service and drive up standards. These same people will also have to pay for the poor. What standard of care should be provided for the poor and should it be lower than that enjoyed by the self-sufficient majority? The NHS copes with this question by providing a (theoretically) uniform standard for everyone, so that it can be said that health care is provided according to clinical need not ability to pay. In effect, the two groups are treated as antagonists and the highest priority is attached to preventing the self-sufficient (usually called the rich) from getting more than anyone else. That is, under the NHS the conundrum is approached in a divisive spirit. Elsewhere in Europe, however - including countries which are socialist or social-democratic - a compromise has been sought which aims to serve both groups. The French, for example, speak of their system as a combination of la medicine liberale (based on choice) and solidarity. Similarly, the German system tries to blend choice with a high and universal guarantee of access. Whatever the particular rights and wrongs of the German and French systems, their overall objective is more defensible than that of the NHS: namely to discover a system which serves everyone. They have found ways of making the market serve everyone. In particular, they have avoided the danger of deepening the division between the poor and the rest; and they have sought to apportion to the government only those tasks it can perform best. Learning From Overseas In the months preceding the National Plan of July 2000, there had been much media discussion about the merits of alternative systems, including European social insurance schemes, but the Government's response was to devote a few paragraphs to their dismissal. However, elsewhere in the document the NHS is compared unfavourably with other European countries. The National Plan admitted, for example, that cancer survival was worse in the UK than in many European countries. There were too few hospital beds compared with most other health systems and too few doctors: 1.8 practising doctors per 1,000 population compared with the European Union average of 3.1. And the Government acknowledged that the NHS carried out too few operations in contrast to countries such as the Netherlands, where twice as many heart bypass operations were performed. For further information about France click here. For further information about Germany click here.