Why, to flourish, the 65 year-old NHS has to change…

Partner Marcus Weatherby considers the problematic future of an NHS approaching its 65th anniversary …

In around 1948, Nye Bevan engineered a notorious ‘bribe’ to win the support of hospital consultants (reputedly stating he ‘stuffed their mouths with gold’). Under his deal, consultants were paid handsomely for their NHS work by the state, whilst also being allowed to maintain private practices.

The NHS will celebrate its 65th birthday on Friday. Bevan’s aim was to make health a level playing field. Under the NHS ‘No longer will wealth be an advantage nor poverty a disadvantage. Healthcare will be provided free of charge based on clinical need and not on ability to pay.‘

Nowadays we take the NHS for granted. Fewer and fewer people can remember the days when healthcare was the exclusive province of the well-to-do. The very existence of the NHS is a comfort that is rarely appreciated until it is needed – safety nets are never needed until you fall. Since it was established, however, lifespans have increased by about 12 years on average years for both men and women.

People are now surviving conditions that used to be fatal such as cancer, strokes and heart attacks. IVF treatment is helping thousands of couples conceive each year. Organ transplants and hip and knee replacements are now considered routine treatments. The effects of conditions such as MS, Parkinson’s Disease and ME are minimised by treatment.
The NHS has, to a large extent, been a victim of its own success. The patients that it services are a bigger population than ever, and advances in medicine mean that more conditions can be treated than ever before.

In times of recession the resources available to service the need that is there have led to some uncomfortable choices. All NHS boards are challenged with making difficult decisions, whether about prioritising which services they invest in, or whether to fund certain treatments for individual patients.

Whilst the NHS has been nominally ring-fenced by the current government, there will still have been £20 billion ‘efficiency savings’ by 2015. Some of these efficiencies are achieved by outsourcing services such as MRI scanning to the private sector, where they can be done less expensively. Whether the quality of such services is the same is debatable and, where errors are made, inevitably an additional burden is shouldered not by the private sector but by the redoubtable NHS.

Moreover the cost effectiveness of such initiatives is also debatable. The Commons Treasury Committee recently noted that “the cost of capital for a typical PFI project is currently over 8% – double the long-term government gilt rate of approximately 4%. The difference in finance costs means that PFI projects are significantly more expensive to fund over the life of a project. This represents a significant cost to taxpayers.”

In any event, the effect of the ring fence is illusory when one considers the effect that cut-backs elsewhere have had on the NHS. For example , with local authority adult social care being cut to the bone by cuts, the elderly population is being forced into A & E and hospital beds rather than receiving outside local authority help.

The effects of alcohol, eating and smoking continue to be the biggest drain on resources, and many argue that the only way to protect the NHS is to shift investment towards services that can help prevent, delay or manage illness. However, these are services traditionally funded out of the far smaller social care and public health budgets which sit within squeezed local government. The best way to maintain the resources of the NHS is for it to stop being a sickness service and to start keeping people well. And it can only do that with the help of a properly-funded social care and public health policy.

The original aims behind the NHS – of medical care being based on clinical need and not individual wealth – should be maintained. However it cannot and will not be able to continue in its current form.

We may have to accept in future that there are difficult decisions we cannot shirk. There may be limitations on what the NHS can achieve. In future, there may need to be an in-built emphasis on the NHS providing for the poor rather than providing a completely level playing field for all. We may have to accept checks to prevent the NHS shouldering the financial burden of ‘health tourism’. We may have to accept longer waiting lists for non-urgent treatments. Maybe those doctors who dedicate their careers to the NHS alone should get better pensions than those who do not. Maybe there should be a mechanism for depriving Trust managers of large payouts when their performance has led to a ‘Mid-Staffs Hospital Trust’ type scenario of widespread, substandard care.

It is, however, important that doctors are left unencumbered by these decisions and allowed to be medical professionals only, and not burdened with what are, after all, political decisions. The problem with this is that politicians realise that an open dialogue about what services are essential and what are not is a politically dangerous one for them to have.

However, with the finances of the NHS in such a parlous state, letting things continue as they are is not an option. In difficult times some radical thought is needed. As Nye Bevan put it: “We know what happens to people who stay in the middle of the road. They get run down.”

We send our best wishes to the NHS. Long may it flourish!