If the Health and Social Care Bill currently being scrutinised in Parliament is passed, it will mean some wholesale changes to the NHS. Nicholas Timmins, public policy editor at the FT, believes the NHS is set to become “much more like a regulated industry of competing healthcare providers”. Ed Miliband has described the reforms as “experiments in right-wing ideology”. But should the public be worried?
The former Conservative Chancellor Nigel Lawson once said that the NHS was “the closest thing the English have to a religion.”
For all the bashing our national health service takes in the press, it remains an institution that we still allow politicians to speak about with sentimentality. The NHS is where we are born, where we have our babies and where more than half of us die. Its hospitals are the backdrop to some of the most profound moments of our lives, its corridors host to anxious waits, tearful conversations and the happiest of phone calls home.
It is all the more cherished because it is, to some extent, an anachronism, an institution born in post-war austerity under the social reforming zeal of a Labour party that remained committed to Clause IV. While we have bid farewell to a host of nationalised institutions, we remain proud of a national health service firmly in the hands of the State, free at the point of use and available to all. I think we’re allowed to feel sentimental about that. When Ed Miliband told the Welsh Labour Conference last weekend that “some things are just too precious to be left to the market” I’d say he was on safe ground.
But is our attachment to the NHS more than sentimental?
It is not difficult to vilify the market, powered as it is by self-interest. The State, by contrast, can be portrayed as an instrument of unity and solidarity, dogged in its unending pursuit of equality. The market is simultaneously universal (we all play a role in it) and impersonal, a set of forces it can feel impossible to argue against without being made to feel naive, simplistic, a throw-back.
Back in 1948 Nye Bevan defied Conservative opposition to the creation of the NHS, telling the nation to “take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world: put the welfare of the sick in front of every other consideration”. Today Miliband taps into our desire for an institution that sits outside the laws of commerce, something even George Osborne did not dare subject to cuts. The Labour leader knows that, because we have grown up with the NHS, we feel queasy about the notion of profit in healthcare. This is despite the fact that we have seen trains, telephones and utilities privatised. The NHS, we are told, is different. Miliband’s warnings that the Government “want healthcare sold to the lowest bidder” will frighten many.
The first thing to say is that his comments are slightly disingenuous. Competition and private sector involvement in the NHS was a concept championed by the Labour government. Nevertheless, changes being made under the current Government are a cause for concern. Notably the foundation trust regulator Monitor will have a duty to enforce competition in an NHS which will be able to contract with any willing provider, including private hospital groups. Doctors believe this will result in fragmented services and, potentially, reduced quality of care.
The healthcare system in the United States is often used as something of a strawman in debates about the NHS – a broken model which no country is seeking to emulate. However, it remains the best illustration of the dangers of privatised healthcare at its most extreme, spending 18% of GDP on healthcare without achieving anywhere near universal coverage or world-leading clinical outcomes. It is a system that collapsed as insurance companies chased ludicrous profit increases at the crippling expense of employers and families. On the delivery side, profit creates some weird incentives, leading to over-treatment and rocketing costs. The Dartmouth Institute for Health Policy and Clinical Practice has reported that up to one third of spending is on unnecessary hospitalisation, redundant tests, unproven treatments, and “excessive” end of life care. Two thirds of American consumers surveyed by PricewaterhouseCooper’s Health Research Institute said that they had personally received “excessive” medical testing. For all the criticism that the NHS’s attempts to ration care receive, it’s important to remember that in healthcare, more does not necessarily equal better. Treatments come at a cost, not just financially but physically and mentally; the profit motive risks a proper assessment of this. See, for example, the Government’s crackdown on private companies pushing ‘MOT’ style CT scans on the public.
The NHS takes huge strength from its universality. We enjoy affordable, accessible and equitable care. But reform is necessary. “Healthcare is not a commodity to be bought and sold” (Miliband again) is a fine principle but if profit is not to drive more efficient delivery of higher quality, more patient-centred care, something other than increased investment must take its place, as falling productivity figures attest. NHS staff know that things need to change better than anyone else. When asked how the service could make savings without damaging patient care, doctors had numerous suggestions so eminently sensible you wonder why they weren’t put into action years ago.
“The NHS is a prized institution precisely because it is not a market, because within it we are all equal. It needs to move beyond a bureaucracy to become much more a democracy in which the people who make it work and who use it exercise control over it.”
This quote from left-wing campaigner Neal Lawson summarises what I think about the NHS. The answer to the challenges facing the service is not to unleash the forces of competition upon it but to challenge and empower those who know it best – its doctors and managers – to redesign it around their patients. They will do this not in the interests of profit but because they want to, in the words of former Health Secretary Andy Burnham, make a good service great and because the alternative is the end of an ethos and an institution which still enjoys the faith of the British people. The constraint on funding might actually be the adrenalin shot the NHS needs.