The FishTank

Archive for August, 2009

Trying to find any objectivity in the current row over the NHS is like looking for a spare liver in a man with scirosis. What we have – broadly speaking – is a bunch of Americans with no experience of the NHS claiming we more or less use the National Lottery to decide who lives and dies, whilst Britons – who have equally never used the American health service – attack a system alleged to allow poor people to die for lack of insurance. Daniel Hannan, a man who does at least appear to have thought about the problem, is only one step from being burned in effigy, and half the nation is twittering about how wonderful the health service is. This being the same service that, when the Americans aren’t attacking it, they spend all their time whingeing about.
I could be equally emotive and claim that the NHS killed my father or that it attempted to condemn one of my friends to a wheelchair. But I think that exploring the issues objectively will do more to advance our understanding of healthcare than simply airing grievances.
My father suffered his first heart attack on Boxing Day in 1982 at the age of 37. He was rushed to hospital and spent some six months there before dying of another heart attack three days before what would have been his 38th birthday (and, just to add an emotive barb, on my sister’s birthday, the day after my brother’s). He could have been saved: bypass surgery, commonplace today, existed in specialist London hospitals at the time, but the decision was taken not to send him. Whether this was due to waiting lists or some kind of financial calculation is unclear, but given his youth it was unlikely to be any kind of risk assessment.
Fast-forward to the last decade and, as New Labour would undoubtedly point out, heart attack deaths have been significantly reduced by targetted funding. But that doesn’t mean the NHS is now functioning perfectly. A friend of mine suffers from serious muscular problems which were deteriorating and would require physiotherapy to keep her mobile. She was told the funding would not be made available, meaning she would end up in a wheelchair (and thus eligible for incapacity benefit costing more than her treatment). Her local MP fought the issue in Parliament and, eventually, she won the right to treatment. But it wasn’t an easy battle and the outcome was frequently in doubt. Other, less determined people would have given in and accepted their fate. Other, less conscientious MPs would have done less to help.
Neither of these cases suggest a system that’s in perfect health, but for each such example of failure there will be many others of success. One has only to look at the “we love the NHS” outpouring on Twitter to see that. And I don’t denigrate that emotional attachment; it’s simply that reducing the argument to “the NHS saved my life” or “the NHS lets old people die” is over-simplifying the issue and preventing genuine reform. Daniel Hannan’s mistake is not in the fact he criticises the NHS, but in the language he uses to do it. The NHS is not ‘a mistake’ and it doesn’t need to be scrapped. If you change the way it works it can still have the same name – saves the cost of a new logo at least. Reform is an easier pill to swallow, even if it technically amounts to a total reboot.
Get beneath the rhetoric and you’ll find the real debate is about funding. How is money raised and how is it allocated. This matters because, without infinite funds, there has to be a measure of rationing. My father’s death and my friend’s battle against incapacity are both instances where that rationing appears to have resulted in the wrong decision. In our system there is one big pot raised from general taxation, largely allocated in response to central government dictat and allocated by targets. In the US system, by contrast, there is a complex web of insurance schemes, providing individual pots for each citizen who can draw on them according to need. Despite the enduring myth, the US system does have a measure of state support for poorer citizens (in fact the US government spends more per-capita than we do), but as with our tax credits system, the complexity of the allocation system means that some people do end up uninsured. Even here, however, US hospitals have a legal requirement to save people’s lives, although there will be limitations on how much they are prepared to spend to do so.
The reason the Americans cling to their system is that, particularly for the right-wing rich, there is a feeling that it is wrong for a citizen who has paid for healthcare their whole life to be denied treatment because their allocation has been spent on somebody else. Somebody who has squandered their money rather than invest in their own future. In the UK, by contrast, we take the view that not everybody can afford the true cost of healthcare and our general principle of taxing by ability to pay and providing by need is fairer and simpler. Hannan’s preferred Singaporean model sounds superficially very similar to the American one, only with better protection to prevent people falling through the cracks.
But is that better? In terms of efficiency, probably not. We already have a tax-collecting system, so an independent means of collecting tax for healthcare, even one for taking money from central taxation and reallocating it, would undoubtedly cost more in administration. The US system is also an engine for profit, with health-insurance provision a lucrative business. Clearly, if companies are getting rich from your taxes, not all of the money is going to pay for your health. On the flip-side, the advantage of an insurance-based system is that the amount of money allocated to health is directly based on the wealth of the country: the costs of care for the elderly become less of a problem when those elderly people have been accumulating a fund for their own care their entire working lives. It does away with the debate being reduced to which party cares enough to put more money in, but fundamentally it achieves very little in the way of efficiency and – as we saw with Brown’s pension grab – there’s nothing stopping a government in tighter times using a tax to raid a healthy looking insurance fund. National Insurance was originally supposed to be just that – an insurance scheme – but it didn’t take long for government to see it as another source of revenue. You could have a privately run national insurance scheme, but it’s a thankless choice, like choosing who you’d prefer to burgle your house.
In terms of allocation, there is a superficial attraction to insurance. After all, if taxation means that everybody’s pot is either the same size or at least a certain minimum size, how could that go wrong? Quite easily as it turns out. Take the case of the long-term sufferer: for example, another friend of mine, who since childhood had been diagnosed with Crohn’s disease. He died of bowel cancer in his late thirties – this time the result of a delay in diagnosing his condition – although, again, I don’t know if the cost of testing the condition was a factor. Under an insurance based system, this friend could well have been worse off: the continual demands on his fund in treating Crohn’s could have left his fund too small to handle the cost of treating his cancer. And, since regular periods of hospitilization made it difficult for him to develop a career, even if he could have found the funds to save his life he could have been bankrupted by it – a situation not uncommon in modern-day America. Meanwhile, a luckier person could be in possession of a full state-funded insurance pot until killed in a road accident never having used the money. The money could be fed back into the system, certainly, but wouldn’t it have been better to save the life of my friend with it first?
Because of the diverse threads of our lives there simply is no magic bullet for allocation. Even if you try to tackle elderly care by assuming that most people live to old age and should thus establish a fund for it (what we used to call assurance) you run into the debate we’ve been having recently about whether it is right that a hard-working frugal citizen should be expected to sell their house to pay for care whilst a profligate wastrel receives the same care for free. It’s clearly not fair to rob people of their hard-earned assets (our equivalent of bankrupting patients), but equally unfair to say that people should simply live as long and as well as they can afford. Try to allocate funding evenly in the name of fairness and you generate waiting lists, target it to deal with specific regional issues, like heart health in Glasgow, and you are accused of creating a postcode lottery. It’s an intractible problem.
Intractible, but not beyond improvement. Because the real problem with our NHS isn’t how it receives its money or how it allocates it to patients but how it wastes it. Too many bureacrats whose jobs are simply about delivering favourable statistics to the government of the day; too many nationally tendered contracts for equipment; too many dodgy PFI deals allowing businesses to profit from the construction of hospitals; too much money going to drug companies who can whip up scares of pandemics in order to dump huge amounts of Tamiflu on the market. If half the money wasted in this way could be saved it would be a massive financial boost to the nation’s health. If the NHS narrowed its focus, ditching fashionable treatments like unnecessary cosmetic surgery, IVF and homeopathy there would be more money in the pot to help cancer sufferers and provide physiotherapy for those with muscular conditions. If services like the blood transfusion service were required to charge at cost, rather than run at a profit; if government-backed university research produced drugs that were provided to the NHS at cost; if local hospitals could source their own equipment and change supplier according to the market at the time… There are countless initiatives that could make our NHS more cost-efficient and thus mean it has to make fewer hard choices about what is truly fair.
Hopefully, by the time we get to the next election, the current furore about the health system will have died down a bit. Because what we don’t want is a continuation of the last twelve years, where success has been defined by the amount of money poured in and fairness by the conditions which grab the most positive headlines. Curing the NHS is not about feeding its addiction to money or treating its more obvious symptoms, it’s about getting to understand what is actually wrong with it. And that can’t be done whilst everybody is just arguing about who cares for it most.