The NHS at 70: Loved, valued, affordable?

Dear Editors

Every time a reader pointed out that UK (and Australia) spends less on healthcare costs (as a percentage of the GDP) compared to the rest of the OECD (ref 1), I would simply ask the reader:

"Would you like to pay 60% more tax than what you are currently paying now?"

The fact is that while there are quite a few OECD countries in Europe who is spending as much 25% more than UK and Australia, the same countries also taxes individual wages 40-60% more than UK and Australia (Ref 2,3).

Furthermore some of these OECD countries also expects co-payment into the national health insurance scheme.

So frankly, instead of us emulating these OECD countries in the healthcare spending, we should be advising the citizens of these nations to ask for their tax-money back since they are paying some 60% tax for only 25% more spending on healthcare.

Also keep in mind that for the first time in this generation we are seeing an explosion of retirees and pensioners who are drawing on the national coffers; the pensioners to working adults are now disproportionate what is seen in past generations, with higher expectation of what the country should provide for them than their parents.

The current social support system depends not on the idea of "saving for your own future costs" but on the concept of paying forward: I am paying for someone's else social benefits and maybe someone else will be paying for my benefits when I stop working.

We are now seeing a lot more people retiring and wanting to draw on these benefits.

At the same time, we are also seeing political interference in the function of institutions like NHS and NICE, whose approach is criticised as utilitarian.

Well, if their approach are utilitarian, then they are doing what they are supposed to do, particularly when the government has demonstrated it has no intention to satisfy the ever-growing appetite of a NHS budget.

Furthermore, disastrous ventures like Cancer Drugs Fund, set up for political purposes, while expensive to run, has not shown to deliver "meaningful value to patients or society" (Ref 4).

Calls to bypass the NICE's vigorous appraisal process (Ref 5), at a time of financial austerity and uncertainty, are simply irrational and will only hurt more people in the long run through unnecessary delay in roll-out of proven treatment program through lack of funds.

We of course do know that the country's monetary reserves are not bottomless? Well, judging from the rhetorics of some readers pushing for more spending in areas related to their own vested interests, I am not sure that is common knowledge.

Whatever happened to "living within your means"?

References
1. https://www.oecd-ilibrary.org/docserver/health_glance-2017-en.pdf?expire...
2. https://www.oecd.org/ctp/tax-policy/taxing-wages-2017-brochure.pdf
3. https://stats.oecd.org/Index.aspx?DataSetCode=AWCOMP
4. https://academic.oup.com/annonc/article/28/8/1738/3768075
5. https://www.bmj.com/content/360/bmj.k1337

I couldn't help but notice the change in the online title from: “NHS at 70: loved, valued, and affordable” to: “NHS at 70: loved, valued, and too costly” in the print version. Is this an example of the economist’s existential crisis, or something altogether more editorial? In either case, I think it shows how prominent shibboleths can lead or mislead the argument. The idea that the NHS is “too costly” is certainly not borne out within the text of John Appleby’s article.

A rise in NHS spending from 9.9% to 10.9% of GDP would vouch a further £20bn or so for the NHS each year. With a little breadth of international vision, it’s easy to see that the NHS must be affordable. If most comparable countries can spend substantially more per capita relative to their GDP, we can afford to spend more on the NHS from what we already have.

We are tenth out of fourteen, and slipping.

The Political choice to fund average increase in NHS spending 2010-2020 of 1% instead of health inflation’s trend of 4% has shifted £35bn away from NHS coffers. We are witnessing the result.

Rationing of finite resources has always been endemic in the NHS, it’s not a new concept, but it is invidious to discuss planned rationing of services from the NHS’s current position. We are at the point where General Practice, A+E, acute, elective and social care services are evidently all overwhelmed. This is not, as we’re repeatedly misinformed, due to rising demand – it’s a reduction in supply. Prof Appleby underplays the siphoning off of per capita frontline resources given to the NHS: £s, beds, staffing, CT/MRI scanners all trailing comparator countries.

The NHS isn’t profligate; quite the opposite. Flawed concepts in measurement of NHS productivity have led to its underestimation, nevertheless we have still outstripped productivity growth compared to the rest of the UK market sectors by ~150% since 2010.

The point at which an increase in health spending would be better spent elsewhere is currently way over our heads. Capacity in the NHS has been systematically reduced to the point where we are now unable to meet the population’s immediate medical needs. Surely another comprehensive Wanless review is essential before we start to question the existential standing of the NHS?

When planning for predictable rise in demand from technological developments, it’s important to maintain effective cost control over procurement. As newer technologies tend to replace and improve upon previous treatments, less effective/efficient treatments become obsolete, so not all developments are additional costs.

The ageing population - surprisingly given the shibboleth it has become - is a relatively small driver of healthcare costs. Gains in life expectancy are most closely linked to improved standards of living, as the huge 18yr variation in life expectancy west-to-east across London confirms in real time. Historical increases in life expectancy have been exaggerated by use of Life Expectancy (mean average) rather than Modal average (the age at which most people die).

In a functioning economy, gains in life expectancy should actually benefit both the economy and the NHS, because more people in better health will work and pay tax for longer.

The relevance of political decisions to this whole debate is underlined by reversal of hard-earned improvements in mortality rates under austerity policies of this govt, with alarming rises in infant mortality rates among the most deprived families. Research showed 10,375 extra deaths occurred in the first seven weeks of 2018 were not caused by ageing, ‘flu or winter…was this austerity and a health service being defunded into disrepair?

An apparent red line for Appleby is that: “In all of this, we argue that one founding principle of the NHS is inviolable: all people should have access to health services that is based on need and free at the point of delivery.” – but, CCGs are refusing to provide major and minor operations for smokers and people who are overweight; Procedures of Low Clinical Value removing whole lists of existing procedures from patients despite genuine medical need; NHSE refusing to provide medications which can be bought; private GP services advertising in competition with, and diverting funding away from, NHS GPs.

We also need to be clear what “free at the point of delivery” means, or whether it really means much at all. Proposed Personal Health Budgets will introduce a charge value to planned medical care. Medically insured care is free to use at the point of delivery, as is a light switch paid for by monthly billing. We already pay out of pocket for prescriptions, dental, optical care. Co-payments for GPs and even hospital services have been mooted for payment by Lord Prior and others, and there are many vocal ‘pay-for-blame’ advocates.

If we look for significant current sources of waste in the NHS, the Political commercialisation of NHS services (H&SC Act 2012) was a detrimental and expensive error of judgement. Look at what has happened and where it has got us. Publicly provided is cheaper and better. Planned further reorganisation of the NHS into ACOs (pointless to argue over the name when you’ve already smelled the contents) will prove costly, at the expense of existing acute and other services, and with further expansion of privatisation to a greater or much greater degree. We don’t need another complex, expensive mess imposed by a government determined to use the NHS as a commercial gravy train.

As for data, commercialisation and confidentiality are key issues: Care.data and NHSDigital’s tendentious oversharing are examples of how key players, industry and revolving doors have rapidly overtaken the interests of patients and of the NHS itself. Big data will serve us well only after we’ve learned how to really use it for the common good.

John Appleby has joined Chris Ham of Kings Fund in “re-visiting the compact between the public and the NHS”. This approach seems at odds with solid evidence in favour of efficiency of the single taxpayer universal system with comprehensive coverage, and cost and quality evidence in favour of a publicly provided NHS. Much of that evidence is before our eyes.

The big question is: how much is enough? And with all due respect, this is really where I’d have expected you guys to step up.

Dear John and Kamran,

Thank you for a great editorial which promises upcoming thorough debate on the financing of the NHS which affects us all. Access to healthcare based on need, free at the point of delivery, is rightly seen as a very important founding principle of the NHS. However, it is not inviolable. NHS dentistry was originally destined to be free at the point of need but the demand for its services was so overwhelming that charges needed to be brought in to curtail demand. Prescription charges are another example where patients pay to get the treatment they need.

Although unpalatable politically and logistically difficult, it would be unfair to leave charging for NHS services out of the debate as it is already part of the funding of the NHS.