Commentary by Sarah HARVEY-KELLY
Britain, 1948: After 6 years of war, the country is rebuilding its economy and seeking to boost productivity of its society. Talks over welfare and healthcare during the last 8 years have resulted in a controversial bill that that has lead into the resignation of many members of the health cabinet, and encountered opposition form highly ranked associations such as the British Medical Association. The bill offers a service that is financed from central taxation, eligible to everyone (including temporary residents) and free at point of use. A healthcare model that diverts away from the Bismarkian European model that Britain’s continental neighbours have chosen to follow. Financially constrained voluntary hospitals set up in Britain during WW2 and small independent bodies who have provided care for centuries (charities, trusts and the Church of England), no longer need to provide mainstream healthcare. The National Healthcare Service Act 1946 comes into effect. The National Healthcare Service is created. Britain, all eyes are on you.
Britain, 2016: Spending cuts, allegations over failure to investigate deaths, waiting times reach an all-time high, and junior doctors are on strike for the first time in 40 years. But there’s more, Britain now ranks 2nd with highest levels of obesity and lifestyle related diseases in western Europe, 20th in Europe in cancer survival, infant and perinatal mortality is above the EU average and the highest in Western Europe. On top of this, a demographically changing population and financial crisis, both of which are putting the NHS to the test. Last but not least, Jeremy Hunt as the Secretary of Health. Yet somehow, the UK ranks 11th in the world in healthcare performance.
Recent years have seen growing number of speculation regarding the NHS’ management and governance. Further critique has seen a few politicians advocating for insurance-based systems similar to other EU countries. Financed mainly off taxes, the NHS offers something unique: it is free at the point of use – in theory. Its financial accessibility has allowed the UK to rank among one the most financially equitable healthcare systems in the world, with some suggesting it is the most cost-effective health system, however some indicators would suggest otherwise. Although these indicators (financial equity and cost-effectiveness) are promising enough to explain the UKs position in international health performance rankings, the health outcome and efficiency indicators lag behind.
Single tax based healthcare comes at a cost. Resources are often constrained making clinical effectiveness difficult. Characteristics of tax based healthcare systems often include: limited consultation time with GPs, gate keeping and referral systems, limited prescription rates, slower and limited diagnostic rates, higher and quicker discharge rates and lower number of hospital beds. A recent report from the House of Commons stated “that radical change is needed to the way services are provided and that extra resources are required if the NHS is to become financially sustainable”. If Britain is to tackle the current health burden in the current economic climate, upfront investment will be needed. Typically the NHS has achieved efficiency in savings through cuts and freezes mainly in staffing. Other mechanism such as discouraging emergency admissions by giving local trust 30% of admissions tariffs were also put in place, but were deemed unsuccessful in reducing demand in these services. Funding the financially and socially overwhelming health burden now and in the long term through the current financial mechanisms will be difficult and unsustainable.
In light of recent austerity measures and changes the NHS has undergone, it’s not surprising that Junior Doctors are striking. They’re being made to work more with the same, or even less, pay. It’s more than just anger over salary, its unsafe for patients too and will reduce quality care. Interestingly, despite its difficulties protesters insist on “saving” the NHS, rather than changing it to be more effective. The NHS must be reformed, not saved.
In hopes to improve efficiency, the government has sought to improve healthcare using private contractors or by developing public private partnerships for decades. The 90s saw hospital infrastructure being outsourced to private contractors, with the NHS delivering the healthcare. The most recent reform, the Health and Social care Act 2012, created Care Commission Groups (CCGs) to oversee funds. Many opponents have criticized these types of changes, suggesting them as moves to “privatize” the NHS. Circle retracting from Hitchinbrooke Hospital, is exemplified by critics to highlight how the private sector cannot interact with public services. However opponents of model would have to also consider alternative methods financing the healthcare system without straining the NHS’ already limited budget. The NHS cannot financially afford to manage hospitals from its current financing mechanism, nor is it equipped enough to manage healthcare services outsourced to private providers whilst trying to provide high quality care services. Increasing income tax will not solve the NHS’ funding crisis. Even with the current model, rising demand and underfunding are leaving the services to breaking point.
Maintaining the founding values of the NHS and universal healthcare, free at the point of usage, whilst keeping a sustainable health system will be a challenge. Fundamentally it will mean changes in how services are delivered and used. Outpatient and community care will increase to reduce the burden on hospitals, preventative care will have to be more efficient to tackle the health burden, and financing mechanisms will have to be reformed to make the NHS more viable.