What is the NHS for?

At a party this week I got talking to a friend of a friend who quickly discovered I was a doctor. The conversation changed from which tube lines were running and who had made the delicious chocolate brownies, to the NHS: specifically its failings. I become, not for the first time, an embodiment not only of the medical profession, but of the entire health and social care system. I was charged with defending the lack of care shown by GPs, the apparent willingness of doctors to prescribe pills for anything and everything but never to listen, the lack of a nutritional perspective from NHS practitioners and the poor funding of mental health services.

The NHS is not perfect. I have heard many stories from dissatisfied individuals, and wouldn’t for a moment dismiss their grievances. I have even been known on occasion to spend an entire dinner party lambasting its’ deficiencies. But conversations like this make me wonder about the expectations of the public of this institution of which I am extremely proud. What do they think the NHS is for?

Sir William Beveridge, founder of the welfare state

When Sir William Beveridge created the welfare state, and Nye Bevan announced the foundation of the NHS in 1948 it was with the  expectation that the costs would be recouped by the beneficial effects on the health of the nation. But the NHS is a victim of its own success, and people now live longer with many more chronic diseases and health needs. Technological advances have exponentially expanded what we can offer with an associated financial burden. The treatment for a heart attack used to be an aspirin and bed-rest, and is now emergency primary percutaneous coronary intervention in state of the art angiography suites and coronary care units. The concept of health itself has also changed from the simple lack of disease to “a state of complete physical, mental, and social well-being”. I don’t think I know anyone who would claim to have woken up in the last week feeling “healthy” if that is the definition.

Many of the problems the NHS faces are not new. In a Panorama program of 1967 practicing physicians identified frustrations that would be familiar to today’s doctors: poor planning of location and design of hospitals with no flexibility for future changes; patient delays awaiting specialist opinions and investigations; and discharge delays awaiting social care placement. Many of these problems are to do with funding, system structures, political priorities, and the interface between health and social care. And that’s without even looking at the wider social determinants of health and their impact on effective healthcare provision. The 1967 physicians also identified the difficulties of financing this vast system and the need for efficiency, with some arguing we spent too much and others arguing we spent too little on healthcare. The NHS is often compared to the US system, with its’ private focus and business ethos. Interestingly in 2009 healthcare spending as a percentage of GDP was higher in the USA (17.4%), than France (11.8%), Germany (11.6%) and the UK (9.8%). The NHS is not expensive and inefficient as it is often characterised and free markets are no panacea – just one of many reasons why the Health and Social Care Bill is not the answer. Collaboration not competition is a growing mantra amongst my colleagues.

Nye Bevan, Minister for Health. “…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.”

So what should the NHS be for? Should it have a limited remit, focused on high-quality but basic healthcare provision? Does this imply newer drugs and technologies would be unavailable to those without additional money to pay a “top-up” fee? Are we happy with such an abandonment of equity and equality? What is defined as basic healthcare, and what would fall outside this remit? Who would decide? Where does public health and prevention fit into the system? Or should the NHS strive to compete with other, privately-funded systems, and provide up to the minute technologies and breakthroughs to all, whatever the cost? Will the electorate agree to paying higher taxes to achieve this? Should it be the NHS’s responsibility to provide complementary therapies if this is what the public demands? Should doctors be more qualified in giving nutritional advice, despite the lack of validated evidence of benefit of nutritional interventions for many conditions? Where do we draw the line between health and social care? Should the NHS’s remit extend to mechanisms for redistributing wealth since inequality is at the heart of so many problems?

Good healthcare should be available to all, regardless of wealth. This principle must never be lost. The NHS employs more than 1.7 million people, and treats 3 million people every week, for free at the point of need. It is the world’s largest public funded health service and one of the most efficient, egalitarian and comprehensive. The remit of the NHS grows daily: stretching from cradle to grave; prevention to cure; physical to psychological, but it can’t do everything. So next time you encounter a doctor at a party feel free to express your grievances, highlight inefficiencies and debate the politics, but don’t expect them to be anything but immeasurably proud of the NHS’s founders and those that work within it today.

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