Issue 159: 2018 06 21: A Pain in the Chest

21 June 2018

A Pain in the Chest

The NHS dilemma.

By J.R.Thomas

The chest is that of the Chancellor of the Exchequer, hidden away in the Treasury, but the pain will be felt by nearly all of us.   And the sickly fingers reaching into our chest – or pockets – for more, are those of the NHS.  Writing anything even mildly critical of the National Health Service is life threatening indeed, the NHS being the supreme icon of the British way of life and, we like to think, the envy of the world.  It is certainly both wonderfully comforting and highly civilised that nobody should be financially ruined by the costs of their health care – few would argue that that is not highly desirable.  To many of us in these islands the NHS is the state function we value most; the best example of caring and sharing the riches of a wealthy and generous society.  But…  There has to be a “but”.  Making things free to users does not mean they are free or even cheap to run, and funding our loved icon has become more and more of an intractable problem over the last twenty years.  The growing costs of medical drugs and technology, and our ever-extending life spans, guarantees this problem will not retreat.

A weekly digest such as the Shaw Sheet could not begin to examine the problems and strengths, weaknesses and solutions, remedies and incurables, of our health service, and how to fund it.  That would take a book, in multi-volumes.  Debating critically the NHS is almost impossible; even gentle pondering, as economists and politicians who have made the mistake of so doing know, leads to shrieking, shouts of “Tory Cuts!” (much ruder in truth but this is a family magazine), and that most ghastly of fate for those who make their living by public pontificating: no-platforming.

The Conservative Party is always especially vulnerable to public concern on funding the NHS.  Labour invented it and created it and has always appeared more open handed to it (in fact the statistics do not totally support that – but it is what the public think).  Every Labour politician knows that the NHS is his party’s get out of jail card, the polling equivalent of wearing a white coat with a stethoscope in the top pocket.   Tories on the other hand are, of course, without heart and always out to cut, privatise and restrict access.

And now, as if the Prime Minister did not have enough problems to grapple with, NHS funding is once again a major issue, second only to you-know-what.  Simon Stevens, chief executive of the NHS and an adept political operator, has several times recently said that for the NHS to meet its targets and obligations it needs an immediate and sustained increase of around 4% in its funding.  On this at least the Chancellor of the Exchequer and the Foreign Secretary speaketh with but one voice and so the money is being found.  It is not quite what Mr Stevens sought but remarkably close to that £350m per week savings from leaving the EU which the Brexit campaign flagged on their campaign bus.

The NHS has a fundamental problem, which may never go away.  It is effectively free to all comers, almost without restraint.  Of course, people do not turn up for heart transplants or gender reassignment or long-term courses of psychiatry simply because they are free, any more than we would eat twice as much if supermarkets were free at the till.  But knowing that something does not have to be paid for does change behaviours.  Would there be any smokers if their diseases were only treated at the smokers cost?  Would we not lose weight if illnesses caused by obesity excluded the fatties from free treatment?  Would we cycle, ski, and windsurf more carefully if resultant injuries required production of an insurance certificate prior to being loaded into the ambulance?

But in truth, and given that most of us have stupid or dangerous habits or generic health difficulties, would we really want to impose such a regime?  It is a civilised edge to our society that we mend our fellow citizens free and without rebuke.  There are perhaps NHS free services that might be curtailed.  But, to take the obvious current barroom topic, should we cancel reassignment of gender operations?  To be trapped in the wrong body is no doubt almost as painful as having a broken one, and a distressed citizen might so easily be made a happy one.  There are users who trot along to A&E with every twinge and twitch, but there would be little cost savings from throwing them out more efficiently (though it might mean the truly broken could get faster treatment).

These things, alas, are not capable of being calmly or thoughtfully discussed.  The easy answer, both to comprehend and for politicians to implement, is to simply increase the funding of the service by increased taxation, as the Cabinet have just agreed, no doubt with sighs of relief and congratulations all round on their generosity.

The Major and Blair governments both made efforts to make the running of the NHS more efficient, by introducing the concept of hospital trusts, which to an extent compete in the provision of services, and certainly permit measurement and pricing of efficiencies.  The Trusts have been much criticised and are certainly not without problems, but overall the regime probably has made the NHS more cost conscious – too much so, the person in the A&E admissions queue or waiting list for a minor op will complain.  The downside, as with big business and big bureaucracy everywhere, is that the administration tends to overshadow the delivery service and many trusts have too many people in offices and not enough on wards.  But even curing that problem would not make significant differences to the cost of the NHS (every little helps, of course).

To really control costs (not cut them, just control them), requires some radical thinking and some very bold political action – politically, at the beginning of a government’s term in office so that the pain is over by the time the next election comes along.

What should be done?  Should some activities require insurance; what sort of A&E would turn away the cyclist who had not taken out insurance before the bus hit her?  How about reintroducing tax deductibility of private health premiums, so that more use private healthcare and relieve the strain on the public service?  Great idea, if the reduction in tax yield did not exceed the savings to the NHS of the migration of patients.  Perhaps a two-tier health service with free treatment of accidents and life threatening conditions but charges for less urgent or less painful matters?  Maybe, so long as we can agree what comes into which category (oddly enough, we probably never would).  Taxes on bad life styles? Smoking is already taxed, alcohol too, and sugar is going that way.  Cream cakes?  Red meat?  And actually do smokers and boozers cost the NHS more; or less, if they die that much younger?  We will soon separate out health care and social care, but that is semantics.  Both will have to be paid for and social care is low level health care – not many people will sit in a nursing home if they could manage at home.  We could stop the NHS always wanting the latest technology and particularly the best drugs – but who is going to tell the desperate parents that their baby cannot be saved or cancer treated for budget reasons?  Compulsory medical insurance linked to ability to pay, with the government picking up the bill for the poor and old?  Maybe, some of all of the above is where we have to go.

There are no easy solutions, not even the Chancellor’s grudging opening of his money chest; in the long term that will become a painful burden on all our shoulders.  But we must at least think about the problem and debate some answers.  Anybody care to guess when our current generation of political leaders will get around to that?

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