03 November 2006
Despite a doubling of spending on the NHS, the public perception is one of a cash-strapped organisation in crisis. Richard Brooks explains how what should be a good news story for the government has now become an electoral liability
In Charles Dickens' Great Expectations, the hero Pip passes from simple and innocent youth, through the corruptions of society and wealth, to the realisation of life's great choices and complexities. It is, of course, also the story of the NHS. More money has not led to happiness, and certainly has not meant we can avoid hard choices.
Labour politicians must survey the scene with incomprehension and dismay. The health service is consistently ranked by the public as one of their most
important issues, and since 1997 the government has responded with an extraordinary investment of financial resources and political capital.
By 2008, annual spending on the NHS will have roughly doubled in real terms. The service will have recruited some 200,000 additional staff, and it will be more than halfway through a ten-year programme of far-reaching reform. Waiting lists are down, survival rates for some major disease groups are up, and the NHS is in the middle of a major programme of capital investment to renew its outdated estate.
Yet the health service remains at the centre of political controversy, with regular 'bad news' stories about deficits, drug rationing and potential closures of hospital facilities. Especially worryingly for the government, recent polls show that by a margin of more than two to one the public believe the health service is getting worse and, by a much smaller margin, that the Conservatives have better policies for the NHS than Labour. This is especially remarkable, given that the Conservatives do not yet really have a set of determinate health policies.
We are also in the midst of another round of debate about rationing. The front pages of the mid-market tabloids have become a battleground where patients fight for access to drugs and treatments. Health Secretary Patricia Hewitt cannot go anywhere in public without facing personal appeals from people, who are often in a desperate situation, for more funding for a particular cause.
It is instructive to take a longer view. Since the early 1980s, public satisfaction with the NHS has remained remarkably stable and, barring occasional peaks and troughs, has hovered at about 40% 'quite' or 'very satisfied', with a similar number 'quite' or 'very dissatisfied'.
Consider for a moment the changes over this period to the outcomes experienced by patients and the quality of the service they receive. Thirty years ago, many procedures that are now routine were high-cost, high-risk and in short supply. Most surgical procedures are now safer, less invasive and require a shorter period of admission. Whole categories of key drugs – such as statins – had not been commercialised 30 years ago. What on earth is going on?
What is happening is that expectations are rising at a faster rate than the NHS can keep up with. Or, more accurately, expectations are rising faster than people's perceptions of the performance of the health system.
This in itself might not be a bad thing. High expectations provide a useful spur for politicians and health service managers. We certainly should not try to manage down public expectations, and any attempt to do so could backfire. Politicians in particular must be seen to be the champions of a demanding public.
However, unreasonable expectations are likely to have two unwelcome effects. The first is that if they grossly exceed the capacity of the service to deliver, then the whole basis of public support might erode. But an individualised, insurance-based system with much higher levels of private funding would undoubtedly mean worse health inequalities, and possibly a much less efficient and effective system overall.
The second problem is caused by the way individual pressures affect the health system. Public debates tend to focus on one issue at a time. When these pressures become acute they can force decisions that are not in the best interests of the system as a whole. Ministers feel compelled to intervene over access to particular drugs, despite the impact on other budgets; hospital departments that are too small to provide safe services are 'saved' for the local community; and primary and preventative care is relegated in importance.
The problem is that we lack a mechanism for resolving fundamental choices about priorities. Such choices are of course necessary, and they are made periodically by ministers, regularly by health service commissioners, and continually by practitioners.
Yet recent Institute for Public Policy Research/Ipsos Mori survey work indicates that only around a quarter of the public thinks that the availability of drugs and treatments should be determined by cost and effectiveness. There is simply little public recognition that resources are limited and that choices must be made.
One easy answer is to blame the pharmaceutical and medical technology companies. I do not think this is the right response. There are legitimate concerns about the cost and effectiveness of new drugs and treatments, and about the role of private companies in stimulating demand for their products, and these require a robust and transparent regulatory response.
We certainly need a system that allows a rational pattern of expenditure rather than focusing disproportionate resources on specific treatments when they hit the headlines. But the truth is that health is a tremendously valuable good to the individual, and this is what is behind growing health demands. The more affluent we become, the more we value our health. Blaming big pharma companies for this is misguided.
Another easy answer involves shifting to a social insurance funding system where the health offer and its limits (the 'exclusion clauses') are much more explicit. But as long as funding is public then the question remains of determining the priorities for its use. A social insurance system would not resolve this issue.
Why not grab the bull by the horns and make the NHS promise much more explicit, perhaps with a formal 'core offer'? It would certainly be helpful to have a more meaningful statement of NHS aims than 'treatment on the basis of need, not ability to pay'.
But a list of core services is a non-starter for two reasons. Every country that has tried this has found it almost impossible to rule anything out categorically. And the list quickly becomes out of date as technology moves on, presenting more choices to be resolved at what were once the margins of the core offer.
Whatever process or mechanism is chosen must have a high level of public trust and legitimacy. The National Institute for Health and Clinical Excellence is a significant step forward, and its remit could be extended to better inform decisions about how to improve public health. But Nice does not really take decisions about drugs and treatments, rather it provides a judgement of value for money which should be taken into account by commissioners. Another part of the puzzle must therefore be to improve the capability and legitimacy of those commissioners.
Finally, is NHS independence the answer to great expectations? The IPPR's forthcoming report on expectations and the health service will investigate these issues in more detail, but one fundamental observation is that many health service decisions are inherently political – they are about making value-laden trade-offs to which there are no technical solutions.
Whatever is meant by 'independence', it cannot mean that the NHS would be free to take such decisions without the appropriate mechanism of public accountability.
Richard Brooks is associate director, public services, at the Institute for Public Policy Research
PFnov2006
