Building a Healthy NHS
by Paul Hazelden

Contents

Introduction

I believe that the National Health Service can be reorganised along the lines I described in the article on Revising the Welfare System.

This is an expanded version of the NHS section from the accompanying article on Fixing the Economy.

The overriding principle should be: what is fair? What is just? What is it right for society to pay for, and what should the individual be expected to pay for? Resources are limited, and choices have to be made, in the area of health care, as in every area, whether we like it or not.

Features of a Healthy System

  Rationing

Possibly the strangest part of the debate is the determination on the part of many people to insist that the NHS does not engage in rationing health care.

This is pure nonsense. In every health care system, the care given is rationed. The only question is: how is it rationed?

The two key follow-up questions are:

• Who makes the decisions about rationing?
• How transparent is the process of making decisions about rationing?

Rationing is essential because the need for health care will always outstrip supply.

Putting it another way, there is no way to quantify the need for health care. All you can measure is demand. And people will always want better health, and better health-related services.

The NHS cannot offer all possible treatements to everyone. Provison has always been rationed - the only question is about the best way to do this. The basic principles are fairly straightforward.

For example, a limited amount of cosmetic surgery after an accident seems reasonable, but providing breast enlargement to someone to boost their self-confidence does not. People do not have a right to look attractive - whatever they consider 'attractive' to mean, and they should not have the right to get the state to pay to make them look more attractive.

More difficult is the question of IVF. I know it generates very strong feelings, but I do not believe that people have any kind of right to produce children, and IVF treatment should not be available on the NHS. In any case, there are too many human beings on this planet: we need to be finding ways to reduce our numbers, not increase them.

  Encouraging Personal Contributions

Just as people should receive benefits from the state plus salaries from their employer, so too they should receive health care from the state plus whatever additional care they pay for.

At present, you have to choose between public and private health care. This is argued for on the basis of 'principle' and 'fairness'. Many people do not want patients in the NHS to be able to pay for better quality treatment, as this would not be fair to the patient in the next bed who is unable to pay.

But not allowing someone to access treatment they could pay for, and would benefit from, is also unfair.

Once we have clear decisions about rationing treatment, the patients will be clear what is available to them under the NHS. They are then in a position to decide if they are able to afford further or more expensive treatment. They would only have to pay for the additional treatment they choose to buy.

This will make private health care accessible to many more people, and will encourage ordinary people to take out health insurance: it will potentially be of benefit even if it is a relatively small amount.

People who have the money and desire to pay for fully private treatment are likely to continue to choose this route: the better food and generally nicer surroundings are worth paying for, and it is in any case still their free choice. I very much doubt that making private health care more accessible to more people will result in less private health care being supplied.

I know that this means the rich will get treatment which the poor are denied. But this has always been the case, and probably will always be the case. I don't like it, but I can't come up with a better alternative.

  Encouraging Personal Responsibility

The NHS should not have an obligation to treat people who have chosen to ignore reasonable advice, and who have not taken reasonable steps to achieve or maintain good health.

We must make people responsible for their own health, and their own choices. We have to restrict access to NHS treatment when people have chosen to ignore normal good practice. This probably needs to be phased in, to give people sufficient warning.

The obvious example is smoking and lung cancer. I would not want to prevent a sixty year-old man from getting cancer treatment because he smoked: in many places it was normal to smoke for many years. But young people today do not have the same excuse of ignorance. My suggestion is that you set an age, and then decide that in six years' time you will not treat anyone under that age for lung cancer if they have smoked in the past five years. And then keep reducing the age. Of course, if people can pay for their treatment, they have that choice.

This is not a nice thing to do, but it is necessary if we are to reward responsible behaviour and discourage irresponsible behaviour. Just as with the Welfare State, we must reward the behaviour we want to encourage. The state cannot give you good health - it must be a partnership. And for that partnership to work, we must have a clear agreement: if you look after your own health, then the state will pay for a reasonable level of treatment when your health fails.

  Encouraging Local Choice

There is a tension in the current system: on the one hand, we want the same standard of health care to be available to everyone - no 'postcode lottery'. On the other hand, we want the various nations, and possibly the English regions, to be able to make their own choices about health care priorities.

But it is obvious that if you give choice, you can't have a single standard for everyone.

However, the system I am proposing does provide a mechanism by which a universal stabndard and local choice can be integrated.

The NHS agrees a universal standard of health care, which will be provided to everyone in the UK for free. Funding bodies, whether they are national (Wales and Scotland) or regional, can choose to raise some of these standards through funding the improvements. The taxpayers in the region should be free to decide that their money should go towards improving specific aspects of the service. And, whatever the local standard provision, any individual can choose to pay for something different or something better.

Going Back to the Start

It might help if we look at some of the key ideas behind the founding of the NHS in Britain.

The NHS was flawed in concept from the very beginning: the people involved had the very best motives, but they did not understand what they were doing. To be fair, they could not understand, since they did not have the information available to them which they would have needed.

The initial ideas included the following.

1. It is not right that some people should be unable to afford health care.
2. A healthy nation will be more economically productive.
3. Once the backlog of health problems has been sorted out, the need for health care will reduce.

  Morality

"It is not right that some people should be unable to afford health care."

You can't argue with this, but life is not that simple. The rich will always be able to afford better health care, just as they can afford better everything else.

The question is how to integrate private and public health care. The way we do it at present does not work.

It is clear that the state cannot pay for all the health care people want to receive.

  Economics

"A healthy nation will be more economically productive."

As far as it goes, this assumption works. It also provides one justification for establishing a free and accessible health care system.

However, we must also recognise that in raising expectations, the NHS increased the amount of health care provision, and hence the amount of time lost to sickness.

The economic argument is valid, but it canot be the only reason why we provide heath care - otherwise we would withdraw care from people once they are no longer economically active. The state would save money if pensioners died off more rapidly.

The real reason why we provide free and accessible health care is ethical: it is the right thing to do, and we can do it. We can't provide all the health care people would like, but we can provide a great deal.

  Demand

"Once the backlog of health problems has been sorted out, the need for health care will reduce."

At the beginning, there were many sick people, many of who were unable to pay for the treatment they needed, and hence remained sick. The NHS was expected to make them better, so that they could return to work and benefit the economy. So far, so good.

What they did not recognise is that there is no such thing as perfect health. So those who were healed of one thing came back with another problem, and another.

They also did not anticipate the incredible expansion of medical capability which has taken place since the NHS was created. Infertility used to be something to live with, now it can often be treated. People can be kept alive with all kinds of drugs and equipment. Most of these developments could not have been forseen at the outset, but the result is that the NHS cannot deliver everything as it was originally expected to.

They also did not see, and probably could not have seen, the way in which human rights legislation has changed the expectations of ordinary people. It is not enough that you fix my leg so that I can walk again - I should be able to walk as fast and as far as someone with a normal leg.

So... the demand for NHS health care increases for a number of reasons.

• It's free. People will always take something if it is free. The more you offer, the more they take.
• People always, and quite reasonably, want to be healthier.
• We are keeping people alive longer, so they require health care for longer.
• We are keeping sick people alive, who would have died, so they remain sick and needing treatment for longer
• We can do more, so there is the additional cost of all the new treatment we can provide.
• Expectations have risen: what was an acceptable level of heath before is no longer acceptable.
• Expectations have changed: childlessness was once something to be endured; now it is a medical problem to be fixed.
• People see health care as the responsibility of the health care professionals, so they do not take enough responsibility for their own health.

All of which means that no system can deliver all the health care people want.

In Conclusion

Health care provision must be limited. The only question is about the best way to limit it.

I am proposing a hybrid system of public and private health care, operating in partnership, in contrast to the present competition.

The public health care system would provide free health care, within certain clearly stated boundaries, to everyone.

Additional or different heath care can be provided if a group of people or an individual decides to pay for it. You get NHS glasses on prescription, and if you want something nicer, you simply pay the difference between the NHS glasses and the others..

Simple.