Oh NHS, thou art sickBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7330.127 (Published 19 January 2002) Cite this as: BMJ 2002;324:127
The NHS's main problem may be overpoliticisation
Papers p 135
It seems to be universally agreed that the NHS is sick. It is plagued by delay, low quality care, and poor outcomes.1 The chancellor of the exchequer has called for a great debate on the service,2 which must include exploring the causes of the sickness and possible treatments. Ideally the debate will be informed by evidence, and the BMJ today publishes a study that is an important contribution (p 135).3 It is a broad brush comparison between the NHS and Kaiser Permanente, a health maintenance organisation that cares for some 6.1 million Californians. The study finds that the two systems have similar resources but that Kaiser performs substantially better. In particular, patients from Kaiser have faster access to both primary and secondary care doctors. In other words, the widely held idea that the NHS—albeit cheap—is remarkably efficient may be wrong.
Comparisons between systems are always difficult, and readers will rightly be sceptical, not least because they challenge a belief that is widely and deeply held in Britain. Our reviewers and editorial team started from that position but concluded that the results could not be explained by artefacts in the study or differences in the two populations. The conclusion that Kaiser performs much better for similar costs stands. Why? The authors think that Kaiser may perform better because primary and secondary care are better integrated and the whole system better managed; because it has hospital stays a third the length of those in the NHS and much better information technology; or because of competition.3 In commenting on the paper Don Berwick thinks that Kaiser does better because it can manage a constructive patient journey right through the system, Jennifer Dixon thinks a host of factors may explain the differences, while Alain Enthoven favours competition.3
The greatest contribution of this study to the chancellor's debate might be to shift the emphasis from funding to other issues. In some ways the chancellor inhibited his own debate by launching it with an assertion that funding the service through taxation was really the only way. 2 4 5 Debate is further inhibited by an almost religious belief in the NHS among Britons.6 To doubt the NHS is akin to sacrilege, and the Observer's health correspondent announced his loss of faith in the way that a 19th century cleric might have declared his loss of belief in God. 7 8 But the idea that the NHS might have had its day no longer leads to political excommunication—and backroom discussions are beginning on what might follow the NHS.
The great debate should begin with the values and mission of the service. Should it still be committed to universal coverage of a comprehensive range of services free at the point of care? The BMJ has argued that it simply isn't possible to achieve all three.9 Prescription charges appeared soon after the start of the service, and coverage has diminished—particularly with the abandonment of long term care. Despite these erosions of fundamental values, it is hard to imagine the British accepting anything less than universal coverage. Indeed, the United States is the only developed country that tolerates some of its people not having access to health care.
The debate over funding is too familiar to need repeating,5 and suggestions about changing the structure are bound to produce a groan within the service. But one structural change that hasn't been seriously tried and might well raise a cheer within the service would be to find a means to separate the NHS from politicians. There is a theory that the most politicised health services around the world do the worst. The short timetables, constant change, and demand for instant gratification that are features of politics do not sit comfortably with running a huge and complex service.10 One of the first acts of the current Labour government when elected in 1997 was to set the Bank of England free to determine interest rates. Couldn't it do something similar for the NHS? Or perhaps Britain might copy Spain and devolve the running of health services to regions11—as has long been the case in Sweden. The health secretary's proposal this week that central government should play a reduced part in running the NHS suggests that he may be listening (p 132). But previous ministers have made similar promises, and in the end nothing much has changed.
Alain Enthoven, the inventor of the internal market, argues in his commentary that competition is needed for improvement.3 Most would judge Britain's flirtation with competition a failure, but proponents of competition would argue that it never happened: politicians could not risk the political consequences of the hospital closures that would be an inevitable consequence of full blooded competition. The concept of increasing competition will probably not feature in the chancellor's great debate, but any collapse of the NHS might be followed by a return to competition. In the meantime, does improvement come from tight management from the centre or from setting targets and giving people freedom, resources, and support to improve in their own way? The government seems ambivalent.10
Despite the chancellor encouraging a great debate, the secretary of state for health has a plan for improvement.12 In essence, it's a triad of increased funding, modernisation, and increased public accountability. As the secretary of state constantly emphasises, the plan will take 10 years to deliver a service that will again be the envy of the world. The debate will consider whether this plan is likely to succeed, but both doctors and managers are disenchanted.13
A cynic might observe that Britons are good at debate but poor at delivery. Nevertheless, the chancellor's debate should be encouraged—and be as broad as possible. Failure to either radically reform the NHS or invent a strong alternative may result in a rump service for Britain's poor—one place where we should not learn from the United States.