Helen Salisbury: Endgame for the NHS?BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4375 (Published 26 June 2019) Cite this as: BMJ 2019;365:l4375
All rapid responses
Salisbury laments the option for patients to buy care that should be available on the NHS but has been arbitrarily rationed by unelected and unaccountable administrators. This is a long standing issue, and I have commented on this in the past. (1). I refused to cooperate with arbitrary rationing, which led to a number of investigations by the local NHS between 2007 and 2018 into my practice.
Salisbury argues plastic surgery should not be in the NHS package, but I have had patients with cancer, with disabling hand conditions and with acquired disfigurement, all eligible and treated by the NHS. There seems to be a value judgement applied by the local administrators (commissioners) whether a disfigurement or condition is worthy, for instance breast reconstruction after cancer surgery is, but congenital breast deformity is not deemed worthy of NHS care. Should a smoker be denied inhalers, or someone that did not eat enough vegetables bowel screening, or should obesity be punished by denial of care? The 'reasons' to deny clinically indicated care are endless.
I do not necessarily disagree with the option to buy additional care, but this should be done equitably, so on a national level, and there should be the option for the population to buy additional insurance in advance, patients should not be faced with the denial of care at the point it is needed. And yes, it means re-writing the NHS constitution from "a comprehensive service available to all" to "a deficient service, available to few".
Competing interests: I have been in conflict with the local NHS for over 10 years over rationing, leading to many investigations of my practice.
Dr Salisbury's argument appears to be based on the premise that the NHS is currently able to provide the care that people need and that these changes will deprive people of services they currently enjoy. Whether we like it or not, there are large gaps in the service the NHS provides, as the funding shortfall increases. This is exacerbated by the development of ever more costly treatments and the demands of an ageing population.
One of the problems is the "free" care people see themselves as being due. I am not sure the average member of the public has any idea of the cost of carrying out their hip replacement and because they do not have to make any effort to cover that cost they assume it will just happen. There is no recognition that if they want that provision to continue they are going to have to contribute more, so when it comes to casting their vote at the ballot box their prime motivations are selfish. Political parties recognise that they have to make promises not to increase taxes or in the Conservative's case, to cut them, in order to be elected. There is no point blaming politicians for wanting to get re-elected by having policies they think people will vote for. Increasing taxation in order to fund the NHS is not a vote-winner whatever people might tell you in the street. They do not see the need for more money given that surveys report that most are happy with the service they get.
When you have a health service which is dependent solely on funding through taxation these policies are clearly going to impact on the care that can be provided. One outcome is some services no longer being available. Another consequence of inadequate funding is excessive pressure on NHS staff and costs are kept in check by effectively cutting salaries through recurrent below inflation pay rises.
I do not think anyone can argue that the status quo can continue. How might change come about?:
1. The service further deteriorates to the point where the public and voters decide that something has to be done.
2. Young people decide that the employment conditions within the NHS are too dire to make them want to work for it.
3. More non-essential treatments will not be provided by the NHS.
The money to pay for healthcare has to be raised one way or another. Taxation is the fairest way to do that but there is not enough money being raised and no sign of a significant, sustained increase. Charities have for many years been asked to fund both key staff and basic equipment, but this is a very inefficient way of raising money. It is not money that appears from thin air, coming out of the pockets of the same people who seem to be resistant to paying that money in the form of taxes.
The only other way of funding healthcare that I know of is medical insurance which could work alongside publically funding, to cover these non-essential treatments. This notion is clearly at odds with the idea of a universal healthcare system free at the point of delivery but might be the only way of making people realise the true costs. A further benefit could be in driving public health initiatives, rewarding people who pay heed to healthy lifestyle advice (not smoking, avoiding obesity etc.) with lower premiums. I would envisage this incentivised model as being more effective than the current take it or leave it public health initiatives. The argument against this is the undoubted promotion of a two tier health system and it is not a solution I would want to see, but given the situation might be the least unpalatable. Otherwise expect to see more rationing decried by Dr Salisbury in her article.
Competing interests: No competing interests