Concerned Hackney GPs have reconvened the Hackney division of the British Medical Association after almost 20 years dormancy in order to fight the government’s health and social care bill. We believe that it will destroy a successful public service and replace it with a series of healthcare markets, risking the very core principles of equitable, needs based, cost-effective care for all.
As a system of universal healthcare, the NHS exceeds all others. Some have said that it is the worst of all systems of universal health care … apart from all the others that have been tried. It stands out in the following areas in particular. I want to highlight them because as the BMA pointed out last week, the government is constantly denigrating its achievements to justify their reforms.
1. Inequalities: fewer adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs in the UK than in any of the other 11 countries surveyed by the Commonwealth Fund last year. They also found that:
“adults in the United States are by far the most likely to go without care because of costs, have trouble paying medical bills, encounter high medical bills even when insured, and have disputes with insurers or payments denied”.
We should be very concerned about the health bill because most people who understand the health bill believe that we are heading for an insurance scheme modelled on the American Health Management Organisations.
2. We have the lowest inequity in the world for access to a GP or a specialist according to the OECD.
The point of the NHS is to provide care on the basis of need. Since health problems are more frequent and more severe among people from lower socio‐economic groups access to care should not be a privilege for the rich. In many countries inequitable access results in wealthier, healthier people having better access to GPs and specialists. This is an example of the Inverse Care Law, which states that “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” (Hart, 1971)
The health bill hastens the conversion of a public service into a series of competitive markets and will widen inequity of access to care.
3. UK healthcare costs per capita are amongst the lowest in Europe. They are less than Sweden, Norway, Netherlands, Luxemburg, Ireland, Greece, Germany, France, Belgium and Austria.
Given that our healthcare costs are so low, we ought to be asking on what basis the Government can claim that they are too high. We ought also to make sure that international comparisons of health outcomes take into account disparities in spending on health care. The government are fond of mentioning the differences in outcomes for heart attacks between England and France, but omit (amongst other confounders) to mention the huge disparity in health care spending. Nor do they mention the crisis the French are facing. More importantly we need to be aware that forcing one of the cheapest universal healthcare services in the world to make the deepest and most sustained cuts of any healthcare system in the world cannot occur without catastrophic effects.
4. Satisfaction has never been higher. Two-thirds of people are now either very or quite happy with the state-run health care, the largest proportion since the in-depth British Social Attitudes study began in 1983. The attempt by the government to suppress this data has been described, rightly, by health policy expert Andy Cowper as “suspect in the extreme”.
5. Desire for change is the lowest in the world: Members of the public were surveyed from 11 countries; UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US.
They were asked that if they looked at the health system as a whole, do they think it needs minor changes in the system; fundamental changes; or do you think it should be rebuilt completely.
Three per cent in the UK think the system needs to be rebuilt completely (the lowest in the world). 34 per cent think there needs to be fundamental changes, and 62 per cent think that only minor changes are needed. The UK public think their health care system needs changing less than any of the other countries surveyed.
The areas in which the NHS leads the world are highly specific for a system of health care. Health outcomes on the other hand, are to a significant degree a consequence of the social determinants of health, factors such as economic, environmental and lifestyle factors. Valid criticism of the NHS has to take this into account.
The first question Steven Dorrell asked me at the health select committee last year was how to make the NHS more efficient. There is no data comparing efficiency between different countries or systems of healthcare. If Mr Dorrell or anyone else says the NHS needs to be more efficient, they need to firstly explain their basis for claiming the NHS is inefficient. They need to compare NHS efficiency with other systems of universal healthcare. They also they need to define efficiency.
To measure efficiency you need to measure for example, how much it costs us for each cancer diagnosis, or how much we spend preventing or treating each heart attack, or how much it costs to deliver or vaccinate each child. You need to do so for a whole population, it is harder to manage patients who behave inefficiently. There need to be internationally agreed ways to measure these processes so that valid comparisons can be made. We know that lack of comparable data is a problem in comparing outcomes for cancer for example.
There’s no point simply measuring how much stuff the NHS does. OECD data for MRI and CT scans shows that in the US they perform vastly more scans than any other country, suggesting one reason for their vastly higher healthcare costs. In my job as a GP one of the hardest parts is to explain to anxious patients why scans are unnecessary. One of the reasons healthcare is so cheap in the UK is because GPs are good at this.
The NHS excels in access to healthcare on the basis of need. It has controlled costs more than almost any comparable country and is probably therefore the most efficient system of universal healthcare in the world.
The denigration of the NHS by proponents of reform is not only inexcusable, but the motives are ‘suspect in the extreme’.
The aims of the reforms are to destroy a successful public service and replace it with a series of healthcare markets, risking the very core principles of equitable, needs based, cost-effective care for all.
The writer, Dr Jonathon Tomlinson, is a Hackney GP.