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7 June 2007

The reverberations of bedpans

Peter Wilby on freeing the NHS from frenzied reforms

By Peter Wilby

When Gordon Brown took office as Chancellor, his first act was to give independence to the Bank of England in setting interest rates. Should he, on becoming prime minister, make the National Health Service independent? The idea received support last month from the British Medical Association while the Nuffield Trust, a health think tank, looked favourably on a BBC-style corporation.

The comparison between setting interest rates and organising national health care is of limited value because the bank’s Monetary Policy Committee focuses on a single, technical decision. All the same, we know government policy on the use of interest rates is clearer and more consistent because it has been uncoupled from short-term political considerations.

Something similar is needed in the NHS. Aneurin Bevan created the service nearly 60 years ago on the principle that if a bedpan dropped in a hospital corridor, the reverberations should echo in Whitehall. The result is the most politicised of all government services. Any change is represented as a cut. Any bungled medical procedure is an opportunity to damage the secretary of state. Any improvement can be dismissed as ministerial spin. The health department lives in a constant din, with a thousand dialysis machines, scanners and pacemakers clattering to earth along with the bedpans. It is assaulted by the discordant voices of a hundred vested interests. To still the clamour, politicians introduce another reform, another initiative, another reorganisation.

As the Nuffield Trust report An Independent NHS: a Review of the Options, by Brian Edwards, puts it, “change equals progress in the political world”. Consolidation, on the other hand, wins no headlines.

This explains why the NHS always seems in a frenzy of reform and why, despite improvements since 1997 (in cancer survival rates and hospital waiting times, for example), many think it’s in a worse state than ever. You may be surprised to learn that, when the Commonwealth Fund, a New York-based think tank, compared six countries’ health systems this year – the others were the US, New Zealand, Australia, Canada and Germany – the UK came top. For example, UK patients report fewest doctor errors. However, the UK does badly on access because of the long waiting times, though not as badly as the US, where lack of health insurance entirely excludes large sections of the population. The UK also does badly on preventative measures and on “care delivered with the patient’s needs and preferences in mind”. It does exceptionally well on equity, on efficiency (relatively good outcomes for a relatively low percentage of GDP) and on co-ordination of care, particularly chronic care.

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Any health system has upsides and downsides and the UK’s are roughly what you might expect from a collectivised, state-controlled service, with (according to this study) the first easily outweighing the second. The danger is that, in trying to eliminate the negatives, ministers lose the positives. Much of the NHS’s present “crisis” derives from an inflation of expectations, which is usually the result of ministers making foolish promises during some earlier “crisis”.

If, for example, people are told they can have personalised services, with appointments arranged and treatments customised to suit their convenience, the service will become, by conventional measures, less efficient. (Any private utility company that maximises its “efficiency” by making you wait half an hour on the phone to report a fault could tell you that.) Since the middle classes usually make more demands than others, it will also become less equitable. Again, if services are broken up into marketable chunks – to take advantage of private sector “expertise” – the NHS will lose its advantages in co-ordination of care.

Some clarity about these issues is needed, and it will not be achieved while ministers can be blown off course by GPs being unavailable at night. The NHS is full of unresolved questions. How can local autonomy be reconciled with equity? How can genuine patient choice be achieved without a surplus of capacity? What should be the priorities for the NHS or how should its services be rationed? These matters might be more fruitfully debated if politicians concentrated on establishing consistent, transparent principles and left the vagaries of delivery to others.

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