Future of NHS Wales 2:
Finding a Welsh way for the heath service

Marcus Longley says that to improve health delivery we need a distinctive package of incentives






operating-theatre

Pretty much every healthcare system in the world wants to be three things: comprehensive (providing cover for all health needs), universal (cover for all people), and affordable. So does the NHS. The problem is we can’t have all three. No healthcare system ever has.

So every country has to work out its own acceptable compromise between these three aspirations. For some, it means not providing certain services, or excluding some people, or looking for new sources of funding. We use waiting times, the USA has millions of people without health insurance, and many European countries find ways to allow people to buy more health cover within a comprehensive system.

But no country is satisfied with its lot. First, the demand for healthcare grows unstoppably, whether it’s because of demographic pressures, or because the never-ending supply of new technology means that we can always do more for people. The healthcare beast is truly insatiable, as are our demands upon it. Despite more money, we are always painfully aware of those things we can’t have.

Second, we don’t help ourselves by overeating, abusing alcohol, and refusing to take exercise. Next time you laze in front of the TV, with that enormous pizza and bottle of red wine, remember: it’s your fault!  Most of what the NHS now does is cope with the long-term ill health, which such lifestyles cause or exacerbate.

Third, money doesn’t buy happiness, in healthcare as elsewhere. So there is no simple relationship, above a fairly low threshold, between healthcare expenditure and almost any measure of success, whether it be patient satisfaction, reduced morbidity or mortality. Hence, there is no easily defined optimal level of funding which we should achieve and then maintain.

But more money can help. So the third problem is how to get it. The NHS relies almost exclusively on central government taxes, with no easy route to allow people to spend more on their NHS care – even if, given the choice, it would be the highest priority for their disposable income.  As John Osmond pointed out yesterday, we compound this in Wales, where the taxation is controlled from Westminster, together with the total quantum of money which heads down the M4.

Growing demand, self-abuse, and budgets that never seem enough, can be found throughout the developed world. The key characteristic of the NHS which really makes it unusual – almost no other country in the developed world has this – is the twin monopoly of single funder and single provider. All the money comes from taxes, and almost all healthcare comes from Europe’s biggest employer, the NHS.

England is now bent on ending the second monopoly, but the rest of the UK hangs on to both. Is this what Wales needs to change? Should we embrace competition and choice in our NHS? We do in almost every other aspect of our lives where a healthy dose of competition does generally seem to spur us on to do better. And wouldn’t it be good to see how different providers – not just commercial organisations, but charities, employee cooperatives, even patient-led providers – tackle some of the efficiency and quality problems with which the NHS has struggled for so long?

Doesn’t experience teach us that large organisations have an inevitable tendency towards preserving the status quo, avoiding painful decisions which may adversely affect sections of that provided interest? Why not shake that up a little? In other words, has this core feature of Bevan’s NHS outlasted its usefulness?

I don’t think so. Every country has a healthcare system which is apparently underfunded. They’re all failing to stem growing demand. And few are obviously more efficient than our own. More money would be nice, but it’s not a panacea. The NHS in Wales could certainly be better, but it’s not obvious that market-based competition would help. Certainly, the experience of England shows how easy it is to get into a real mess when you try to import conventional market economics into healthcare. Why take the risk?

So what is the answer? Let me suggest three partial solutions.

  • First, we’ve got to be honest about where the NHS in Wales is letting people down. We must have reliable information, in the public domain, about how all the various parts of NHS Wales compare with elsewhere. This would banish complacency. It means counting the number of avoidable deaths and disability, and comparing ourselves with others, relentlessly and with determination. Sometimes this will be really painful, even frightening, but keeping such information behind closed doors – or even worse, not counting it at all – is not acceptable. Stroke services in Wales have recently started to improve significantly, but it took a damning audit from the Royal College of Physicians to make this happen. In the future, lets find out these problems for ourselves, much sooner.
  • Second, we need to get serious about living more healthily. The NHS has a role in this, especially in helping people with long-term conditions maintain the best health they can. But quite frankly the NHS doesn’t have the levers, the skills or the inclination to address intractable problems such as rising obesity.  This requires an effort from us all, through taxation, education, encouragement, discussion, joined-up policy. We’ve achieved a lot with smoking, but obesity is much harder. After all, while smoking kills, eating is necessary to stay alive.
  • Finally, we’ve got to think a lot harder about the Welsh model for public services improvement. It’s fine to eschew competition and markets, but what is to replace them? Transparent information would be a very good start. But monopoly providers don’t generally make life difficult for themselves, so exhortation and relying on good people to do the right thing probably won’t be enough. We need a package of incentives which work for us.

Now that really would be a worthwhile legacy for the next generation – almost as good as Bevan’s founding vision.

Marcus Longley is Professor of Applied Health Policy and Director of the Welsh Institute for Health and Social Care at the University of Glamorgan.