Marcus Longley says that to improve health delivery we need a distinctive package of incentives
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.
Perhaps with the need for ‘openess’ we can find out the full extent of private medicine within the NHS in Wales, which as we know is a beacon for socialists all over the world. It is clear talking to friends that there is large and healthy ‘parallel’ service going on, i.e. a) Need to see consultant = 6 months, or b) Pay £100-£200 you’re in tomorrow. Waiting for operation on NHS then dont bother, pay up front and you are in for an NHS hospital pretty quickly. Plainly this is perfectly legal/ethical, however it is hidden away from view as it might be embarrasing for our political masters. The ‘growth’ in private medical services (outside NHS) for the affluent is also indication of the extent of crisis in NHS, however once again never discussed/clarified.
Support a proper debate and ongoing conversation with Joe Public about the failures and succeses of our NHS. I suspect that may go some way to stem the growing disengagement that people genuinely feel about public service number one – their local NHS. How does one influence it really? Second big issue – people taking responsibility for their own health – active ageing is the new label but it has a serious message we must urgently embrace – we are living longer and we need to remain healthy longer! Quality versus quantity – otherwise we all will pick up a bill of monstrous proportions so that only the rich and the severely needy will get anything. Inequalities widening we are on the cusp of something of staggering difference across age cohorts and communties. Local authorities are being elected in May for a five year term, together with our NHS partners that gives us a medium-term horizon to harness coordinated action across all the determinants of health which largely fall to communties and councils together with a focus on the keeping the 50-70 generation as healthy and active as we can. Sustainable health and social services cannot be secured without drastically stemming future problems. More serious investment in prevention and public health. What happend to Health Challenge Wales?
Marcus, I am left seriously worried that no-one is coming up with any coherent approach to the problems that you identify so clearly. You say we can’ t have everything, but we know that every time any kind of reform is mooted the protest banners come out and one party or another jumps on the bandwagon in search of political pickings. You say that market style competition won’t work, but no alternative strategy is offered other than better information – in a political system here that is resistant to league tables in education and arguably too sympathetic to the producer interest in general. We can all wish that people would adopt healthier lifestyles, but the public, worldwide, seems resistant to being nudged into better living, and we live in a country that seems light years away from economic recovery and radical poverty reduction. It is unclear that, to date, giving the public ‘voice’ is any more effective than ‘choice’ in producing improvements that are scaleable across the system. So where do we go? 1. Could not some helpful element of market provision, particularly in the urban concentrations, be made compatible with maintaining the spirit of the Bevanite service without going down the English road? Since you say that we are the only country trying to provide a health service via both a single funding stream and a single provider, are we really saying that we are right and that everybody else in the world is out of step and delivering a worse service? 2. We may need to create a powerful source of independent information on health service performance – possibly an enhanced role for the public service Ombudsman, beyond the mere handling of complaints. The more pro-active role of the Catalan Ombudsman may be a model, although I cannot see a Welsh Government easily ceding such potentially critical authority to an independent body. Alternatively, one might give a statutory role to Consumer Focus. 3. Sisyphean though the task may be, we have to invest more in health education. 4. Perhaps we need to construct a cross-party agreement to pilot a radical reform of service provision in one area of Wales, so that we can create room for experimentation, give the public a sense of what is possible, and minimise opportunistic political obstruction. But now, I acknowledge, I may be entering the realm of fantasy – yet even that may be better than just waiting for something to turn up.
Hats off to the Institute and participants for providing some thoughful contributions here. To echo the sentiments of others if only our body politic would approach Welsh public policy issues in a similar vein. Of course similar principles apply to nearly all public services, especially those provided collectively e.g. health and education. Over the last decade when there were significant real increases in spending on Welsh public services and Government preserved the social democratic delivery architecture, who remembers “clear red water.” For many of us these levels of resource allocation will never be repeated in our lifetimes. The results seem to suggest at least in the Welsh case there exists a systemic flaw in a collaborative model that places the professionals in pole position. Is this purely a case of Welsh institutional weakness or has the model failed? I don’t know the answer to the question I pose. Intuitively though I feel a mono-culture of service provision is no longer defensible and will not be affordable. There are alternatives without going down the ersatz marketisation road. For instance mutuals and the third sector all ready exist in health and have much to commend.