Medicine has never been in better shape. Its scientific rigour and patient benefits have both improved dramatically in the last 30 years. Yet this truth is obscured by the nihilism and venality of journalists, politicians, lawyers, patients and just about everyone else. In consequence, we risk alienating the medical professionals whose sense of vocation is central to a well-functioning health service, thereby making predictions of crisis self-fulfilling. Politicians should hand over the money and let the practitioners get on with it.
So argues Raymond Tallis, professor of geriatric medicine at Manchester University in Hippocratic Oaths: Medicine and its Discontents (Atlantic Books, 2004). Others in the medical profession disagree. The editor of The Lancet, Richard Horton, suggests: "Less trust is a good thing, for it suggests greater transparency regarding the reality of medical practice. The present difficulty is not loss of trust, or the challenge to doctors' traditional authority. It is that we are in a phase of uncertain transition."
My guess is that if asked to choose between Tallis or Horton, most doctors would back Tallis. For them, his book will be powerfully affirming. Indeed, its importance lies not in its frequently tendentious claims about the NHS, but for what it reveals about the deepest fears and legitimate concerns of honest, hard-working doctors worldwide. Think of professional vocation as being supported by the complex interplay of autonomy, status and reward. Then chip away at one or more of these elements. The result is rising medical alienation across the industrialised world. (The obverse is rising professional confidence among nurses.)
Tallis's book conveys an overwhelming sense of a medical profession being "got at." He warns, rightly, that in striving for more responsive and accountable services there is a danger of damaging professional motivation, but too often his invective sounds like a defence of an inadequate and haphazard status quo.
Tallis appears to argue that unless everything can be improved immediately then nothing should be—on the grounds that "the prioritisation of one problem means the 'posteriorisation' of another." In one sense this is obviously untrue: at a time of rapidly growing health expenditure there is no reason why improving one service should mean another gets worse. In another sense it is merely banal: of course not everything can be a priority. The issue is how priorities are chosen and what they are.
This government, like its immediate predecessor, not unreasonably selected cardiovascular disease, cancer, mental health problems, chronic diseases and cutting waiting time as its initial priorities, because they are the biggest premature killers and sources of disability and public dissatisfaction. Of course there can be legitimate criticism of targets and their unintended consequences, but the painful truth for the clinical professions is that governments can only persuade electorates to part with sufficient tax to fund the NHS if they can agree on an implicit contract with voters about what they will get for their money. That is the price to be paid for a well-funded tax-based healthcare system in a modern democracy. If governments consistently get it wrong they will be voted out. The corollary is that, contra Tallis, politicians and even the media often discern what needs to change in public services before the providers. This government has also recognised the limitations of its mechanisms for dialogue and collective choice, and is therefore seeking to introduce more consumer choice than many professionals are comfortable with.
Tallis accepts that waiting is the most pervasive "source of dissatisfaction with the medical profession," but objects to any attempt to reduce it. He rightly criticises the shortage of doctors, but then decries "the political imperative to get more hands on deck" (medical school places have increased by over 55 per cent since 1997). He worries about the impact of female and indeed male doctors' demands for family-friendly working patterns, and predicts that consultant working hours will fall "possibly quite dramatically"—yet thinks that "doctors will rebel against their increasing workloads." And he claims he has experienced budget cuts every year since 1982: a period in which the NHS budget has more than doubled in real terms, as has the number of hospital doctors and consultants.
For more than three decades, David Mechanic of Rutgers University has been researching this large gap between what doctors believe and what is actually happening. He notes that, "in almost every era doctors have perceived themselves as 'running faster' but there is little evidence to support this." There are more doctors, consultation time has increased and home visits are less common.
For patients too expectations continue to rise. The American philosopher Richard Rorty has observed that in 18th and 19th-century Europe and North America, human hope shifted from eternity to future time, "from speculation about how to win divine favour, to planning for the happiness of future generations." We may now be witnessing the beginning of a further shift, as citizens of rich countries focus instead on their own longevity and how to secure it.
And as we do so, we will have access to more information about our conditions, treatments and caregivers. Type "breast cancer" into Google and it offers you 9.6m links. Will this really deskill doctors and democratise medicine, as some hope and others fear? To an extent. Over time, the boundary between lay ignorance and professional expertise will clearly shift, a challenge all professions are facing. Yet as the volume of information rises, so does the need for synthesis and interpretation. Forty years ago, fewer than 125 randomised controlled clinical trials were published annually worldwide; now it is over 10,000. That is more research than any doctor, let alone patient, can keep up with. Faced with this overload, many patients will need more hand-holding, not less, just as health professionals will need to rely more on computerised expert decision support.
So the NHS will need to support patients' responsibility for their own health, buttress informal care, substitute technology for labour, increase team working and continue to attract health staff from abroad—albeit in an ethically responsible manner.
The centrality of the doctor-patient relationship and the importance of the professional ethic will not diminish. But in the same way as the safety and quality of an airline depend on more than the technical skills of its pilots, so too the safety and quality of healthcare depend on more than the skills of its clinicians. Professional recognition of the need for evidence-based medicine on the one hand, and of the prevalence of avoidable medical errors on the other are both surprisingly recent. Benjamin Spock, for example, probably caused thousands of avoidable sudden infant deaths with his evidence-free advice that babies should not sleep on their backs.
It is the public backlash against scientific and medical expertise in general that partly explains the legitimate frustrations of many health professionals. Tallis rightly takes aim at the media coverage of medicine. Particularly corrosive is the idea that journalistic "balance" requires equal prominence for serious research and mumbo-jumbo. Worse still is the self-righteous circulation-driven campaigning, lauding any available David against every putative Goliath. Just as Watergate helped to poison political journalism, so science is now filtered through the prism of the BSE debacle. Taking the MMR triple vaccine as a case study, Tallis dissects the idiosyncratic stance of the Daily Mail and others, and their tendency to confuse statistical association with biological causation. This confusion led some to argue that the NHS should offer single vaccines, regardless of the consequences for other people's children (children too young to be immunised would be at higher risk of being infected by those whose extended series of single jabs was not yet completed). So on classical liberal grounds alone, there was good cause to restrict parental choice. Yet, records Tallis, "as the evidence exonerating MMR came in, the media, far from apologising for their assault on an important measure to improve the public health… started to blame the authorities for their arrogance and bullying."
The case of Andrew Wakefield, the doctor behind the unsubstantiated MMR allegations, also reveals a deeper tension in modern medicine. Several years ago, I met him in the company of parents whose children had autism and gastrointestinal disorders. It was clear that, regardless of the science, he was performing a quasi-priestly function for these understandably desperate parents: offering treatment, but above all, supplying empathy and meaning.
Perhaps he was taking his lead from Nietzsche, who wrote in 1878: "A doctor is no longer at his intellectual peak just because he knows the best new methods… he must also have a talent for conversation… the tact of a police agent or lawyer in divining the secrets of a soul… in short, a good doctor today needs the skills of all other professional groups."
And here lies the difficulty for western medicine. The paradox, as Tallis explains, is that "as medicine-takers we are not organisms but complex selves, but the effectiveness of the medicine we take is owed to a view of ourselves as organisms." Yet, as Nietzsche understood, the doctor has to "maintain a quadruple vision that encompasses the pathology of the illness, the symptoms experienced by an individual patient, the unique impact on the patient's life, and the meaning the illness has for the patient."
What is true for the individual clinician is true for the NHS as a whole. It has to earn rather than assume the support of each new generation. Only then will there be continuing popular support for the taxation required to sustain it and the social solidarity it embodies. So, at least, runs one of the defining beliefs of New Labour.
Between 1972 and 1998, Britain spent £220bn less on healthcare than the EU average. Why we tolerated such drastic underprovision is one of the puzzles of the postwar period. In part it was insularity; international health comparisons have only recently acquired domestic political salience. In part it was conspiracy, famously identified by Rudolf Klein—the medical profession agreed to a tight rationing of tax-funded care in return for being granted wide clinical autonomy by the state.
But periodically the pact would threaten to dissolve, particularly when growth in NHS funding was squeezed for prolonged periods. This phenomenon became acute in the second half of the 1990s, and only the warm glow of a new government kept the NHS running on eye-wateringly tight settlements. (Another paradox: financial crises have stimulated NHS reform, but reform has succeeded only when new resources were available to implement it—a point missed by Nick Bosanquet's recent Reform pamphlet criticising the 1997-2000 period.)
Economists will argue over whether the post-1997 throttling of NHS spending growth was a macroeconomic necessity or a deliberate signal of fiscal rectitude. Either way, it produced its own crisis, as waiting lists ballooned and staff vacancies rose. When flu rates peaked in winter 1999, the service seemed to be in meltdown—as the BBC took pains to highlight.
Various think tanks took this as their cue to argue that, whatever its theoretical merits, taxpayer resistance meant a well-funded tax-based NHS was impossible in practice. After all, hadn't the proposition that British voters would pay more taxes for better public services been tested—and rejected—in 1979, 1983, 1987, 1992 and even 1997? This was the think tanks' opportunity to elide the argument for more health funding with the argument for more private funding. Almost any country whose funding system included the word "insurance"—even if preceded by the words "compulsory social"—received fulsome praise. First it was France—until the doctors started striking, pensioners expired in a heatwave and the health minister declared the system broke; then it was Germany—until business denounced the spiralling costs of labour and unemployment rose sharply; and most recently Switzerland—until it was pointed out that it has the second most costly system in the world.
These arguments ignored four realities of healthcare finance. First, the richer a country is, the more it wants to spend on healthcare. But second, a country has to pay for its healthcare however it raises the money. Third, in western Europe this is mostly a collective rather than an individual choice. While individuals are free to spend extra cash, nations raise most of their health funds compulsorily, and then pool it. From this pool, the healthy pay for the sick, the young support the old and the rich subsidise the poor. Fourth, the method of funding owes more to history than to current public policy: no major industrialised country has changed funding system in the past few decades. Instead, there have been gradual adjustments as tax-based systems raise spending and social insurance systems try to limit it.
Britain last changed its health funding mechanism 57 years ago, when we ditched Lloyd George's social insurance system—a mix of contributions from individuals, employers and the state. The irony for right-wing critics of the NHS is that had we stuck with the continental model they sometimes advocate, we would have wasted more cash and created far stickier labour markets. The irony for left-wing critics is, as the French and German examples suggest, that we would have spent a higher proportion of GDP on health, producing more generous care and greater responsiveness to patients.
But a tax-based system does not have to be underfunded. It is a fiscal choice. This became clear on 16th January 2000 when Tony Blair sat down to the most expensive breakfast in British history. In the company of David Frost, he unilaterally committed the government to match European levels of health spending through a tax-based NHS. This will see British spending rising to around 9.2 per cent of GDP by 2008, from 6.8 per cent in 1997. The opponents of a tax-based system were quick to see the significance of this pledge. In the blink of an eye they abandoned the "taxpayer resistance" objection and replaced it with two new ones. In practice, they argued, the NHS would squander any new cash. And in principle, a tax-based system could never deliver patient responsiveness.
So public debate has shifted from the financing question to supply-side controversies—despite the fact that, on almost any objective measure, the NHS is in better condition now than at any time. Nursing and medical staff numbers have increased significantly, even after accounting for retirements and part-time working; the proportion of buildings which pre-date the NHS itself has halved; premature deaths from heart disease have fallen by over a quarter since 1997, thanks in part to much greater use of cholesterol-lowering drugs; long waits for surgery have halved from 18 months to nine months, and are set to halve again by 2008; and so on. (For chapter and verse, see the NHS chief executive's December 2004 report at www.dh.gov.uk.)
Yet right-wing ideologues depict the NHS as the healthcare version of the North Korean economy. And left-wing romantics tend to agree, delighting in the idea of the NHS as a socialist peninsular in a sea of capitalism, where workers are selfless and markets have no dominion.
This belief guides the NHS in Wales, which has rejected almost all the English health reforms. Perhaps this is what Tallis and colleagues advocate too. If so the comparison is instructive. The Audit Commission reports that "both the northeast of England… and the northwest have similar patterns of apparent comparative poor health but have consistently delivered more healthcare at lower cost than Wales."
It has become fashionable in some quarters, however, to campaign against Blairite "marketisation" of the English NHS, without ever being especially precise about what this is. It cannot refer to changes in how patients pay for their healthcare since, as far as I am aware, the entire cabinet opposes new treatment charges or tax subsidised private medical insurance. Indeed, Tony Blair has presided over the biggest expansion in care on the basis of need, rather than ability to pay since the foundation of the NHS. Nor, if "marketisation" is supposed to be a new threat, can it refer to the 14-year-old division of functions between NHS purchasers on the one hand and care providers on the other, a policy that has been supported by the last seven health secretaries.
The objection, therefore, must lie in the way healthcare is provided rather than in how it is funded. And now we get to the heart of the matter. The idée fixe of the anti-marketisers appears to be that market forces currently play no role in the production of NHS care, and that is how things should stay. Of course, the reality is different. NHS care is produced by employing staff in labour markets, and buying goods and services in product markets.
Are the anti-marketisers rejecting labour markets or product markets? Presumably they accept the idea that the NHS has to pay its way in the labour market. As the NHS unions rightly point out, ignore labour markets for too long and eventually nurses decide to work for British Airways or Boots.
So it seems that the grandiose anti-marketisation slogan unwinds into a prosaic argument about where the in-house/buy-in boundary should lie; in other words, the balance of inputs to be sourced in labour markets versus product markets. According to the Office for National Statistics the NHS spends 46 per cent of its budget on staff, and 52 per cent on goods and services such as medicines, scanners and expensive job adverts in the Guardian. The government has suggested that 15 per cent of elective surgery might be sourced from private treatment centres by 2008. This would increase spending on external services as opposed to in-house labour by less than two percentage points—and yet it is said to herald the beginning of the end of the NHS.
However there is no obvious ideological distinction between inputs sourced in labour markets as against product markets. Take an NHS cancer patient. Her care will be a subtle blend of inputs from labour, product and capital markets. She visits her GP (mostly private for-profit contractors) who refers her for surgery (in an NHS hospital built by a for-profit construction company). She then has radiotherapy (using a privately built and possibly privately owned machine). She receives chemotherapy (manufactured by a for-profit pharmaceutical company), collects a prescription (dispensed at a for-profit chemist) and is visited by a Macmillan nurse (supplied by a charity). And this pattern has been broadly constant throughout the NHS's history.
One contemporary variant in the debate is the use of the private finance initiative (PFI) to build and maintain NHS hospitals. Without rehearsing the well-worn arguments for and against, we should simply note in passing that NHS hospitals have always been built by for-profit construction companies. But as the treasury points out, before PFI the NHS picked up the tab for numerous construction delays, cost overruns and gerry-built roofs that needed major repairs within months of opening. Now the contractor does. (Had the new Scottish parliament been a PFI, it is most unlikely to have been ten times over budget.)
This does not mean that we should be indifferent to the boundary between labour markets and product markets. It may be more efficient to provide and run emergency general hospitals publicly rather than on contract from shareholder-owned companies, because there are high barriers to entry for competing private companies and it is hard to measure performance. But the opposite is true for many diagnostic tests, or routine cataract and hip replacement surgery. A greater variety of suppliers may bring multiple benefits if—and this is a big if—it is matched by a sophisticated NHS "purchaser." For example, across the rest of the economy, new entrants into a sector are estimated to account for 20-40 per cent of productivity gains, but the NHS has generally relied on incumbent providers gradually improving their efficiency. The point is that these are essentially technical questions where insights from institutional economics will be more useful than ideological lines in the sand.
Take the idea that because general hospitals should not be owned by for-profit corporations they should by default be owned by and accountable to central government. This belief clashed with government proposals for locally accountable foundation hospitals and provoked the biggest parliamentary health controversy of Labour's second term.
Public hospitals in most European countries tend to be either independent non-profit or religious foundations, or accountable to an elected local authority. The direct accountability of our acute hospitals to our health minister is highly unusual. These arrangements—usually attributed to Aneurin Bevan—owe as much to a 16th-century Pope, the Luftwaffe and Kenneth Clarke. The fact that British hospitals are under secular rather than religious control is a result of Pope Clement VII's refusal to allow Henry VIII's divorce, with the consequent suppression of the monasteries. The Luftwaffe's bombs legitimised state control during the second world war, allowing Bevan to nationalise the hospitals. And it was Ken Clarke who, in freeing self-governing hospital trusts from local health authority control, made them accountable to the secretary of state. Richard Crossman, as social services secretary in the late 1960s, complained of being a "weak Persian emperor," but by the end of the 20th century his successor had almost complete control over the nation's hospitals.
Is this a good thing? Evidence suggests that countries such as the Netherlands and Germany are able to combine greater variety of supply (both private and public) with greater equality in delivery than the NHS has achieved. Furthermore, government ownership of NHS hospitals—as distinct from the ability to raise and allocate NHS funding—has done little to ensure uniformly high standards. In fact, it has probably made the state more reluctant to "look under the stone" for fear of what might be found wriggling there. I vividly recall a former permanent secretary telling me a few years before the public inquiry into the deaths of heart patients at Bristol Royal Infirmary that we were wrong to propose an independent healthcare inspectorate because "we would be inspecting ourselves and would be responsible for what we found." While the answer to this conflict of interest is not to turn a blind eye to the quality of NHS-funded care, he was right that with ownership comes responsibility and thus blame when things go wrong. And with blame comes a set of defensive behaviours and cultures which impede patient care. (I know, having had an intimate view of most of the NHS's major "dropped bedpans" for the past seven years.)
To argue that health ministers should simply interfere less is to ignore these environmental pressures. Non-interference with hospitals was the intention of the Tory government when it established the NHS internal market. But by the mid-1990s, the weight of political and institutional pressure meant that central control had reasserted itself under the rubric of "performance management." Hence the decision of the current government to convert hospitals into foundation trusts, legally accountable to a locally elected board and an independent regulator rather than the secretary of state. While these circuit-breakers will never be absolute, if they make hospitals more like schools—where the education secretary is not regarded as personally accountable for every lesson or exam result—many would consider that a step in the right direction.
Critics of the use of private providers and of foundation trusts believe that without state ownership of the means of healthcare production, a public service ethos will die. Labour markets, they implicitly believe, are "purer" than product markets. But are they?
It is true that the ethic of service is central to the identity and work of many health professionals. As a society we should cherish, champion and sustain those values. Without them, we are all diminished. But let us also accept that although the interests of NHS staff, patients and taxpayers largely overlap, they are not identical. Indeed, one of the shared insights of socialism and neoliberalism is that workers have interests as workers. Is it really plausible that, uniquely, these interests never influence attitudes or behaviour in health services?
Health secretaries such as Nye Bevan or Barbara Castle certainly did not think so, at least not after a few years in office. In 1946, Bevan was promising "to create an apparatus of medicine and then leave the profession to exercise it in freedom and independence." By 1950, he was complaining, "There are a vast number of pressure groups… there are the doctors themselves, then there are the nurses… then of course there are the hospital administrators… One after the other takes the stage and makes its presence known until before very long one gets the impression that the NHS is being created for them and the poor patient is hardly heard at all."
For this reason, most healthcare systems supplement reliance on professional "conscience" with a degree of regulation and targeted financial incentives. The trick is to ensure that these three mechanisms reinforce rather than undermine one another. If autonomy and status are reduced too much, taxpayers will have to compensate professionals with higher pay, and the results may still be worse.
The first recorded attempt at specifying an incentive is found in ancient Mesopotamia. The code of Hammurabi determined that, "If a physician heals the broken bone or diseased soft part of a man, the patient shall pay him five shekels. If a physician make a large incision with the operating knife and kill him… his hands shall be cut off." In similar vein, the new pay for performance contract for GPs will reward them by £1.9bn in return for improved quality measured against 146 evidence-based indicators.
Yet as the crudeness of the Mesopotamian approach illustrates, the problem in medicine is not that incentives don't work, but that they are hard to specify precisely and can work rather too well. And different medical specialties attract different kinds of people, so one type of incentive won't suit all. Orthopaedic and plastic surgeons are often high-earning entrepreneurial types; paediatricians and geriatricians generally are not.
For this reason, some have argued that the NHS would be better off as an incentive-free zone. But that is impossible precisely because it has to compete for inputs in labour and product markets. Better-off patients can pay for private treatment, which in turn creates incentives for NHS consultants to transfer some of their effort to private patients. The effect is compounded when the public sector is paying a flat salary through a base contract, but the private sector is paying on a fee-for-service piece rate. If the NHS succeeds in eliminating most waiting time for surgery, it will also eliminate much of the demand for private practice. Unless all consultants are saints (and some are), it strains credulity to think that, without more powerful countervailing incentives, they will willingly forego the £500m-plus currently earned from private practice.
One response would be a complete ban on NHS consultants working privately. But health secretaries of all stripes have decided that the industrial relations fallout would be too great, hence the more subtle solution now being implemented. This entails breaking local provider cartels by introducing competing private treatment centres specialising in single operations, such as a cataract, and often staffed by foreign medical professionals. It gives patients the choice to switch providers and links hospital income to the choices they make. The results are dramatic. NHS waiting lists are at their lowest for 17 years, and the chairman of the BMA's private practice committee recently observed, "the re-duction in waiting times for NHS patients is reducing the incentives for both corporate and individual subscribers to take out medical insurance and, indeed, for patients to self pay. The effect will vary with specialty and geography but we have already seen some cardiac surgeons lose all their [private] practice and I suspect that ophthalmologists adjacent to treatment centres will be next."
So it is the modernisers' solution of giving NHS patients the choice of publicly or privately provided care which is helping to deliver the old Labour dream of reducing the demand for privately funded care—thereby sustaining cross-class support for an equitable, tax-funded healthcare system.
This points to a wider paradox: poorer patients will only benefit from a solidaristic NHS if middle-class patients feel it is improving. And improvement means challenging the status quo. But this risks weakening the moral and psychological engagement of the dedicated professionals, such as Raymond Tallis, who are central to its future. The bad news is that it is a risk the NHS has to take. The good news is that the reform medicine is now working. The result should be an NHS fit for the 21st century.
