THE NHS AT 60


“The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion... Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.” 1

When I attended the service celebrating 60 years of the National Health Service in Westminster Abbey, I couldn’t help but reflect on those stirling words. I was there to celebrate the extraordinary achievement of the men and women of our National Health Service. Whether they be doctors or nurses, porters or cleaners, managers or secretaries, they perform an extraordinary job in often the most difficult of circumstances, often working harder and longer than they are paid for.

However listening to the Prime Minister and other speakers, they were there to celebrate the system – the centralised, bureaucratic, restrictive system that this Government has accentuated.

The opening quotation is from Winston Churchill as he looked forward to a new National Health Service on 2nd March 1944.

More than 60 years on from that vision, we can only conclude that the National Health Service has failed to live up to those original ideas. Clearly today’s patients are not able to benefit from the most up-to-date medical and allied services available. Around the world, new drugs and treatments are introduced quicker, treatments are made available immediately and outcomes are better.

When I grew up, as a child the National Health Service was the best in Europe. It has now tumbled down the league tables. The index of European Health services published in October 2007 by Health Consumer Powerhouse shows the UK as 17th out of 29 countries – the EU 27 plus Norway and Switzerland2. The countries ranked below Great Britain are almost entirely from the poorer Eastern European states.

What’s gone wrong?
If it was funding, then after more than 11 years of New Labour our health service would have been transformed. In 1996/97 spending on health in the UK by the Government was 42.7 billion pounds or 54.6 billion pounds in today’s money. It took about 14% of public expenditure.3

Last year the Government spent 107.2 billion pounds of taxpayers’ money on UK health, nearly 20% of public expenditure.4 With such a massive increase in expenditure, health treatments should have been transformed. Yet this has not happened.

Health outcomes are measured by Finished Consultant Episodes (FCEs). In England, the latest figures available from 2006/07, showed that there were 14,784,581 FCEs.5 In 1998/99 there were 11,983,893 FCEs 6 – an increase of 2,800,688 which is an increase of 23.37%. Yet in the same period, Government health expenditure in England increased from 36.6 billion pounds to 80.6 billion pounds 7 – an increase of 44 billion pounds, a cash increase of 120.2%. When adjusted for inflation, an increase of 81.66%.

So we have taxpayers paying in, in real terms 82% more and getting in return for it a 23% increase in outcomes. Only in a massive, centralised, nationalised organisation could that be considered an achievement. Pumping taxpayers’ money into the NHS under New Labour has been inefficient and disastrous for the patient.

History has shown that any large nationalised organisation is inefficient and a black hole when it comes to expenditure.

If we look at the cost of healthcare for last year, the average cost per household in England for all healthcare whether it be through taxes, charges or insurance premiums came to just under £5000. 8  This year it is likely to exceed £5,200 per household. Healthcare in this country is both expensive and inefficient.

At the same time, NHS staff morale has hit a new low. In the NHS Staff Survey by Incomes Data Services published in August 2007, 61% of NHS staff reported that their morale and motivation was worse than a year ago. 9

Much has been made of Labour’s reduction in waiting times and its target culture. In November 2005 the then Prime Minister Tony Blair claimed that nobody waited more than six months for an NHS inpatient operation.10 Despite Ministers regularly repeating this claim, it has never been true, even using the Government’s own bogus criteria.

In the National NHS Patient Survey Programme 2007, 21% of adult inpatients surveyed said that they had to wait more than six months to be admitted to an NHS hospital. 11 Clearly, the Government’s claim that no one waits more than six months is false. In 2006, 16% of adult inpatients reported a wait of over six months so waiting times are getting longer, not shorter. 12

But there is an even greater scandal involving waiting times. Although long waiting times have been reduced in the last 11 years, short waiting times have increased significantly. To meet the Government’s target of six months, patients who would have been seen within weeks are now having to wait five and a half months for admittance to hospital. The median wait for an NHS inpatient operation is now longer than it was in 1997. 13

The average NHS waiting time today is 49 days. Under the Conservatives it was 41 days. 14

I spoke recently with a very senior liver consultant who is one of the best in the country. He told me that he is having to see patients who could be seen by a junior doctor but because of central government targets patients had to see him. At the same time, people who are very seriously ill with liver problems are having to wait longer to see the top consultant because he also has to deal with minor cases.

Another scandal in our health service is that when new drugs and treatments are developed, there is an extraordinary delay in getting them approved for use on the NHS, if approval is given at all.

Over the last year I have worked hard lobbying the Government and the National Institute for Clinical Excellence (NICE) to approve sight saving drugs on the NHS for the treatment of Wet Eye Age Related Macular Degeneration (Wet AMD).

People all over the country who suffered from Wet AMD were told to either pay thousands of pounds of their own money to buy these proven drugs or lose their sight. Only a centralised, nationalised health care system, the likes of which Stalin would be proud of would allow people to go blind unnecessarily.

New treatments once developed, must be approved quicker for use on the NHS.

The uptake of new drugs in the NHS is half that of Germany and a third of that in France. The Wanless Interim Report produced a table of both the adoption and diffusion of new technologies. The NHS came bottom.

                                                                                    Adoption                                Diffusion

                                        US                                         Early                                      Rapid

                                Australia                                         Late                                       Rapid

                               Canada                                           Late                                       Rapid

                               France                                            Late                                       Rapid

                               NHS                                              Late                                       Slow

(10.13, Wanless Interim report) 15

What needs to be done to improve things?
The Government is slowly beginning to recognise that by giving organisations local independence, they run much more efficiently.

Foundation hospitals are certainly a step in the right direction. Because they are allowed to keep their efficiency savings for future patient care, they have bothered to make efficiency savings. 1.7 billion pounds is being held in foundation hospital accounts for future investment in patient care 16.

However dinosaurs in the Labour Party want that immediately handed back to the Government. If that was done, there would be no incentive to make the efficiency savings in the first place and the savings just would not be made.

Another vital issue to improve the NHS is that Whitehall-set targets must be abolished. We have seen that after 11 years of a Labour Government, targets do not work. We have seen plan after plan, report after report and reorganisation after reorganisation. It is like the old communist system – five year and ten year plans. One consultant said to me recently that the only good thing about NHS 10 year plans is that we know we can ignore them because we know that they will be scrapped or changed in two years. What we need in our health service, is clinical judgement, not politicians in Whitehall dictating in a most extraordinary, prescriptive way what our doctors and nurses do.  

The Conservative Party should be praised for its radical new thinking on health provision and making it its number one priority. Andrew Lansley has produced a whole series of health initiatives for improving health outcomes. Concentrating on health outcomes rather than targets must be right.

David Cameron in a speech to the Royal College of Surgeons on 24 June 2008 detailed how a Conservative Government would improve health outcomes by halting the constant re-organisations of the NHS; by giving GPs real control over their budgets so they can re-invest savings and negotiate contracts with service providers to deliver the best deal for their patients; by letting patients choose any provider that meets NHS standards and delivers at NHS costs; and most importantly by publishing the details of healthcare outcomes so that the patient is fully informed of their options. 17

Taxation and the funding of healthcare needs to be transparent. We currently pay for the NHS through our taxes each month but how much of this taxation actually goes on healthcare? We do not know. Taxation which goes towards the NHS can not be identified under the present fiscal system.

Expenditure for healthcare is just paid out of the consolidated fund and not hypothecated to any tax.

The system could be much more transparent if taxation to fund the health service is isolated from other taxation. We need a hypothecated tax system for health funding. If some of our monthly tax contributions are called National Insurance Contributions, why not use these contributions as the sole funding for the NHS?

Last year the Government spent 107.2 billion pounds of UK taxpayers’ money on total health spending18. In the same year, the amount of revenue raised in the UK through National Insurance Contributions was 97.4 billion pounds. 19

Given that National Health Service spending is only a proportion of overall health spending by the Government, it would be very easy to adjust the National Insurance Contributions rate to match that of NHS spending each year. It would show individual employees how much they were contributing each month towards the health service and also how much their employers were contributing each month to the health service.

And why not run the system as it should be? National Insurance Contributions should be exactly that – an insurance programme as envisaged by Sir William Beveridge in his 1942 Report on Social Insurance and Allied Services. Patients should have the right to be treated where they want whether it is in a NHS or independent hospital. It is their money and they should be allowed to use it at any healthcare facility. If you were able to do this, it would bring in new independent providers and force NHS providers to become more efficient.

One of the more sensible policies from the European Commission is to give patients of EU countries the right to shop around Europe for the best and quickest medical treatment. If the purpose of the European Union is to be a large free trade area in services as well as goods, then this is a natural and sensible progression. However, the UK Government has opposed this move because it does not compute with the regimented, nationalised health service. It is ironic that when the European Union comes up with a free-market policy, this Euro-fanatic Labour Government doesn’t want to know.

People should not be penalised for seeking private treatment. In fact, in the present climate it should be encouraged because if a patient goes private, they are freeing up the NHS for someone else. If a desperately ill cancer patient chooses to pay privately for treatment not available on the NHS, how on earth has the Government got the right to say that further treatment will not be paid for by the National Health Service?

It is morally evil and financially stupid. The cancer patient would have paid their National Insurance Contributions like everyone else. How can this Labour Government then deny them NHS treatment? This is the sort of action you would expect in a communist state of the 1960s, not a British Government in the 21st Century.

And let us not forget, the NHS is not free at the point of need. People have to pay prescription charges; dentist bills – especially in a time when NHS dentistry has become virtually privatised in many areas; optician charges and they also have to pay for treatments that are not available on the NHS. Our National Health Service has never been free at the point of use and this myth must be dispelled.

It is nonsense that we do not involve the private sector more in the NHS. If you look at all the countries in the world that have a first class health system, they successfully use the private sector to provide innovative new treatments, first rate health care facilities and have no waiting times.

Independent sector involvement would ensure competition. Our health system would be delivered on a demand basis rather than a supply one. The inverted balance of supply and demand in the NHS today is one that is endemic of its top-down management. We have today a nationalised system of health rationing.

I am not advocating the abolition of the NHS but instead ways to improve it.

My proposals of a transparent taxation policy, independence for clinicians, the removal of state controls, the increased use of independent health providers and more choice would all strengthen the National Health Service.

It would be a health care system fit for the 21st Century.

Disclaimer:
The views expressed above are those of the author alone and intended to provoke discussion and debate. They do not necessarily reflect the views of other members of the Cornerstone Group.

Peter Bone is Member of Parliament for Wellingborough, Member of the House of Commons Health Committee and a Fellow of the Institute of Chartered Accountants England and Wales.