The NHS is loved and efficient, so why the obsession with reform?
The Guardian, by Will Hutton
At University College Hospital, London, in the small hours of every morning, a nurse quietly checks the stools of patients reeling from the side-effects of their chemotherapy treatment for leukaemia. It is an unlovely but vital job. See or suspect anything untoward and immediately the system kicks into action. Signs of a kidney or liver malfunction need to be caught early; these are patients whose biochemistry has been so wrecked by chemotherapy that their bodies cannot correct the shutdown of a key body organ. An early warning is an unusual stool. Death is a real possibility.
Across the hospital – and in every hospital in the country – something similar is going on. Over the last six months, I’ve got to know the interior workings of UCH’s leukaemia wards better than I, or any reader, would ever want. You just offer thanks that there is such a system on hand for the crisis my family and others are going through. And that the leukaemia wards are embedded in a general hospital with such depth of expertise and range of resource. Whatever cruel side-effects that emerge, there are experts and teams on hand to take charge as the needs arise. It is integrated 21st-century healthcare. It saves lives.
It is also value-driven, as is the case with all great organisations. Curing leukaemia often culminates in a bone marrow transplant, with the molecular structure of the donor’s bone marrow carefully matched with that of the recipient. Only healthy new bone marrow will prevent the cancer from reappearing. But that needs donors. The Anthony Nolan Trust has more than half-a-million volunteers who give their bone marrow and blood for free; the bigger the pool, the better the chance of a match, and thus of survival. They are unsung heroes and heroines, the best of humanity.
These donors are animated by the same value system as the NHS. The nurses who inspect stools and the consultants who mastermind the cocktail of drugs are united by the drive to cure, to give health and life. They are givers and sharers. They know humanity demands solidarity, empathy and looking out for each other – or else, who are you?
Of course they are imperfect and sometimes make mistakes. The sums have to add up, as they do in any organisation, but they add up to serve this larger purpose. You give your bone marrow for free to a service that provides health for free, funded by commonly created resources. Life-threatening disease is a lottery. Before this existential truth we stand together. Profit maximisation cannot be the value system at the heart of our healthcare system.
This is a way of thinking foreign to the army of centre-right commentators, economists and politicians who solemnly intone by the day that the only answer to the NHS’s alleged failings is more market, more competition and more incentives.
Last week, Reform, David Cameron’s favourite thinktank, published Going with Change by Paul Corrigan and Mike Parish, a classic of the genre. The NHS, they claim, is in a twin crisis of affordability and uneven treatment. It needs to open itself up to dynamic corporate entrants who will lead necessary structural re-ordering, as has happened in high street retailing. Unfortunately, the NHS "is particularly hostile to competition". Professionals, unionised workers and meddlesome politicians need to stand aside and allow the system to become rational, transaction-oriented and incentivised. Only thus will it survive.
Corrigan and Parish write in ignorance of international trends, developments in economics and, above all, the centrality of values. Rather than suffering from a twin crisis that needs their silly nostrums, the NHS is the cheapest system in the world producing the best health outcomes. The New York-based Commonwealth Fund ranks 11 advanced countries’ health systems for cost and health outcomes. Britain spends $3,404 (£2,000) per head on health compared with the $8,508 (£5,001) by the open-to-new-entrants US system, with the other nine countries in between.
Yet on effectiveness, safety, patient centredness, co-ordination, quality and access, Britain scores number one. It an uncomfortable truth that trumps Corrigan and Parish’s argument. The NHS may have problems, but it is not in crisis. It faces an ageing population and more expensive treatments, but from the best starting point.
If there is a financial squeeze looming, it won’t be because of the NHS’s excellent performance. Rather, it is because the government has decided, for no reason but ideological zeal, that Britain should shrink general public spending to the same proportions of GDP as we had in 1948.
However, as the country grows richer, we will want to spend more proportionally on our superbly cost-effective and efficient healthcare system, but that is prohibited because, as a tax-funded system, that would imply higher taxation, which obstructs "wealth generation". Even if true, it supposes that the definition of wealth should not include tax-funded health and wellbeing as part of what we want from our civilisation.
Nor are markets quite the catch-all, unalloyed virtue Corrigan and Parish suppose. The hyper-transactional financial system turns out to be highly unstable, imposing vast systemic costs; worse, its values, as Mark Carney, the governor of the Bank of England, argued in a recent speech, in which the quest for the next bonus becomes the overriding preoccupation, are undermining the trust and integrity on which capitalism depends.
The shareholder value revolution has created a crisis in corporate values and the amoral, ownerless corporation mindlessly cutting costs – the very insurgents Corrigan and Parish want to welcome. Yes, the NHS is rightly suspicious. It tries to run an integrated system crucial for cure and health, but ownerless companies cherry picking lush contracts, with executives’ pay tied to share price performance, will drive up costs, making healthcare less effective, the system more unstable and induce a crisis over values.
Already, the NHS is fragmented into more than 500 statutory organisations. It does need more big hospital "hubs" and fewer smaller hospitals, but that should not be the excuse for more brainless wrecking of what remains a phenomenal organisation – cheap, generally high quality and value-driven, as you find when you are inside it.
Anyone could find themselves stricken with leukaemia, even health secretaries and report writers. Their chance of a successful cure will depend on the rest of us resisting the "reforms" they so ardently advocate. We can own and we can pay for a great health system. It just takes the collective will.