The NHS is actually a pretty odd beast. It is full of contradictions

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What exactly is the British National Health Service? Professor Marcus Longley believes that it is a collection of absurdities
I WANT to explore what exactly the British National Health Service is, in all its marvellous absurdity.
At one level, the answer might seem obvious – it is the organisation, which provides most of the healthcare for the people of this country, from womb to tomb, without regard to means or merit, whatever condition you may have.
Well not really, actually. Is it one organisation? I reckon that there are at least 38 separate bits of the Welsh NHS alone, not to mention the Welsh Assembly Government and its various progeny, Nice (National Institute for Health and Clinical Excellence), NLIAH (National Leadership and Innovation Agency for Healthcare), HCW (Health Commission Wales) and the rest of the alphabet soup.
Second, from womb to tomb? Antenatal care is pretty ubiquitous, but end-of-life care depends heavily on the voluntary sector, and many aspects of healthcare that people actually seem to want – chiropractic, osteopathy, acupuncture, even dentistry in some places – are hard to come by on the NHS.
Without regard to means or merit? Try telling that to people in many of the communities around here. Finally, whatever condition you may have? Well, don’t make the mistake of misusing substances in the wrong part of Wales, or being a child with mental health problems, or needing infertility treatment, having prostate cancer or even having a stroke.
One survey placed the UK ninth in the world for overall health system achievement and 18th in terms of overall efficiency.
The point I want to make is simply this – the NHS is actually a pretty odd beast. It is full of contradictions. For many, particularly perhaps Gordon Brown, it’s the essence of Britishness – compassionate, egalitarian, indefatigable and yet it is absurd – a monopoly in a globalised world; paternalistic in the age of consumerism; trying to manage a million professionals.
Is the NHS charmingly paradoxical or approaching paralysis? On July 5, 2008, it will be 60. Is it fit for immortality or retirement?
We still have a folk memory, – albeit fading now with time – of a grim Britain before the NHS, where social injustice was multiplied in people’s health. There still exists today, I think, a notion that while unequal incomes may be acceptable, there is nevertheless something deeply offensive about the idea that people can suffer ill health and disability just because they are poor.
Health seems to have a different moral status to some of the other qualities which money can buy. We really don’t like the idea that money should change hands so visibly when professionals provide care.
In fact, there has been a very strongly felt, almost visceral objection to private practice in healthcare in Britain since the beginning of the NHS.
In part it is because it reminds us of the fundamental inequity of differential access to good quality healthcare, but in part, it’s an affront to a core value – an expression of our solidarity which demands that all of us at least receive good healthcare when we need it, rich and poor alike in the same queue, even though other inequalities may be tolerated.
It is one of the main reasons why we really don’t like Nice and other organisations trying to tell us what we can and can’t have on our NHS. We much prefer it when money doesn’t come into the equation.
This NHS has three defining characteristics, which have barely changed in the last 60 years – funded from taxation, available to all, with very few defined limits to the range of treatments which it offers.
All of those are anomalous inter- nationally. There are few healthcare systems around the world funded from taxation – especially since the collapse of the Soviet Union.
Most countries of the developed world have either a system based on social insurance, or one also based on private payment and private insurance. These embody, in various ways, the notion of “earned entitlement”, with supplementary payment providing enhanced service.
They also tend to have much clearer boundaries around what services are – and are not – available.
Which approach is better is a subject of endless debate. But the foreigners’ approach at least provides some options when it comes to another of those ubiquitous problems facing healthcare in developed countries – the fact demand always exceeds supply. The British NHS seems ill equipped to deal with it.
We know that healthcare has the potential to grow almost without limit, meeting new demands, which it creates itself, and able to absorb perhaps twice what we currently pay for it, and to come back for more.
Yet we have a healthcare system which knows no boundaries on entitlement, and no limits to the scope of treatment, and which relies almost exclusively on one source of revenue – the taxpayer.
When the service tries to say “no” to a new drug or intervention – through the voice of Nice or HCW – it is rarely praised for improving the quality of patient care.
During the past few years, the NHS has seen real terms growth of something like 7% per year – 50% since the start of the decade.
This is certainly marvellous, astounding even, but as an approach to the future, is it also absurd? Some will argue the taxpayer has paid so far, and will continue to do so.
The NHS is hugely popular, and the principle of “from each according to ability, to each according to need” is cherished by us all. But this period of growth is almost without precedent, and is already coming to an end.
For the future, we have Labour MP Frank Field’s stark warning. He said politicians in his party who argue that the middle class will forever support redistribution to the poor are a “public menace, distracting from the real task”.
The fact that we have this problem is, if not absurd, at least a bit odd. Here we have a hugely popular service that we clearly desire more of. There are elements of it we are happy to pay for – witness complementary medicine, which people are paying millions for every year, voluntarily. And yet we seem very reluctant to allow ourselves to buy more of the mainstream variety, allowing the NHS a near-monopoly, and setting it a budget well short of our desires.
It’s not that we can’t afford to have more – other similar countries manage to spend more on healthcare than we do – just that the mechanism of funding through taxation seems – if we believe Frank Field – to have natural limits beyond which we cannot go.
And why is the NHS so unresponsive to the needs of its patients? That may seem an unfair question – how can an organisation imbued with professional ethos, which does nothing but care for millions of patients every year, be accused of unresponsiveness?
I do not mean to criticise individuals. But just as the police service has been accused of institutional racism, I wonder whether in the NHS we may have a touch of “institutional indifference”?
In a general hospital not far from here there is a busy urology clinic, treating people with a variety of problems associated with the urinary system. Within easy reach is just one disabled parking space.
Disabled patients attending the clinic therefore have a choice. They can turn up 20 minutes before their appointment and risk finding the space full. Or they can turn up early enough to ensure they get the space.
This can mean for a 10.30am appointment, turning up by 8am. If they get it wrong, they have a long way to push the wheelchair.
One disabled parking space. Contrast this with your average Tesco supermarket, which will have a bank of disabled spaces right by the entrance, and a virtual guarantee of availability at any time.
Why the difference? Is it that Tesco managers are brighter than their NHS counterparts? Or that Tesco can afford the few pounds needed to paint some yellow lines on the car park, but the NHS can’t?