Funding and efficiency in the National Health Service.

Abstract

It may be that by the time this is read some truce will have occurred to halt the vicious war between the British Medical Profession (almost united at present) and the British Government over the Government's White Paper heralding the re-organisation of the National Health Service along business lines. The underlying conflicts are unlikely however to have been resolved. They are worth scrutinising. First an outline of the White Paper's proposals (1). Control of the NHS is to be de-centralised; an internal market is to be set up so that if patients from one health authority's area are treated in another, money will 'follow the patient' and be paid by one authority to the other; hospitals who want to run their own shows can become self-governing hospital trusts, while staying within the NHS they will be able to set their own rates of pay, and earn revenue from the medical services they provide; large general practices can also run their own shows, and be given cash-limited practice budgets with which to buy hospital services from the public or private sector; all GPs will be given 'indicative budgets' for their drug prescribing and will have to justify any spending above these 'indicative' ceilings. The NHS will be in direct commercial competition with the private medical sector and the NHS will be able to buy services from the private sector; management of the NHS will be 'reformed on business lines'; and the system of medical peer review known as 'audit' will be extended. The Government's expressed rationale for all this is straightforward, and essentially rests on the objective of improving services for patients by increasing the efficiency with which the mammoth National Health Service is run, and thus getting a better service for the 26 billion pounds per annum currently spent by Government on the NHS on behalf of, and using taxes raised from, the population: thus the Government's objective in the White Paper, as its title 'Working for Patients' (1) indicates, is improved health care under the NHS. The medical profession's view (it is rare to be able to talk accurately in such broad generalisations but this is an occasion where the profession is at the time of writing at least so united in its rejection that this generalisation seems justified) is that the White Paper reforms will actually cause deterioration in patient care, while totally failing to address the real problem of the NHS which is chronic Government underfunding. Political opponents of the White Paper, including Her Majesty's Opposition, espy two main Government objectives underlying the White Paper's proposals first, straightforward cost-containment of Government spending on the NHS; second, what they see as a more sinister and una vowed objective, notably the gradual and covert destruction of the National Health Service and its replacement by a two-tier system of health care on American lines, with the bulk of health care being provided through private health insurance, leaving a residual and minimal national 'safety net' system of health care provision for those too poor or ineffectual to provide their own insurance. At the invitation of the British Broadcasting Corporation I was able, earlier this year, to interview a variety of leading combatants in the conflict in order to discuss the ethical perspectives that underlay their stances on the White Paper. As a result of those discussions only short extracts of which could actually be used in the resulting 45-minute radio programme (2) various conclusions became clearer, at least in my own mind, and they may be of some more general interest. The first is that the demand for resources for the provision of health care is enormous and ever increasing, and satisfying it is ever more expensive. Increased efficiency, while it may temporarily free additional resources to meet some of the additional demand, cannot meet this increased demand for long. The demand stems from two things: first a health-care need (most ill people have health-care needs either to get better improve the quality of their lives and/or to stave off undesired death and go on living improve the length or 'quantity' of their lives): second, the possibility of satisfying that need. Thus, as ever more health-care techniques are developed to satisfy people's health-care needs, so ever more health-care demand is created. Occasionally new methods of health-care supersede and replace existing methods, even more occasionally they do so cost-effectively that is to say they obtain the same desired health-care objective more cheaply than before. In the large majority of cases, however, advances in the techniques of health-care do not replace, but add to, existing techniques and thus cost additional money if