There is a paradox in healthcare: the more you spend on it, the more it costs. It seems hopelessly naive in retrospect but, when the NHS was founded in 1948, it was thought it would actually reduce the country’s healthcare costs by making everybody healthier. The reverse, of course, has proved to be the case.
There are two principal reasons for this. First, if people live longer, their health costs rise because they will develop the diseases of old age – cancer and dementia. By the age of 70 the risk of cancer is 1,000 times greater than at the age of 20 (although all the cancer charity advertisements show children and young people). One in six people over the age of 80 has dementia. Second, medical technology is always advancing. Treatment becomes simpler and safer – so that people who were previously deemed unfit for treatment can now be treated. Diagnosis becomes ever more sensitive so that we increasingly treat diseases in their earlier stages when they are still asymptomatic (and perhaps do not need treating).
New treatments for once untreatable diseases, in particular for cancer, are constantly being found, usually at great expense – the pharmaceutical companies are not altruists. Healthcare costs are steadily increasing all over the world, just like global warming. In short, healthcare is a bottomless pit – you could spend the entire national income on healthcare (the US now spends close to 20%) but everybody would still die.
England spends less on healthcare as a proportion of national income than any other major European country and has done so for many years (with a brief period of largesse under Blair and Brown). There is therefore a huge backlog of relative underinvestment as well as the current deficit. We should not be surprised by all the reports of the current stresses and strains in the NHS and the way that the country lags behind most of Europe in cancer survival rates (although the analysis of such rates is very complex).
Contrary to what many people believe, the NHS is by no means unique in funding healthcare out of general taxation, with “free” treatment for everybody. The Scandinavian countries, Canada and New Zealand, among others, all do so. They manage to spend a higher proportion of GDP on healthcare than England without, seemingly, too much difficulty (although all are struggling with rising costs).
How to spend money on health and community care and how much to spend are immensely complex questions. Politicians are naturally loth to increase taxes for fear of losing the next election. As Benjamin Franklin famously observed, the only certainties in life are death and taxation, and we all try to avoid both.
There are no easy answers – we cannot live for ever. What is so depressing about the present government’s policy – for want of a better word – is the denial that there is a problem. Instead of discussion and deliberation there is only spin – the government talks of reconfiguration, transformation and efficiency savings and, when the news about the NHS is especially bad, blames doctors for being lazy and reluctant to work at weekends.
In the wake of the Mid Staffs scandal – where cost-cutting management oversaw and effectively encouraged appalling care of geriatric patients – the government has made “duty of candour” a statutory obligation for doctors and healthcare providers. Apologising when a mistake in a patent’s treatment has occurred is now compulsory, the General Medical Council recently directed doctors. It helpfully added that an apology has to be genuine if it is to be meaningful.
I fear that it is too much to expect politicians – experts in PR but amateurs in everything else – to admit to making mistakes, even less to apologise for them. But is it really impossible for a government to admit that a problem is difficult? Anyone who has read Anthony King and Ivor Crewe’s book The Blunders of Our Governments will know of the massive waste of public money over the last 30 years by many different administrations, with ill thought out programmes rolled out too quickly, with a lack of consultation and deliberation.
Through a combination of cowardice, denial and a muddled belief in markets and privatisation, it would seem that the present government is content to let the NHS slowly wither, forcing those who can afford it to use the private system. Private healthcare is inherently more expensive and less efficient than socialised healthcare, not just because of the need to make a profit but because decisions about investigation and treatment will inevitably be distorted towards overtreatment, which is a growing problem. Furthermore, the private sector has always been subsidised by the taxpayer – staff are trained at taxpayers’ expense and, if patients run out of insurance or their treatment becomes too complicated, they are transferred to the NHS.
Do you want to live in a country where the quality of your fellow citizens’ medical treatment depends on how much money they have? Is it not time for some kind of public debate about how to fund healthcare in this country? One of those old-fashioned royal commissions, perhaps, where the options can be put clearly in front of the public and the politicians?
Admissions: A Life in Brain Surgery by Henry Marsh is published by Weidenfeld & Nicolson.
