‘Toxic dependency’ and the NHS

Civitas, 5 March 2009

This email spun its way into my inbox from a consultant working in the NHS, following our discussion around AHSCs last week.  It may well be a controversial view, but a thought-provoking one nonetheless:

“It was fascinating to hear your guests unanimous in their conviction that the NHS needs a fundamental re-think if it is to survive and compete internationally.  Some mention was made of the predicted reduction in the health budget forcing the NHS to change its way of doing things; i.e. greater parsimony, waste reduction, amalgamation and partnerships, reduction of service duplication etc.  One of the speakers also ventured that more radical changes to NHS culture and resource allocation will be resisted by management and politicians.

However, in my view this is only part of the problem.

The main barrier to change will come from the public. Amazingly, 60 per cent of Britons believe the NHS is ‘good enough’.  I wonder if this simply reflects a kind of apathy, or learned helplessness in the population, or even a fear that criticism will mean that the service is withdrawn?  Perhaps baseline expectations are low in the first place-from years of exposure to phenomena such as having to wait 16 weeks for urgent cardiac surgery, for example.

By any objective measure, the NHS is very sick. Probably terminally sick. The problem itself dates back to 1948 or thereabouts. I don’t view the NHS so much as a 60 years old failed experiment, but rather it’s the culture of social welfare in which it sits that is the failed experiment.

The citizen in Britain expects…the unemployed mother of five expects the NHS to pay for her sixth child; expects the NHS to pay for her lap-banding, contraception, and her home-help and social work visits; expects to be moved to larger, free government housing; etc. There is zero incentive for her to change her ways. And her children will inherit that legacy of hostile-dependency.

Such dependency is toxic, and it is killing Britain. It’s no surprise that the most dependant in society have the poorest health. I would argue one of the tenants of the NHS helps contribute to this: the seductive ‘free at point of contact’. Users are very difficult to pry from their habits, and free money can be just as intoxicating as free drugs.  Unlike shareholders or real customers, the tax-paying NHS patient cannot withdraw his funds in protest at standards of service.

The second problem lies in much of ‘public health policy’, and the postmodern incursion into medicine. Most current measures aimed at improving the health of the public are either unsuccessful, or only partially successful. What’s more, the same people who provide the ‘solutions’ create the policies that cause the problems. Devotion to ideology, and vested career interests, blinds policy makers to obvious connections such as this.

By using terms like ‘health inequalities’ you create, by definition, a problem that can never go away.  I baulk at the concept that person A is poor (or sick) because person B is wealthy (or healthy). Persons A and B will always exist, and there will always be inequalities. Good healthcare will, like a rising tide, lift all ships in absolute terms.

Third, the NHS is, and always was, a socio-political experiment. The reason that it languishes in the bottom of league tables for cancer, cardiovascular disease etc. is that medical and surgical care (‘task’ activities) have at some level been approached as afterthoughts.  Look at all the’ anti-task’ activities that the NHS promotes: ‘diversity’, ‘health and safety’, ‘awareness’ campaigns etc.  Do any of these things mean that Mr Smith is going to have his bypass surgery promptly, and then wake up in a clean ward that doesn’t look like something out of the Crimean war?

The solutions are going to call for tough love, I’m afraid.  For example, the only way to increase out-patient attendance rates is to charge or fine non-attenders.  I found that refundable deposits worked well at my clinic. I think there must be some patient accountability in any new system. In principle this might involve an out-of-pocket expense that is reimbursed (Australia, France), or mandatory health insurance (Holland, Singapore) that is means-tested.  Perhaps health top-ups could be bought by patients and perhaps they could be linked to other rewards such as gym membership or mobile phone minutes. This would free up generic services for the genuinely poor and disadvantaged.

I think that the internal market of the NHS only looks at things from the service provision point of view. It is the public who need to be encouraged to adopt a new view of their health and healthcare.  Anyway these are just some of my thoughts.”

The author is an NHS consultant working in Glasgow.