- The Observer,
- Sunday October 14 2001
Anthony Browne concludes that the NHS has had its day. We agree. All of us are, or have recently been, NHS GPs. The government must now as a matter of urgency move towards a funding system similar to those in operation in most of Western Europe. The French and Germans have social insurance funded health systems and a higher proportion of GDP is spent on healthcare than in the UK. On the island of Guernsey, part of the British Isles but like all the Channel Islands not covered by the NHS, most residents have personal medical insurance with the Guernsey government paying the fees of those unable to pay for themselves.
The crucial difference from the NHS is that European systems encourage patients to contribute private funds for their care. When people spend their own money on healthcare they expect (and receive) better quality services. They also expect to exercise choice to an extent that is unimaginable in the NHS. The NHS has a particularly malign effect on general practice. NHS regulations expressly forbid patients contributing extra funds, for example preventing them from paying for more time with their GP. GPs attempt to deal with complex medical problems in consultations which rarely last longer than ten minutes and frequently as little as five, aware that this rate of working is not safe for either their patients or themselves.
It is time for the NHS to go.
- Dr P Buttar, Dr J Halfhide, Dr S Hunter, Dr M Oliver, Dr M Pasola, Dr S Plant, Dr J Reggler, Dr G Richards, Dr A Risk, Dr T Roscoe, Dr L Russell Independent General Practitioners Association
I share some of your concerns about the NHS. I am the chief executive of a Primary Care Trust, and I've been working in NHS for about 15 years. In the months following publiciation of the NHS plan I have gradually developed concern that it may not be possible to 'turn round' the NHS. I think there is a danger of saying 'our system doesn't work, so lets re-structure it' and you do need to make the case more robustly that other models could work better. I assume that insurance-based systems would be more expensive to administer, but that this might be offset by greater willingness of the public to invest in health services and by changed patient and clinician behaviour.
-Name and Address Supplied
I am a clinical negligence lawyer before which, I spent 13 years working in the NHS. I have seen several major changes to the organisation of health care, none of which have achieved anything other than to swallow huge amounts of money and encourage the organisation to become increasingly introspective.
I now speak on a daily basis to those who have had devastating encounters with the NHS. It is perfectly clear that no matter how much money is thrown at it, nothing improves the standard of care - on the contrary. My impression is that it has got rapidly worse over the 8 years I have been doing this work.
Systematic lapses have extended steadily over time, from levels of provision (can we afford this or that procedure/drug?), to reach the most simple human care, so that now one cannot confidently expect to be nursed at all, or to be in an environment where basic rules of hygiene are observed. Last week, on a social occasion, I was being pressed to say what I thought should happen and I heard myself say that I didn't think it was possible to continue to provide healthcare free at the point of delivery and that we had to give up on that idea and look to other, insurance-funded, models. As a life-long Labour supporter, it was strange to find this is what I believed, but inescapable.
- Cecily Cameron, Oxford
Our frustration is not that with the government's intentions which I believe to be good but that the current structure of the NHS militates against delivery of first class care. The challenge is to retain the parts of the NHS that undeniably do work well (such as an effective system of primary care provided by GPs and national collaboration in trials) whilst incorporating the improved funding and management systems of Europe. The message remains however that the status quo is not acceptable and that it is hard to see how a purely government funded organisation can deliver.
- Consultant Haematologist, Name and Address Supplied
I was a lifetime defender of the NHS but have now realised that it simply does not and cannot work. Having seen my father-in-law in hospital for the last weeks and witnessed at first hand the lack of dignity, the impossibility of speaking to doctors and consultants, the run-down condition of the ward, the general air of hopelessness, the refusal to diagnose or prognose and so on, my belief that something has to change has been confirmed. I lived for some years in France and Germany, so I understand their system, but I cannot understand why we are so reluctant to copy them.
- Nicholas Pritchard, Southampton
We cannot hope to deliver a health service when we insist on running it as if we lived in a command economy. Medical technology moves so fast that we can't predict demand for medical services 5 or 10 years ahead, but that is precisely what we are all expecting the NHS to do. Sadly, no-one is that gifted with foresight. And we completely ignore the fact that patients, and their relatives, expect choice in every other part of their lives, but are denied it when it comes to the most important aspect of their lives - their health. We should be honest about the achievements of the NHS and accept that we now need a fundamental change.
- NHS Manager, Name and Address Supplied
The problem with the NHS is not just a major lack of money but also the organisation. Experiences within my family show the problem. For example my daughter, ill in France, was able to arrange specialist consultants at a day's notice and to get results of tests, x-rays immediately. On the other hand my father has to go through a wait of months for consultant appointments, a wait for scans, then a wait for the result - each step requiring additional administration and time by Health Service staff. One system is patient led the other is bureaucracy and professional led. However much money is put in the NHS can never match the French approach without a total cultural change.
- Geoffrey Mail
Anthony Browne's central claim (among many different kinds of charge) is that a tax-funded health system cannot work because it will never have enough money. But he dismisses without examination a serious response to under-funding: an earmarked or 'hypothecated' NHS tax. This was proposed by the Fabian Commission on Taxation and Citizenship last year, which examined in detail how it could work and both its merits and drawbacks. The Commission's research showed that a large majority of the public would pay more tax if they knew it was going to the NHS. An NHS Tax based on income (replacing around half of current income tax) would be equitable, unlike insurance schemes; and would be entirely compatible with many of the fundamental management reforms the NHS also needs.
-Michael Jacobs, General Secretary, Fabian Society
Anthony Browne is right to blame the failings of the NHS on its centralised, 'Stalinist' structure and lack of patient choice. We need more delegation to the local level; more diversity of provision from not-for-profit hospitals and public-private partnerships but with the patient still finananced by the taxpayer; and the restoration fo patients' rights to choose which hospital treats them. But he is mistaken to suppose that continental health insurance systems would make a big difference. In fact compulsory insurance payments which are proportionate to income are virtually the same as taxation.
-Peter Lilley MP
I am a 29 year old left leaning woman with left leaning friends who all think that something has to give. Nobody I know has a good word to say about their treatment when it has been neccesary to draw on what we pay for from our taxes.
I don't mind paying for it, I am more than happy to pay for it. What I really begrudge is paying for a service as bad as the one we have. I think France would make a wonderful model, I would be happy to pay for the odd visit to the Doctor if i knew that if I needed treatment I would not have to wait.
As it is at the moment to make an appointment to see a doctor i have to wait about two weeks otherwise I queue for two hours to see a locum. My partner needs minor surgery - they will not even give him an approximate date but have said they will give 8 weeks notice.
- Emma Calloway, Bristol
No-one would deny that the NHS fails and fails badly in some areas but it does suceed in providing high quality care to the majority of patients most of the time. The World Health Organization assessed it quite highly and certainly not as the worst in the developed world.
Any alternative system would still require additional payment by individuals and higher administrative costs. The basic cause of the NHS's failings is inadequate funding over many years. Cultural change is certainly required but more nurses,doctors,other staff and beds are essential to provide the sort of care we all desire. This, unfortunately, cannot happen overnight and a judgement about the effectiveness and efficiency of the NHS can only be made when this investment is in place. Well managed investment in the NHS must be the first priority before we decide in whether the system itself has failed.
- Dr. Guy Routh, Chairman, NHS Consultants Association
As a lay Community Health Council member monitoring the NHS at close quarters for over nine years, I cannot agree with Anthony Browne's conclusions about the NHS. He is right that far too many patients have a ghastly experience in an NHS, which all too often displays systemic indifference to their fate. However, for every dreadful experience and avoidable death - and there are many - there are thousands of life saving and life enhancing experiences.
As for the private sector, how do we know they can do a better job? The consultants who operate in private hospitals are not even employed by those hospitals. If we cannot make consultants who are employed in the NHS properly accountable, how are those who work on this basis in the private sector to be held to account? The health service must be a comprehensive service free at the point of delivery and available to all. We cannot have a society where those who can afford to do so pay insurance while we waste money on administering a financial safety net for those who cannot. The ideological objective of equal access to quality health services is sound.
- Elizabeth Manero, London N12
I am appalled to read Anthony Browne's article denigrating the NHS. France spends about 9% of GDP on health compared to 6.7% in the UK. The UK Governments of either hue want a first world health service whilst resisting the responsibility to pay for it, despite clear evidence that the general public would be willing to pay for such a service by increases in taxation. Politicians have always stated that expenditure on the Health Service "is a bottomless pit". Clearly France, Germany and most other Western European countries do not feel so. There is no evidence, however, that the fundamental principles underlying the NHS (a universal service equally accessible to rich or poor, free at the point of delivery) are any less relevant today than at its inception and the dissatisfaction expressed by the general public is aimed in general at the delays and deficiencies in service provision. These problems, however, are left to the NHS to deal with but are fundamentally the responsibility of central Government. The NHS cannot be blamed for the shortage of doctors in the UK compared to the rest of Western Europe, rather it is a victim of poor planning and limited vision by medical advisors to past Governments.
- A Bakran, Consultant Surgeon
Anthony Browne raises a large number of very different worries about the current state of the NHS and the real difficulties in achieving a tangible improvement in services.
He questions whether the current method of funding and organising the health service can ever yield the first class service patients deserve and doctors would love to work in and he raises the vexed issue of charging patients to visit their GP.
A major funding review which we conducted last year in concert with patient, nursing and managers' organisations firmly rejected them as being both inequitable and unlikely to yield any major savings. Nevertheless there is a consistent, and substantial minority of GPs, around 30 per cent, who do favour the introduction of charges to encourage more responsible use of health services and thus provide more time for patients. Our funding review concluded that the ideal of a completely comprehensive service may have outlived its usefulness. Decisions about which treatments should be excluded from NHS care are not for doctors, but for the wider public.
I regularly receive cries of distress from both GPs and hospital doctors who, despite the record levels of new investment going into the NHS, cannot see a light at the end of the tunnel. This must beg the question about whether there are better ways of delivering care. The BMA has pledged to support any sensible reform measure that improves care for patients. We have no ideological opposition to involving the private sector more fully in the provision of care but if new resources are to be directed towards the private sector, it must enhance, not detract from NHS provision.
There is in fact a fundamental reorganisation of the health service taking place right now. Old health authority boundaries are being swept away, new strategic bodies are being created and thousands (check) of new primary care trusts are poised to take over 75 per cent of NHS budgets. At the moment, it is difficult to see what the reorganisation will achieve, other than further upheaval. It distracts managers' attention from the task of improving services and it will not produce a single extra nurse or doctor.
Dr Ian Bogle, Chairman of BMA Council
Anthony Browne is wrong to dismiss the idealism of people who defend the principles of the NHS If a public health service does not exist to offer comprehensive treatment to all, regardless of wealth, what does it exist for? It is not the principles of the NHS that are at fault but successive governments' execution of them. There is nothing specific to a social insurance system that causes European countries to spend more on health. It is simply a matter of political will. Denmark, for example, has the same universalist system as ourselves but a more generously funded and a more successful one.
But Anthony Browne is surely right to point to the "crucial" distinction between the NHS and continental systems: in the UK you cannot choose where you are treated. But such choice is not an opportunity open only to social insurance systems. Denmark, with her tax-based system, offers a free choice. So should we. Patient choice would begin to allow the best hospitals to thrive and it would show up the hospitals which are failing. It would engage the expertise of the people who know most about the quality of secondary care: GPs. It is certainly possible that the electorate would be more prepared to pay for a better funded NHS if they felt they had more control over the health care they received.
- Anthony Rowlands, Director, Centre for Reform
Anthony Browne tells us why the NHS is bad for us. Many users of mental health services would agree. One in four of us will suffer from some form of mental health illness in our lifetime and many will use NHS services. Too often Mind hears from users of inadequate services (with 1 in 3 turned away from services) lack of care, and an over-emphasis on medication. Encouragingly, this government has recently begun to give a higher priority to mental health services. We wait to see what happens. Users of services and Mind will continue to strongly campaign for improvements. Should it be replaced, even with his "safety" net, by Anthony Browne's proposals? I think not; the risk of even greater inequalities and poor services is too great.
-Richard Brook, Chief Executive, Mind - The Mental Health Charity
It is extremely heartening that those on the left of the political spectrum have joined those of us on the right in accepting that the current model of healthcare is unworkable, that throwing more money at the NHS will not work and that the only solution is fundamental reform.
I have long been arguing that the NHS is not sustainable in its present form, most recently during my speech to the Party Conference this week, where I argued that "the sick are at the mercy of a rigid state monopoly... It is time to end the serfdom of the NHS monopoly."
We need to redefine the role of the NHS. We need a flourishing health service, free at the point of use for everyone, regardless of age, health or background. It must better reflect the needs of patients as all too often the system puts the hospital before the sick.
I want the NHS to identify all those healthcare providers who can offer the appropriate quality of care, and I don't mind whether they are in the NHS, the private sector, the voluntary sector or the non-profit sector. I want the best care they offer to be available to all of us, because what matters most is how and when a patient is treated and the quality of that care.
-Liam Fox, Conservative Party Health spokesman
When Anthony Browne argued that "the belief that [the NHS] can be meaningfully reformed is a triumph of hope over experience" he was largely correct; this government has proved that reforming zeal in public services is never proportional to the effectiveness of the results. In August, Demos argued that only through "progressive transformation" could schools ever become the excellent centres of learning we aspire to, with teachers driving change from within. The NHS has many of the same depressing hallmarks of our school system, with its demoralised staff and dilapidated buildings. Throwing more money at the problem, or demands by ministers for yet more target-based reform based on five-year plans will not have the transforming effect that patients demand. Only by making healthcare workers responible for change from within, and giving them the resources of both money and professional autonomy will this be possible. A national health service - note use of lower case - implies a flexible, varied and above all responsive system which can adapt to change from within. But there is another issue too which is that our national health can no longer be seen as a professionalised service to be delivered exclusively by doctors and nurses. Instead should be an active process involving all citizens - young and old, sick and healthy - throughout their lives. Paying for health benefits must become an investment rather than an insurance policy; when this happens the distinction between private and free at point of use healthcare become far less ideologically charged.
-Matthew Horne is a Demos researcher specialising in public sector transformation
Anthony Browne argues that we will never pay properly for the NHS and that this will always be centralised. Ergo we ditch it. Neither of these assumptions need to be true. I believe that people are prepared to pay for the NHS, provided that the money goes into health, and that they can see that it is being used effectively - particularly as the administrative costs of any social insurance system are bound to be far higher than those of the NHS. That is why NHS Alliance has called for a hypothecated health tax.
As for centralisation, the choice is no longer between a bureaucratic monolith or a privatised health service that rewards its shareholders. Primary Care Trusts have changed all that. They should provide locally sensitive services run by local people, professionals and managers in tandem, which would ensure that in future we will get the sort of treatment that we would want for ourselves or our families. The challenge for government would be to let go and to allow Primary Care Trusts to achieve their potential. It would be absurd to ditch the NHS just as new money is coming into the system and the new structures are beginning to show their potential"
- Michael Dixon, Chair, NHS Alliance
You cannot run the health of 50 million people by central plan from Whitehall. You cannot pay enough for health from tax alone. Hospitals and doctors should be set free to care for patients competing as independent providers. Present levels of tax funding should go directly to individuals (making now for a health insurance premium of c £1.100 per person).To this can be added extra - e.g.insurance contributions (with more for those in greater need). The principle would remain of comprehensive health care, free at the point of use. -Sheila Lawlor is Director of Politiea, who will shortly publish her pamphlet on a new health system
"The National Health service is no longer national-patients are not guaranteed the same standards whether they live in Aberdeen, Aberystwyth or Amersham.
It's not about health-global clinical standards are secondary to "reorganisations" by a closed shop bureaucracy. And it's not a service-it is secretive, with customers denied basic clinical information and simple redress - our leaflet " A Guide to the Complaints System" is 36 pages long. That says it all. Politicians offer platitudes and tokenism to a trapped public that learns the truth via media horror stories and public inquiries
- Vanessa Bourne, Chairman, The Patients Association
" The article by Anthony Browne is written in extreme language and hence belittles all the good things and good outcomes the NHS acheives for hundreds of thousands daily. It also dismisses the impact of the poor comparatve funding too lightly and forgets that the attempts by the Conservatives to intoduce choice and competition into the NHS was one reason they lost office.
However I am fresh back from our Annual Conference and amongst senior managers and heath commentators I did sense a willingness to debate alternative models to a centrally driven NHS. At a personal level I have addressed small groups of MPs and written articles on this issue since I am clear the debate must be had. The debate must include a greater personal responsibility for our health as well as alternative ways of responding to ill health." Stuart Marples CEO IHM
-Stuart Marples, The Institute of Healthcare Management
