Professor Donald Light
Center for Bioethics

The Golden Anniversary of any institution, especially a world-class one, is a fit occasion to celebrate what has been accomplished, but also to think about the challenges that lie ahead.

Two comparative strengths of the NHS strike one right away. It raises funds through income taxes, and it has what an authoritative study concluded is the best primary care system in the world. Let us look at each in turn.

Compared to forms of health insurance, income taxes are the cheapest and most fair way to collect funds. They also help to hold the health care budget in check, because health care has to compete against other major programmes (like education and economic development) every year to get its share.

The other great strength of the NHS, primary care, is being made stronger as it is broadened to embrace a comprehensive array of services. The new White Papers are a model of what the WHO analysts of European systems say needs to be done.

Dissatisfaction

British surveys consistently show a high level of satisfaction and support for the NHS, but a comparative survey done at Harvard University that asked samples in five countries how much change was needed in their health care system found that more Brits said fundamental change was needed than people in any country except the United States. Both views might be true - a strong appreciation for the NHS but also a feeling that fundamental changes are needed. What do you think? The NHS provides fewer nurses and specialists per thousand than any other country in Northern Europe, amongst the fewest beds and bed days per thousand, the longest waiting times for elective surgery, and the most run-down buildings. Is it worth an extra one percent of GDP to solve these problems? Or would it be better to spend it on education, employment or housing?

Let us look at some key challenges from past decisions now embodied in present arrangements for the future.

Besides creating a single, national basis for collecting funds, the NHS created a single, national system for providing services. But that system was rife with divisions and fiefdoms.

Challenges to Primary Care

Based on experiences with capitated contracts in HMOs, American observers would immediately be concerned about GPs dropping sicker patients from their lists and referring on too many problems in order to reduce their costs. Are British policy makers uninformed about the risk de-selection and cost shifting are taking place in some primary care practices?

The Future of General Practice

Since the founding of the NHS, GPs have been protected by an independent contract. Yet functionally, U.S. and British experiences indicate that two-thirds of primary care work can be done by less expensive nurse-practitioners. What will be the functions of the general practitioner that make economic sense?

Challenges to Hospital Care

Modern technology profoundly threatens the concept and costs of district general hospitals, because so much of specialty medicine no longer requires large buildings and overheads to diagnose and treat The big savings lie in reconfiguring specialty services to minimise hospital admissions and length of stay; but that implies stepping on some big toes. Are managers and ministers ready to do that?

And more challenges:

• What steps can be taken to move the information agenda forward?

• How can the value of management be improved?

• What kind of balance between centralisation, delegation, and devolution do we want to see develop?

There is widespread fear that over the next generation health and welfare costs will inexorably rise, driven by an ageing population, and therefore the NHS is not sustainable in the future. But in fact, costs are not spiraling up.

From an international perspective, British costs for these basic services of a civilised society are the lowest in Northern Europe.

As for ageing, the UK has already experienced a substantial portion of its ageing burden. The 'support ratio' of working age people to elderly people will decline less than in any other country except Norway.

The Challenge of Rising Demand

Despite these reassuring basic trends, short-term demand seems up everywhere. There is talk of a new waiting list - to see your own GP! Yet there is no evidence that people are actually sicker.

Some American HMOs are pioneering what they call "demand management", an array of techniques using patient education, advice lines, telephone screening and protocols to reorient demanding patients.

Will the information revolution and the internet help? What should be done to develop and steer it?

One way to empower patients and enable them to manage more of their health problems is to encourage self-help (actually, mutual help) groups. What steps should be taken to empower patients more?

Rising expectations and demand suggest to me that the NHS needs a new social contract with the people who pay for it and use it. What should be its terms?

Let's face it. Aside from some screening, immunisations and patient counseling, the NHS is largely a medical service, an NMS. Over 50 years ago Beveridge saw that Britian needed a service that integrated medical treatment, prevention and public health.

How might that vision be best realised?

The payoff could be large. A prominent American group of research and policy leaders have concluded that 70 percent of diseases and disorders can be prevented or postponed, saving billions in acute services. The trouble is, the NHS does not measure or reward wellness or health gain. Successful prevention is just an added cost.

User Involvement, User Vote?

User involvement is an effective way to:

• get patients to manage more of their health problems,
  

• move the NHS towards being a health service, and
  

• save money.

National policy now requires users to be involved in setting standards and in developing policies. This is a far cry from practices today. It seems to me that for a "national health service" in a democratic country, the NHS is surprisingly hierarchical and autocratic.

Setting Policies, Priorities

There is a new commitment to patient involvement and openness. Given this commitment, four basic challenges face the next generation:

• How should the public be involved in setting standards and making policies?

• What procedural rights should be established to frame and protect that involvement?

• How should basic principles and priorities be set?

• What substantive rights should patients have to health care?

Between now and 2020, the NHS will have to recruit and train a large and steadily growing number of nurses, doctors, clinical specialists, and managers. Yet the conditions of work, the level of pay, and the chances for promotion are becoming less and less attractive for the young men and women one wants to recruit compared to other lines of work.

What do you think?

• How much of the problem is level of pay?

• How much of it has to do with career ladders with only two or three rungs?

• What role do you think working conditions play?

A new report from the Nuffield Trust on the health of the NHS workforce sheds light on some of these dimensions.

• Work is getting more intense, and hours are getting longer.

• In hospitals, patients come in sicker, and there is less time to treat them before they are hastily discharged.

These trends result in NHS staff having much higher sickness rates than the general public.

• NHS staff quit at high rates, creating a high level of wastage for the Service and high replacement costs.

• More doctors are seeking early retirement.

The Nuffield report reviews and recommends a number of positive interventions that can improve communication, support, interpersonal skills, and work environment. But will they be enough to recruit and retain good clinical staff of all kinds and grades over the next decade or two? As you can see, they do not address pay levels, career ladders, or the more costly structural problems of work conditions.

Basically, the NHS keeps getting more productive and provides a remarkably comprehensive service on an internationally low level of funding. Further, as indicated above, recent rises in demand do not reflect greater need and could be addressed by developing a new social contract with patients that mobilises as active partners in managing many symptoms and problems. In addition, there is room for even greater productivity by reducing inefficiencies within current services, though tackling them would require taking on powerful entrenched interests.

Nevertheless, at the end of the day, an optimistic realist is still left with good reasons for believing that the gap between services and funding will widen.

• The increased workload from ageing, though less than in most countries, will occur.

• "Need" will grow steadily as medical advances enable doctors to diagnose more and treat more.

• The number of specialty episodes has been growing steadily at 5 percent a year.

• The NHS is widely perceived as rundown

• The high levels of stress, sickness, and turnover in NHS staff indicate that major investment will soon be needed.

• The managerial and professional classes are abandoning the NHS for private care in growing numbers. This erosion threatens financial support for a good service.

Limit the NHS to just Emergency and Acute Services?

Does this sobering evidence of a widening gap between funding and a good comprehensive service mean that the NHS should - or will have to - narrow its services to emergency and acute interventions.

It is worth remembering that the more narrowly health care services focus on acute intervention, the more they exploit unpaid labour and women.

When in 2010 or 2020 you are laid low, or in pain, or about to exit this world, do you want compassionate care from nurses and staff in the NHS? Is that a priority or more of a luxury you think is not worth the extra cost?

Go Private?

Private care is an easy way for politicians to provide an outlet for discontented managers and professionals. The danger is that if it becomes too extensive, it threatens the legitimacy and solidarity on which the main service depends.

Moreover, I think private markets now give Brits a raw deal. There's no market information on price, so consultants charge exorbitant rates, higher than on Fifth Avenue in New York, because even clever patients cannot compare price and quality. Private insurers operate under rules that allow them to select what procedures they want to cover and leave all the rest on the NHS. Other countries lay down fair rules for private markets. Shouldn't the UK?

A Supplementary Health Care Tax?

Such a tax would address a major concern for the 60-70 percent of the population who say they think more money should be raised for health care, but they're afraid that their money will be used for other things.

The health care contribution would have to be supplementary, or the Treasury will stop allocating 14 percent of the government budget to health care.. Even better, it could be ear-marked for services people really want improved.

A Voluntary Contributory Scheme?

Another way to provide funding for rising demand over the next 20 years is to establish ground rules for voluntary contributory schemes. Functionally, these are like private health insurance in that they are a voluntary upgrade for quicker or better service. But they can cost less than half the price and be community-rated so they do not discriminate by age or health risk.

What do I recommend? I think there is a clear challenge to fund rising demand, and I think you should DO ALL THREE. Establish fair rules for private insurance and care AND set up a supplementary health tax AND establish ground rules for contributory schemes that support the NHS. Get new equitable sources of funding started and see how each unfolds.

What do you think about these challenges to the NHS for the 21st century? What do your colleagues think? Come to Earls Court July 1-3 and find out. Join the interactive 50th celebrations!

Professor Donald Light
Center for Bioethics

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