Evidence to the Labour Party Investigation into Health Service Organisation

The author is a member of BMA Council, a former (1987-97) President of the Medical Practitioners’ Union, a former (1992-8) Chair of the BMA Public Health Committee, a former (1987-90) Chair of the Greater Manchester Socialist Health Association, Director of Public Health for Stockport, UNITE’s Spokesperson for Doctors Employed in Local Government and author of “Medicine and Labour – the Politics of a Profession”. The evidence is entirely personal and not connected with any of the organisations and offices above, which are quoted for personal descriptive purposes only.

1948-1974 the NHS cleared the slums, cleaned the air, eradicated polio and diphtheria, established new rehabilitation services, rebuilt the hospitals, and created an internationally-admired general practice system, all with the lowest level of health spending in the developed world.  The mechanisms for these achievements have now been abolished. Consequential failures led to further dismantling, like saving the Titanic by repeatedly attempting to ground it on the iceberg. Health policy since 1974 has done for health systems what design of the Titanic did for maritime safety. A wide consensus, portrayed as state of the art, delivers its main contribution from analysing the disaster.

The NHS was a mechanism to pursue health as a social goal, deploying  committed health professionals and health workers to support socially owned organisations addressing the determinants of health as well as providing health care free at the time of use, according to need rather than ability to pay, planned to optimise resources, and financed by general taxation.

Little of this remains in England. Health care is still funded from general taxation according to need rather than ability to pay. None of the other principles remain.

NHS principles have been destroyed by

  • 1974 reorganisation which diminished local control
  • Centralist managerial policies of the Thatcher Government
  • 1974 removing local authorities from the NHS, redefining environmental health out of the NHS, and thus removing NHS mechanisms to address social and environmental health determinants
  • Competition introduced into NHS markets by the Blair Government
  • The 2012 Health & Social Care Act

The case for an NHS remains compelling because

  • At most 50% (and perhaps only 10%) of health improvement results from health care – most  derives from social, environmental and behavioural determinants. Bevan’s vision, shared with the BMA, of an NHS addressing determinants of health remains fundamental. Indeed the BMA was right in 1945 to advocate factory inspectors becoming part of the NHS for expansion into an occupational health wing; Bevan supported this but Bevin successfully opposed it.
  • Healthcare and health improvement require active engagement of communities and individuals. Bevan’s vision of an NHS pursuing health as a social goal is as valid as ever, reinforced by Warnock’s calculations.
  • Communities and individuals need honest committed professional advice in those decisions. The BMA was right in 1945 to defend professional responsibility; Bevan was right to concede that, shaping an NHS professional family.
  • Economically, healthcare markets do not work. EU law requires either full blown markets or a public service. The former will bring deteriorating quality and rising costs.

Commercial healthcare markets do not optimise resources or improve quality because

  • Consumers depend on provider advice
  • Risk sharing is necessary, creating “moral hazard” (a belief in the best rather than the optimal).
  • Commissioning authorities as market-makers of the market fail to solve this since measuring performance adequately is difficult. Making profits by exploiting information anomalies is easier than by improving services.
  • Hospitals and pharmaceuticals both have downwardly sloping cost curves and high entry costs so, according to Pigou’s theorem, a simple market will clear with unused capacity and high prices. (Adjustment of this market leads to some other versions of Pigou’s theorem such as that where the market in unrationed services clears by reducing quality, relevant to waiting times)

The argument that the “NHS must be reformed” because “it must meet the needs of an ageing population” is valid, but the reform needed is NHS restoration not commercialisation.

  • An ageing population will reduce healthcare costs, not increase them, provided that healthy life expectancy rises as fast as or faster than life expectancy. This necessitates a healthy ageing strategy rooted in prevention.
  • An ageing population especially requires collaborative efforts of society in reablement and promotion of independence
  • NHS restoration is than commercialisation at  resource optimisation

An NHS Restoration Act should

  • reverse commercialisation provisions of the 2012 Act
  • address determinants of health
  • improve healthcare planning
  • establish occupational health services
  • ensure provision independent of ability to pay, addressing the problems of charges and top-ups
  • democratise the NHS
  • promote a social and professional ethos and restrict competition, but provide alternative routes to innovation and dissemination of good practice
  • protect professional freedom to give honest advice
  • abolish the distinction between health and social care
  • account for health impacts of government policies
  • stop economic markets acting as choice editors obstructing healthy lifestyles
  • provide redress and appeals processes more efficiently than current clinical negligence processes