3 Underprovision and Oversale

Predictions of extravagance and bureaucracy having failed, the next line of argument was that though the NHS might indeed be cheap at the price, this was only because it didn’t deliver the goods. Potentially unlimited demand for free medical care in the NHS had to be limited in practice by long waiting lists unknown in marketed medical care systems; and when patients finally got care, it was of inferior quality.

Nobody doubts that waiting lists were indeed used to discourage demand, though that doesn’t prove that demand would have been infinite without them. Part-time consultants always had a cash incentive to maintain long NHS waiting lists; how else could they ensure full bookings for their private clinics? This fact, known to every patient who ever asked their GP if a private consultation would short-cut the waiting list, could always have been verified by politicians, simply by comparing waiting lists of full-time and part- time consultants. No such study was ever commissioned by any Health Minister. It is hard to avoid the conclusion that waiting lists were a convenient brake on demand for specialist care in NHS hospitals, and were tolerated for no other reason. Had any Ministers been seriously concerned to abolish waiting lists, they would have collected meaningful data centrally. In fact, the only data collected and discussed related to delays between seeing a specialist and admission to hospital; the even more significant delays between GP referral and seeing a specialist (in my part of South Wales, commonly three months or so, occasionally two or three years) were neither collated nor discussed in parliament. Local figures existed, because they were circulated by Health Authorities to GPs, presumably in the justified hope that many referrals might be thereby discouraged as more or less futile, but these figures were not gathered centrally. Of course, these delays cost lives. Even if cases marked “urgent” were seen sooner (and there is still no consistent policy on this), they had first to be recognised as such by GPs.

The NHS was never adequately funded by any government, Labour or Conservative. There were always other, more pressing demands on public spending, whether clinging to empire, stoking up the fires of the cold war, repaying the gnomes of Zurich, or reducing tax-burdens on the rich.

Underfunding in a State service is not inevitable. Nobody expects a poor nation to provide a rich service, but like the health workers it employs, it should do the best it can with the resources available. We can and should demand that if our country can produce so many nonessential consumer goods that an army of advertisers and salesmen must persuade us to buy them, we can certainly afford to pay for the rational application of medical science to basic human needs. The level of state funding depends on real rather than rhetorical social priorities. If sufficient private wealth exists for the whole population to pay individually for medical services in the market, it must exist also as a potential tax base for services to be paid for collectively, at lower cost and with greater efficiency.

Even with long in-patient and out-patient waiting lists (in my own experience, up to three years for one speciality, where the same consultant could be seen privately in a few days), NHS specialists were eventually accessible to the whole population. Virtually everyone was registered with a family doctor to provide primary care, and to act as informed advocate to get specialist care. Not so in the USA, where despite spending four times more per head on health care, 15% of US citizens had access only to hospital emergency rooms, another 30% had insufficient insurance to cover major illness, and even the highest payers could not get more than 80% cover for catastrophic illness. As for family doctors, they earned so much less than specialists that they almost disappeared, and are now having to be expensively re-invented.

However, it is still true that cheaper care in the NHS also meant less care, even if spread more justly throughout our population. Figure 3 compares rates in the UK and USA for some common surgical procedures.

Figure 3. Admission rates per 1000 population for operations on tonsils, gall bladder, inguinal hernia, prostate & uterus, UK and USA, 1980.

Tonsil Gall bladder Inguinal hernia Prostate Uterus
UK 26 78 154 144 250
USA 205 203 238 308 557

from McPherson K. International differences in medical care practices. In: OECD Social Policy Studies No.7 Health care systems in transition. Paris: OECD 1990, Table 3, p.22.

There is no evidence of large differences in prevalence of illness to account for these huge differences in surgical activity. Rates might be too low in the UK, too high in USA, or both. However that may be, they give no support to charges of extravagance against the NHS, and in fact an independent enquiry set up by the first post-war Conservative administration (the Guillebaud Commission) concluded that

Any charge that there is widespread extravagance in the National Health Service, whether in respect of the spending of money or the use of manpower, is not borne out by our evidence…. we have found no opportunity for making recommendations which would either produce new sources of income or reduce in substantial degree the annual cost of the Service. In some instances – and particularly with regard to the level of hospital capital expenditure – we have found it necessary, in the interests of the future efficiency of the Service, to make recommendations which will tend to increase the future cost.”

This scotched the charge of NHS extravagance, though none of those who forecast this ever admitted their error; and it confirmed chronic underfunding. It therefore implied the probability of some underprovision in the NHS, and there has in fact been good evidence that some interventions, notably coronary bypass grafts and kidney dialysis, have been underprovided, particularly for older people. There were also gross delays for some routine operations like cholecystectomy (removal of the gallbladder), operations for cataract, and hip joint replacement. For technical interventions as a whole, the issue is less simple than it is often made to appear, because professional attitudes to treatment are generally less aggressive in Britain than the USA, a view often shared by patients. Attitudes are certainly biased by the pressures of contrasting care systems, the NHS toward complacency and low taxes, the US medical market toward sales promotion and high fees.

Despite large differences before the war, since the NHS there was no evidence of within-region social differences for any common surgical procedures up to 1985. In their family doctors, all NHS patients had potential informed advocates, most of whom evidently maintained enough pressure to prevent social bias in distribution of services, and ensure that priority went to need rather than status. This was an important social gain, and suggests that professional integrity not only survived, but grew in a socialised service. In marketed care in the USA, on the other hand, there was evidence of gross overprovision for the rich and underprovision for the poor for both coronary bypass grafts and caesarean section. Higher professional groups , and higher earners , got more elective surgery. There are some prosperous areas of the US with evidence of only minimal social gradients for surgical process , so economic pressures are not the only determinants of professional behaviour, but they are bound to favour wealthier consumers in a free market.

Overprovision of medical or surgical interventions may be as dangerous to health as underprovision. No care system can of itself ensure appropriate care, which depends on clinical judgement and professional integrity. There will be some lazy doctors and some greedy ones in any system; but to give doctors economic incentives to remove parts of our bodies or interfere with our natural chemistry seems almost as silly as paying to have our brains washed by Rupert Murdoch’s newspapers.

Even in fee-earning systems, it is unlikely that most doctors work consistently to maximise income rather than improve patient care, though a few certainly do. More commonly they, like other entrepreneurs, complacently assume that their own and their customers’ interests coincide. United States doctors are about twice as likely to remove a uterus as doctors in the NHS, but as they recommend this for their wives even more often than for their other patients, their beliefs are honestly held. Once doctors are paid according to production not of better health outcomes, but of processes assumed to result in those outcomes, the stage is set for clinical inflation, because the market rewards credulity and penalises scepticism.