On July 5th the NHS marks its 70th birthday, and the occasion will be marked by a significant financial injection as a means of life support by the Conservative government. This should keep it breathing for a while yet, but like any ageing process we should consider whether the condition is terminal, and what the objective of continued treatment is. Is the NHS a model of health care fit for the 2020’s or are there better ways of organising it in the modern world?

Why then was 1948 the moment of the birth of the NHS? And why has it taken up such a central place in Britain’s self-image? Other nations do not seem to fetishise their health care system to the same degree, or make it such a sacred cow. British politicians find this both a benefit and a curse, but as we saw with the £350 million per week Brexit Bus pledge, it is one that moves votes. The NHS was a central part of the first truly secure Socialist majority government in the UK, but also a product of its times.

In 1948 there had been substantial governmental involvement with management of hospitals for a decade, beginning in 1938 with planning for anticipated mass bombing casualties, health care staff had also spent a decade either in uniform, or in civilian government control. It was a unique moment in British history, when Attlee’s genteel Socialism and Blitz spirit of national unity came together as parents of the NHS. It was also the year of peak post war austerity.

The NHS was a sickly child from birth, with a vast legacy of untreated conditions, inadequate finance and staffing, and unsuitable legacy estate. Waiting lists were immediate, and the first co-payment charges shortly followed, precipitating Cabinet splits and resignations.

While waiting lists, central planning, and grey bureaucracy were acceptable, even state of the art, in 1948 they became increasingly grating to a population that had become more sophisticated and consumerist. Since then there has been a political desire to satisfy consumerist demands by both Conservative and New Labour governments, and also to introduce elements of competition. Largely this has been via the mechanism of internal market and contracting out of services to private providers, and one that continues today.

This element of privatisation has rarely met the desire for consumer choice, as the competition has been for contracts from the government. Operations and services are put up for bidding like cattle at auction, with the winner rarely being awarded the contract on the basis of clinical outcomes, but rather on the basis of price. This demonstrates that the customer is the government rather than the patient. We have arrived at a solution that meets some of the government’s aims, but at the expense of combining the worst of central planning, corporate profiteering, and lack of consumer responsiveness.

The  challenges to the future include medical inflation exceeding consumer inflation, rising expectations, failure to recruit and retain staff, the obesity crisis, and each of these deserve analysis. The biggest challenge is the demographic one, as summarised in this tweet:

Population prediction of UK 2016 to 2041. Significant population growth, but almost entirely of the elderly, with a few teenagers. The working age population remains stable. pic.twitter.com/3GNp63A3Ph

— Foxy (@foxinsoxuk) March 26, 2018

Just as the solution to the pensions issue will be a combination of working longer, paying in more and getting less, the answer in health will be much the same. We will need to stay healthy longer, pay more (either in tax or privately) and get less, or a combination of the above. Staying healthy longer requires a public health approach such as that in the Marmot Report, and it seems increased rationing is on the way. The latter is likely to increase consumer dissatisfaction.

Funding remains the political football. Whether funded by a single government payer, or via compulsory insurance, universal healthcare is essentially redistributive. Those that gain are the elderly, the poor, the mentally infirm and the chronically sick, while the system is paid for by light users, who by and large are young healthy and relatively affluent. There will therefore always be tension between payers and recipient.

Any universal system has to be based on the greatest good for the greatest number, but should this be on the basis of need or of economic benefit? Should the system favour the working plumber over the retired one? The stockbroker with a breast cancer over the dinner lady with the same? I would argue that to do so would be politically suicide, and strike at the founding principle of the NHS. One parent of the NHS was that feeling of wartime national unity that defines postwar Britain, and is central in British psyche and in particular of social conservative voters.

As such, benefits have to be independent of economic utility, and defined on cost effectiveness for the whole nation. How then should we address the increasing restiveness and consumer demand for 24 hour access and rationed treatments? Well, the safety valve for this has historically been the private sector, but this is much smaller in the UK than in comparable OECD countries with universal access. To meet the demand, the UK private sector needs to grow, reform, to become more affordable, more transparent on price and outcomes, and to have robust clinical governance over rogue clinicians. If these were to happen then the consumer would find it more palatable to fund out of discretionary income.

This could be done via a combination of tax relief for private health insurance, vouchers for co-payment by the NHS to pay for an element of the private cost, and a Speedy Boarding co-payment for private wings at NHS hospitals. Private insurance has its merits, but insurance companies are rather prone to sell umbrellas on sunny days and take them back on rainy days, with nearly all policies excluding chronic conditions, mental illness, and pre-existing conditions.

Perhaps the answer for this is for individuals to be permitted to save for their own families health care in tax-deductible accounts analogous to private pensions, with the funds restricted to self funded health care. These could be preserved post retirement and include funding for approved social care. In many ways, such a system would be a return to the pre-NHS mix of workhouse hospitals, friendly societies and private provision, but better adapted to modern Britain.

Are there betting implications? Not really, other than that the NHS will become increasingly frail as it moves into its dottage, and post Brexit will return as a touchstone issue in British politics. It is also likely to remain fatal to political careers, whether in government or opposition. Health Ministers rarely get the top job. In the immortal words of John Reid, on being reshuffled into the job “Oh F***, not Health!”

Dr Foxy

Dr Foxy is a Hospital Specialist in NHS and Private Practice in Leicester. He also has worked and studied in the USA, Australia and New Zealand. He has an interest in statistics and public health planning, is an occasional political punter and longstanding contributor to PB.