The National Health Service came into existence in 1948 as part of the Labour government’s decision to ensure that the entire population of the UK received free health care at the basic level (general practitioner) and the more complex level (hospital). Whatever its political causes and ramifications, this decision was altogether commendable at the social and humanitarian levels, and was also good for the country in yielding the significant economic advantages of a working population less afflicted by diseases which caused people to miss work but were readily treatable.
Yet since that time the NHS, in its current form as one element for each of the four political components of the UK, has grown steadily and remorselessly to swallow an increasing proportion of the nation’s annual budget. We have now reached the stage at which the current level of spending is no longer readily sustainable, and future increases in spending on the NHS are essentially impossible (except, of course, in the minds of politicians more concerned with garnering pro-NHS ‘brownie points’ for the next election than with the reality of the situation). Moreover, this is not in itself an issue that can be divided along party lines, despite the perception of large elements of the voting public, spurred on by the public utterances of politicians, that the Labour party is ‘pro-NHS’ and the Conservative party, now abetted by its Liberal Democrat coalition partners, is ‘anti-NHS’.
Whatever the causes, and no matter how high-flown the statements of politicians and pundits, it is an inescapable fact that the NHS has ballooned, indeed mushroomed, in the period since 1948 into a bloated, shapeless and unaffordable monster that is committed to achieving too much for too many. In the process the NHS falls increasingly short in a number of important aspects of its work. If the NHS had an unlimited budget to build, and also to train and employ staff, there would be no problem. But any such suggestion could never be anything but a venture into an impossible ‘cloud cuckoo land’. Instead the NHS is faced with the prospect of very real cuts in its budget, with consequent fears that so-called ‘front-line services’ will have to be trimmed.
What almost everyone ignores is that the the UK can no longer afford the type of NHS that people have come to believe is theirs by right. It is inescapable that if the country is to live within its means, then the NHS must be cut back to a more manageable size and at the same time adjusted in its proportions and priorities. This is a process that will hurt both the NHS’s employees, at every level, and also what the NHS now likes to call its ‘clients’ or ‘customers’. This last is, of course, part of the problem, for the original emphasis on the care of the patient, in the sense of one who is ill or injured, has long disappeared with the loss of carefully planned structures to ensure speedy and effective cures.
There is no single answer to the NHS’s malaise (I use the word advisedly), although major amputation of necrotic material is essential and, I hope, inevitable. An organisation as large, complex and costly as a modern hospital clearly needs the backing of a capable administrative structure so that the medical staff can concentrate on patient care.
Here a major improvement could be made by eliminating some vertical tiers and/or lateral positions in the management structure. This would inevitably place greater emphasis on the skills and commitment of those who remain, but this could be compensated by the payment of higher salaries. In this respect, I would urge, the greater salaries would not be a matter of annual right, but gained only through manifest and provable improvement in performance. I also believe that a greater focus could be given to the work of administrative personnel by making them personally liable at levels that would range from the financial, via loss of position, to criminal prosecution for the worst cases in which lives were lost or materially affected. The same regimen could also be applied, with changes, to members of the ‘front-line’ medical staff.
This is only tinkering round the edges of the problem, however, and we have now reached the stage at which a radical reconsideration of NHS priorities is needed. Much of what the NHS now does is very far removed from the fundamental level of medical care that was initially envisaged as its remit. We have to return to something like this level, and here I suggest the removal of many types of NHS service. To take just one minor example, is it right that the taxpaying public should pay, via the NHS, for people to receive cosmetic surgery for anything but essential reasons? Here I am thinking of matters such as breast enlargement and/or reduction for reasons merely of supposed ‘self-esteem’. Matters are altogether different when cosmetic surgery is required to remove or at least reduce disfigurements resulting from accidents or assault.
Another facet of the NHS’s work which should be re-examined carefully results from what I would regard as ‘self-inflicted wounds’. Among these, I would suggest, are:
- lung cancer resulting from smoking, etc
- hard and soft drug overdoses and their consequent problems
- excessive alcohol consumption (alcohol poisoning, cirrhosis and physical damage resulting from resultant car crashes or brawling)
- involvement in hazardous pursuits
- criminal activities
I concede that it would be difficult at times to decide whether or not an incoming patient was suffering from a ‘self-inflicted wound’ of this type, but a measure of life-saving care could be provided until the situation has been made clear, by the police for example. A reduction in tobacco and alcohol taxes could (a pious hope) allow smokers and drinkers to take out specific medical insurance in the knowledge that the NHS would no longer be at their beck and call. Those who pursue lifestyles likely to lead such ‘self-inflicted wounds’ should be taught by their parents and schools that the NHS would no longer provide anything but initial life-saving care, and that they should assume full responsibility for their own physical welfare either by avoiding dangerous life styles or by taking out the appropriate insurance to pay for further care in private or NHS hospitals.
I readily allow that any such change in the NHS would be extraordinarily difficult to plan and execute, and that changes would probably be required in the nature of National Insurance contributions. But I am just as convinced that changes of this type, and more, are the way forward. For too long we British have accustomed ourselves to the idea of universal health care ‘free at the point of delivery’, but this is plainly impossible from this time on even if it was feasible at any earlier time, not least in view of the fact that any planning of the NHS’s future must now consider how it is to cope with the medical demands of an ageing population with what seems to be ever larger levels of dementia.