Increased funding risks propping up a system that has to change
A growing clamour of voices insists that the NHS is underfunded and should be given more money. I disagree for two broad reasons.
Firstly, the NHS does little for health. Indeed, it reduces health by diverting resources from investments that would do much more to increase health, and it increases ill health by keeping people alive in a poor state of health. We know that health systems account for about 10% of health; the other 90% results from environment, genes, and lifestyle. Healthcare rapaciously swallows up funds that would do much more for health if invested in education, housing, poverty reduction, the environment, community development, and many small scale projects that deliver real change.
Secondly, increased funding props up a system that everybody who understands health systems recognises has to change. More money now might keep the system tottering on in its present form, but ageing of the population, changing epidemiology, and more than anything the increasing cost of new technologies and drugs will mean we will be back in the same predicament in a few years’ time. Plus increasing the number of doctors, as the government plans, will increase still further the need for more money—because of the ill understood but powerful phenomenon of “supply-driven demand.” I resent greatly the constant refrain of increased patient demand: patients are not demanding more, rather they are being offered more—much of it, unfortunately, of limited value.
Increased funding allows continuation of a minor variant on the status quo, whereas substantial funding cuts force change. This was the mistake made in the years when Tony Blair dramatically increased funding: the investment inhibited rather than encouraged change.
There is wide agreement on the changes that are needed, and they were expressed well in the 2005 report for the Scottish government Building a Health Service Fit for the Future. The challenge is to change a health service geared towards acute conditions to one that is geared towards long term conditions. There needs to be a shift from hospitals to communities, doctors to teams, episodic to continuous care, disjointed to integrated care, reactive care to preventive care, patients from passive recipients to partners, self-care being infrequent to being encouraged, and from low tech to high tech. That last change might seem odd in a health system bristling with MRI scanners and expensive equipment, but it refers particularly to information technology, which has transformed many industries but not healthcare. In broader terms there needs to be a shift from hospital care to primary, community, social care, and self care. We should as well move from an emphasis on patching up the diseased to creating health, and that’s a change that is profound—needing new actors, cultures, and attitudes.
The problem is not the direction of change, but the process. It means a dramatic reduction of resources going to hospitals, which inevitably prompts howls of protest—and from the most powerful people in the health system as well as their patients. At the moment, hospitals are taking most of the extra resources available, denuding primary care. We are heading in the wrong direction. Because about three quarters of the cost of hospitals is staff, shifting resources away from hospitals would mean substantial redundancies. Such redundancies might be (just about) politically tolerable for miners, but they won’t be for health workers without inevitability—and cuts rather than increases can provide that inevitability.
The standard argument is that extra funds above and beyond increases to cope with changing demography and new technologies are needed now in order to make the necessary changes in the system, but the danger is that they would block change. Substantial cuts force changes that are, otherwise, politically impossible.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS is an NHS patient and has no private insurance and has never had. He was until 2015 employed by the UnitedHealth Group, which has customers in the NHS, although he had nothing to do with the business side of the company from 2007. He still has shares in the company. He is also the chair of the board of Patients Know Best, which has customers in the NHS. He is unpaid but has some equity. The views expressed in this piece are entirely his own.