NHS Anniversary

The NHS debate Is the NHS a clapped out behemoth or the best gift the British people have ever given themselves? Rebecca Coombes reports on last week’s debate hosted by the BMJ and the King’s Fund

As Ara Darzi was preparing to deliver his has been instrumental in the success of many final report into the future of the NHS, businesses, including Pizza Express, stepped four experts from the worlds of business, up to support the motion. Perhaps unsur- journalism, clinical services, and Whitehall prisingly for an entrepreneur, he believed gathered to discuss whether it should have the NHS suffered because it was divorced a future at all. The motion of the debate was from the commercial world’s twin drivers of that “The founding principles of the NHS— ­efficiency and value for money. services funded by taxation and available to all regardless of ability to pay—are no longer An outdated model relevant in 21st century Britain.” The NHS was nothing but a “politically The motion was supported by entrepre- controlled state monopoly that is inefficient, with high levels of chronic disease. Politicians neur and businessman Luke Johnson and outdated, and unsustainable,” he said, claim- had limited management experience and Karol Sikora, cancer specialist and champion ing the UK taxpayer does not see an ade- wasted public money with “extraordinary of privately funded medical schools in the quate return on its almost £105bn (€133bn; abandon.” UK. Opposing were Polly Toynbee, from the $209bn) annual investment—an average of “This government boast that they have UK’s leading liberal broadsheet ­newspaper £3500 for every working Briton. “Yet we been increasing our spending of our cash by the Guardian, and Paul Corrigan, special have some of the worst survival rates in 7% per annum in real terms in recent years, adviser to two successive health secretaries Europe for cancer and strokes. Spending on as if this is somehow clever, difficult, or mor- at the Department of Health. the NHS under this government has more ally a good thing. After all, any fool can A poll of the invited audience at the Royal than doubled in less than seven years. Where spend money badly.” He cited as evidence Institution, London, taken before the debate on earth does all the money go? Are we twice “incompetent” pay negotiations with doctors: showed that just under a quarter (24%) sup- as healthy?” “Nowhere else in the entire world can such a ported the motion, 71% opposed, and 5% What was holding the UK back, thought lavish settlement have been agreed for such were undecided. Mr Johnson was “intellectual dishonesty” by minimal productivity gains.” Luke Johnson, chairman of Channel 4, who politicians that the original NHS model could But patients themselves had also changed studied medicine at Oxford University and possibly serve a rapidly ageing population, since the NHS started 60 years ago. People

“The healthcare demands of our population and the expectations they have of the NHS are on a massive collision course” Luke Johnson

From left: Jacky Davis, Wendy Savage and Shirley Murgraf are members of “Keep our NHS public”; Paul Corrigan, director of strategy and commissioning at NHS London; Polly Toynbee, Guardian columnist and opponent of the motion

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Included in the audience were clinicians, researchers, patient representatives and independent providers of health

“Wherever you are in the world, the tax funded system turns out to be the most economic”

ALL PCTURES BY MARK THOMAS MARK BY PCTURES ALL Polly Toynbee

now see themselves as consumers; if visiting NHS was designed for a different era, “An son for his lack of a credible alternative to their doctor they “expect to leave with a pill.” age of deference when people had much the NHS. He said the “fee exempt” British public saw shorter life expectancies and no one could “What is the alternative? We could just the NHS as a “bottomless pit.” learn about expensive treatments on the have less health care. Wherever you are in Tackling NHS efficiency, Mr Johnson internet.” Now people have a powerful sense the world, the tax funded system turns out to claimed that the number of NHS managers of entitlement, he said, but the idea that we be the most economic. If you don’t want the had doubled to 40 000 under Labour so the can all have the health treatment we want at state to pay, if you think it is all too expensive, health service now had fewer than five beds anytime is “a fantasy.” then it must be because you want to deny per manager. He said more insurance, copayments, and health care to somebody, or squeeze it in He also pointed to the £1trillion public proper pricing must be brought in, with the some way.” sector pension deficit, in which NHS workers NHS “as a safety net only.” Far from being wasteful and expensive, Ms are the largest component, and the £180bn Toynbee said, the NHS is actually the most worth of private finance initiative schemes An efficient service efficient way of running a health service. that would be a burden to the UK for dec- But Polly Toynbee, a political and social “The facts show that what is fairer also, on ades to come. commentator at the Guardian, vehemently this occasion, happens to be cheaper.” Data The thrust of his argument was that the opposed the motion, and derided Mr John- from countries pursing alternative models

“There is something absurd in the motion that just because something is 60 years old it lacks modernity” Paul Corrigan

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From left: Fiona Godlee, editor of the BMJ; Karol doubling of the NHS budget in real terms is transplant was 50 because people fell apart at Sikora, medical director of Cancer Partners UK having a real impact.” 50. Now there is no age limit,” he said. and Doctors for Reform; John Humphrys, BBC On the charge of value for money, Ms “Because these people are going to pay Today programme presenter who hosted the Toynbee offered more evidence. “If you less tax after retirement, they’re going to debate; Luke Johnson, chairman of Channel 4 look at the figures for mortality amenable to consume money paid by younger taxpayers. health care—the crucial measure of avoidable There is a limit to which younger taxpayers seem to confirm that the UK has made the deaths—latest figures show a 21% improve- are going to subsidise the new gerontocracy. right choice. “Funding the NHS from taxa- ment during 1998-2003.” It was a much faster The equation doesn’t stack up.” tion is more efficient than all other systems, rate of progress than in France or Germany, Returning to the wording of the debate with lower administrative costs than insur- around 13%, or the US, only 4%. motion, Professor Sikora pointed to the three ance based systems, no cross billing, no col- She said that the founding principles of the founding values of the NHS—universality, lecting from employers and employees.” NHS would have renewed relevance in the equality, and quality. He acknowledged the She pointed out that within eight years future—technological advances would surely NHS had universality but it had failed miser- of the NHS being launched in 1948, the mean we need more collective funding, not ably to bring equality. universal service had actually reduced less. “There are people going to the high court health costs. “Once genetic testing can predict which next week for judgments to overturn appeals She went further: “In those countries that patients are high risk and which are low risk, to the primary care trusts about cancer drugs. do have more private spending, costs tend private insurance will be impossible. Only Some will get them. Some won’t. And these to rise. Dutch and Ger- the pooling of the risk col- people are white, middle class, educated folk. man experiments in mak- “There is a limit to which lectively can really ensure They do not represent the average NHS ing the rich pay for their younger taxpayers that a universal service patient.” insurance have resulted survives that.” Turning to quality, the third founding value in increased overall costs are going to subsidise Ms Toynbee warned the of the NHS, Professor Sikora attacked the in both the public and the audience not to treat press fact that it was so variable. “You can get the private sectors, and worse the new gerontocracy” headlines as a barometer best cancer treatment in the world in many equity. France recently Karol Sikora of how the public really parts of England and the rest of the UK. increased its tax funding felt about the NHS. You can also get some of the worst. One is because private funding for consultations “There will always be egregious cases of terri- ashamed to see some of the second opinions caused costs to rise. Famously, the US spends ble treatments to splash across the front pages that I get to do—people who have been writ- far more for far less. In the UK, areas with of the newspapers,” she said. ten off without properly being diagnosed.” the highest levels of private insurance don’t Like his debating partner, Mr Johnson, result in lower NHS costs.” Failing an ageing population Professor Sikora advocated allowing people But what about Mr Johnson’s charge that Karol Sikora, medical director of Cancer to pay for care in different ways, including the NHS care compared badly with that in Partners UK, then entered the debate to insurance. the rest of Europe? Ms Toynbee acknowl- support the motion and Mr Johnson’s ear- edged that the biggest cause for discontent lier contribution. He began by condemning Choice and competition for UK patients was traditionally waiting tax based healthcare systems as “doomed” Paul Corrigan, director of strategy and com- lists. because of the “new gerontocracy.” missioning at NHS London, disagreed. But, she said, “Latest figures show not only Back when he was a young doctor, older “There is something absurd in motion that have the long waits gone but average waits people had poor cancer survival rates. “Now just because something is 60 years old it lacks are now down to four weeks. The biggest new technology can actually work in old modernity.” All we had to do was to “renew” drop came in the past two years, suggesting— people safely. When I first started work in the values of the NHS in the nature of the contrary to what Luke Johnson said—the oncology, the cut-off age for a bone marrow modern world.

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He alluded to the fact that the motion’s pro- ageing population and not a passive ageing destroying the American economy. There posers had called for choice and competition. population.” are more strikes in the US about healthcare That’s exactly what the Labour government He rejected the claim that technology was systems than about wages, because that’s the had set about doing, with foundation trusts, going to bankrupt the NHS. “Every other issue that people care about all the time.” payment by results, and polyclinics. “The industry does well because of new technology, He said that the US famously paid 16-17% BMA is saying if you open a polyclinic next and health services go bankrupt because of it. of its gross domestic product (GDP) on health to an existing general And that’s because in care. “Well, that’s private money. That’s fine. practice, the public hospitals across the Actually, no. Fifty per cent of that money is will choose to go to world there hasn’t taxation—is state money—going on Medicaid the polyclinic. Yes, been a competi- and Medicare.” So the US spends the same it’s probably right. tive organisation to proportion of GDP as the UK does on state And that is because drive those hospitals healthcare.” we thought, 60 years into modernity. I Summing up Mr Johnson criticised the in, we might want to think with founda- “evangelical” and “almost religious” tone renew the NHS by tion trusts, with pay- adopted by Ms Toynbee and Mr Corrigan applying the principle ment by results, with when defending the NHS. “It shows how of choice.” competition we’re irrational and how sentimental and how Professor Sikora starting to get this. ­unrealistic these arguments are. had complained that How the vote went. The first bar in each is before And that’s how we’re “The simple and profound point is not the NHS wasted the debate and the second is after going to squeeze that we can’t afford it this year but that in the money because indi- enough value out of medium and long term the NHS is unsustain- vidual hospitals, unlike private industry, taxation to make this happen.” able. The grandeur with which the current had no incentive to get value for money. But He quoted his old boss, former health government has been spending on the NHS Mr Corrigan vehemently denied this was secretary John Reid, who said the NHS was is all very well, but the bills will come home any longer the case since the government “the best gift the British people have ever and they will have to be paid. rewarded high performing hospital trusts by given to themselves” “The danger is that healthcare demands giving them foundation status, which con- of our population and the expectations they ferred preferential treatment. US dream have of the NHS are on a massive collision “If you go to University College Hospi- The US healthcare system was particularly course.” tal [London] now, they know the price of derided by those opposing the motion. Ms In the end, the audience disagreed and the things. They know how to drive down the Toynbee said that Mr Johnson and Professor motion was lost, with 65% of the audience cost. They’ve increased business by 14% in Sikora had failed to say what would make the opposing the motion and 33% supporting it. the last year. And you go to Guy’s and St health service cheaper to provide. There was, however, a 9.3% swing in favour Thomas’, you go to Homerton, and you see “I’ve seen quite a bit of US healthcare; it is of the motion. institutions that are themselves now becom- a vastly wasteful system. It is hugely extrava- Rebecca Coombes journalist, London ing leading institutions in European and gant and fantastically expensive. There is [email protected] world health care. That’s because we’ve got enormous overtreatment, fantastic numbers Competing interests: None declared. some competition.” of diagnostic tests nobody needs, and virtually Cite this as: BMJ 2008;337:a628 Mr Corrigan played down the problems nothing for huge numbers of other people.” of an ageing population. “The ageing pop- Mr Corrigan threw in the fact that US car VIDEO LINK ulation is me. And I’m not going to bring giant Chrysler now pays more a year for Watch a video of the debate at down the NHS because I’ve decided not to health care of its employees than it does for bmj.com/nhs60 die. We have the opportunity to be an active steel. “The American healthcare system is

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