Saturday, July 24, 2010

Another Reorganization for the NHS

Another government, another round of reorganization and change in the English National Health Service (NHS). When teaching my class in comparative health systems at Duke, one of the things that we highlight about the NHS is the near constant tinkering with the NHS. This tinkering takes place within the context of the overriding big idea of the NHS since its founding in 1948 (care is free at the point of service, with resources distributed based on need). The NHS is primarily tax financed, and they spend about $1 dollar per capita each time we in the US spend $2.50, with societal level outcomes that are certainly more similar than different. One of the primary ways they hold down costs is making access to the primary care part of the system easy, but access to the secondary care (and expensive) portion more difficult. One of the primary tools used to ration services is the use of waiting lists for care.

The most notable thing about the NHS and waiting lists is not that they have them, many nations do, but that they are so explicit and honest about them. For example, one of my children waited 5 months for a diagnostic procedure last year at Duke. I asked the doc about this and he said that the demand for the procedure just outpaced Duke's ability to supply it since it was not an emergency.....that is exactly what a waiting list is. One year in my comparative health systems class I had students research waiting list times in England and at selected hospitals in the US. Waiting lists are much longer in the NHS, but it was often hard to tell. Several students reported encounters like this. How long is the wait to get an X? We don't have waiting lists here. When can I get X? 9 weeks....

One interesting aspect of the NHS for many students is the presence of a private insurance system, in which around 10-15% of the population 'go private' and avoid long waits if they need secondary care that is not of emergency nature. This seems to not only be tolerated, but based on my time as a post-doc in England, it is almost viewed as a way to help out the NHS by getting some secondary care outside of the system. This seems to bother many US undergrads in that it seems unfair. I think it is mostly just a lot more explicit than various differences within the US vis-a-vis health care that are just more subtle. And in any event, the person who lives here gets to do so simply because she was they are in touch with the idea of different social strata.....

Against this backdrop, the new coalition government (Tory and Lib Democrats) has issued a white paper (Liberating the NHS) noting a planned change in policy. This is typical, and most new governments have grand plans for changing the NHS, again within the context of a tax financed system that in one sense is best described as the absence of insurance, and is instead a capitated system in which taxes are collected and distributed from the central government to different levels based on population weighted for certain factors linked to need.

Margaret Thatcher famously claimed to want to dismantle and privatize the NHS; when it was time to run for re-election, she had changed her tune to 'The NHS is safest with us'. John Major, her Tory successor, introduced General Practitioner (GP) fundholding, which introduced a 'purchaser/provider split' and was meant to introduce an internal market into the NHS, with GPs playing a larger role is purchasing hospital care on behalf of their patients. The Tony Blair government focused on modernization and actually explicitly sought to increase spending on a per capita basis, with a goal if increasing the relative spending levels in the NHS to closer to the median for European nations.

The new plan put for by David Cameron, Deputy PM Clegg and their coalition government makes clear the underlying big idea of the NHS is going nowhere. The first point of the document is thus:

*The Government upholds the values and principles of the NHS: of a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay. The second is,

*We will increase health spending in real terms in each year of this Parliament.

This is from the new Prime Minister of the conservative party in England. [As an aside, Margaret Thatcher, beloved of conservatives in the US, would be branded a socialist if she were running for Congress this year, but I digress]

There is lots of typical flourish (Our plan will put patients at the hear of the NHS....), with the actual policy proposals sounding a lot like GP fundholding to me, with a goal of moving control of money from more centralized authorities to groups of GPs who would purchase hospital care for the patients, presumably after and while being more in tune with their patients. The details are still not totally clear. However, it will be the umpteenth round of reorganization and policy change in the NHS. It will be interesting to see what changes are really made,and to what effect.

Here is one source of policy analysis on the White Paper and otherwise, The King's Fund.


  1. Dear Don - when teaching your Duke students, you may want to mention that the NHS was legislated into being in 1946 and began operating in 1948 (not 1947 as this article suggests).

    Also you say that "Margaret Thatcher famously claimed to want to dismantle and privatize the NHS". What are your sources for that which contain statements she made to that effect?

    Absent those references it might be more accurate to say "Margaret Thatcher was thought to want to dismantle and privatize the NHS..."

  2. It is a post, not an article! You are correct, the NHS was founded on 5 July, 1948. I apologize for the error. The point that I emphasize to the kids when I teach comparative health systems is that the NHS was given birth in the midst of post world war II destruction that the US homeland did not experience. This means that a 'big bang' reform generally, and certainly not along the principles of the NHS would never happen in the US. I will do a bit of digging, esp on how she ran her election in 1979...of course ending the NHS would always have been nothing more than a sound bite/fantasy.