CAN WALES SAVE THE NHS AS A PUBLIC SERVICE?

Julian Tudor Hart

Global Health Network Conference on global commercialization of health care, Institute of Child Health, London 24 November 2007

Yesterday I went to the funeral of a dear friend, my wife’s niece’s husband.  He died aged 34, from brain metastases from a malignant melanoma.  He leaves our niece with three children under 3 years of age.  He was an imaginative teacher, whose pupils will remember for the rest of their lives that he introduced them to a lifetime of learning.  His death was a crime by nature.  Like millions of others every day, he was randomly selected for murder.

Justice is an entirely human concept, requiring human action to impose it on the natural world, as much as on societies.  Health workers of all kinds are therefore agents of justice.  Most do recognise this role, and exert it so far as they can, limited by the level of civilisation in which they operate.  But many do not recognise it.  They trade profitably in the desperate hopes of sick people and their families in whatever market they can find.

In 1948, through the political energy, imagination and courage generated by a decade of bloody struggle against fascism, the British National Health Service took health care out of the marketplace,[1]  creating the embryo of an entirely new gift economy.[2]  Attempts to produce healthier births, healthier lives and healthier deaths, the most wanted and potentially most profitable of all commodities, were made available to every citizen and every visitor according to their need, whether or not they had money in their pockets.  It was paid for by taxes, which in those days bore more heavily on the rich than the poor – so in effect, the NHS transferred wealth from the rich to the rest of society, which they were then transiently too weak to resist.

It also threatened medical trade, then almost entirely in the hands of doctors themselves.  If state-of-the-art care was available free from the NHS, who would still be willing to buy?  By 1975, when all UK political parties still supported the NHS as a profit-free public service, private medical practice had dwindled to 9% of total UK spending on health care.  Public service formed 91% of our health care economy, a level exceeded only by Norway and Denmark.[3]

Initial resistance from medical traders soon crumbled, as most doctors came to recognise that medical fees, far from assisting care as they had imagined, actually obstructed access and distorted clinical judgement.  Medical care, as opposed to medication, was still too much a cottage industry to attract serious corporate investors.

Dr Richard Smith, who will follow me as a speaker to this conference, was a crusading editor of the British Medical Journal until 2004.[4]  One of his crusades was his insistence that contributors to scientific journals should openly declare any commercial interests that might influence their judgement.  Judgements certainly are influenced by such interests, more profoundly than even he may imagine. 

Our classification of disease, and therefore our entire medical philosophy, still rests on traditions of medical trade, which require that all health problems, and measures to solve them, be discrete and clearly defined, simply in order to make trading possible.  Medical philosophy therefore still differed profoundly from biological philosophy, even after 90% of medical activity had moved from hopeful guesswork into potentially rational application of scientific knowledge.

To show what I mean, consider the case of high blood pressure, the single most frequent reason for contact between patients and professional carers in developed economies.  As human biologists, we have known since 1954 that arterial pressure is continuously distributed – there is no clear division between normal and high blood pressure, any more than there is a clear division between short and tall people, or thin and fat people.  Of course, short and tall people, thin and fat people, and people with unusually high or low arterial pressures do all exist, but though all these are measurable quantities, none provide naturally quantified definitions.  At best, the rational border between normal and abnormal depends on available treatment, and the shifting balance between probable gains and losses we may anticipate from research experience.

This is a situation very familiar to any thoughtful health worker in primary care, where about 90% of our work concerns diverging possibilities we deal with ourselves, rather than the average 10% or so of converging probabilities we refer to specialists.[5]  Increasingly, workers in primary care need to develop a medical philosophy based on biological and sociological evidence, which no longer compels us to impose categories derived from end-stage disease familiar and useful to hospital-based specialists, on the still ambiguous problems we usually see in the community. 

This will make huge demands on professional judgement, and will require from us enough rethinking to keep us fully occupied for several generations to come.  It is a paradigm shift which will be very difficult to achieve, even though the rewards in more effective and efficient care will be enormous.  The old paradigm, qualitative disease labelling without regard to quantity, is even more precious for corporate medical business than it is for GPs in transition from a small way of business into local human biologists.  Business needs tradeable packages, discrete diagnostic labels provide them.  Business will therefore impede rather than accelerate real progress in health care.

Effective and efficient care depends upon trust.  Caveat emptor - let the buyer beware: and beware most of all, when the buyer is a frightened patient, or a clinically and politically inexperienced commissioning agency.

Effective health care has never, ever, anywhere been delivered solely through medical trade.  Even in USA, 43% of care in 1975 still had to be funded by government, but there, state-funded public service was the devil incarnate and commercial enterprise already sat on the right hand of God.  So if individual or corporate commercial providers couldn’t make a profit from care, the state had to subsidise their business.  As a public service, NHS England is now being degraded to a similar state.

We can’t say we weren’t warned.  The clearest warning came from Dr Richard Smith, our next speaker, writing an editorial in his own journal.  I quote:

"what happens in a country is increasingly driven by what is important for business... The businessmen who run the for-profit managed health care plans in the United States see no reason why they should not follow the path of their colleagues in other businesses and compete globally.  Indeed, they may have to.  Wall Street expects them to keep growing, which means signing up more people to their plans.  And, as one chief executive of a health plan put it, 'We are soon going to run out of people in the United States.'”

Well, perhaps not exactly “run out of people”, because even in 1996, about 43 million Americans had no health insurance, now risen to about 47 million.  What they really meant was “run out of profitable people”, the only sort business can easily recognise.

Richard Smith went on to say that these US businessmen saw their biggest new opportunities for profitable investment overseas precisely because foreign governments were still sufficiently concerned with their poorer populations to fund their care.  If this funding could be piped through the pockets of corporate for-profit providers, possibilities for government/corporate partnerships might open up on a grand scale.  Poor people could thus be made profitable, and therefore be recognisable by the care system.  Then, to quote again:

“...perhaps managed health care - which has emerged from a country with one of the world's most irrational health care systems - will end up being exported around the world.  Just as more and more of us are fed by American fast food chains, so many of us may receive our health care in some way through American managed health care plans."[6]

Like fast food chains.  Yes indeed.  In for a quick food fix, out again to lives devoted to maximum consumption, without which capitalism can’t grow, and without growth it can’t survive, even if this means consuming the planet.  You can’t get more antibiological than that.

But does all this really matter?  Perhaps, as the late, great Geoffrey Rose said, the contribution of personal health care to public health generally is vanishingly small compared with collective public health measures?[7]  Or perhaps the net consequences of all medical activity actually detract from human life rather than adding to it, as claimed by Ivan Illich, Richard Smith’s favourite author?[8]  So perhaps you, whom I have described as agents of justice, are in fact inadvertent agents of injustice?

I don’t think so.  The evidence considered by Geoff Rose couldn’t include recent evidence that personal care can and does have a significant and growing impact on both health and survival, so much so that marketed care now actually widens the gap between mortality of the rich and poor,[9] [10] [11] unless we can achieve full equity in services, when this gap might indeed disappear.[12] 

He also ignored the enormously important potential effect of the NHS as our first example of a gift economy in a nationalised industry, which worked more cost-effectively than any market until it was invaded by business.  My chief witness for that conclusion, a consensus at the time, is Alain Einthoven, the US health economist who led the neoliberal assault on European public health care services in the last two decades of the 20^th century.  In 1989 he asked:

“What can Europeans learn from Americans about the financing and organisation of medical care?  The obvious answer is ‘not much’.”

As Einthoven went on to admit, Americans were then spending 12% of their Gross National Product on healthcare for only 82.5% of their people under 65, with infant mortality worse and life expectations no better than in Western European countries, all of which provided care for all citizens, either free or at low cost.  Since then, the proportion of US citizens without insurance has actually risen, health care consumes 16% of GNP, and per capita spending on health care is now more than double the median value for all other developed economies in the OECD countries.[13]  US health care leads the world in just two important respects; it contains most of the leading edge of research and development, and chief executives of US corporations now earn 245 times more money than their employees.[14] 

Europe had a lot to teach, and Geoff Rose was among the best teachers.  The answer to Geoff’s criticism was not to drop personal care in favour of exclusive investment in public health measures, but to integrate both so that personal care could be led by public health objectives rather than either the narrow imaginations of entrepreneur doctors, nor the demands of corporate shareholders.

I’ve a lot less time for Illich, who is important only because of his appeal to liberals needing to justify wringing their hands about the world instead of acting in solidarity to change it.  I know from my own experience that doctors generally are not enemies to health, and that if they use the knowledge we already have rationally, they can have a huge positive impact. 

In 1991 my research team published the results of 25 years of planned primary care in a former coal-mining community, using unobstructed patient demand as our opportunity to search systematically for needs.[15]  Our aim was to rationalise interventions at an early stage in departures from health, starting with community control of high blood pressure and smoking, moving on to systematic interventions for many common chronic disorders.  Compared with an adjacent, socially indistinguishable community receiving high quality but unplanned, demand-led care, premature mortality (under 65) over the last 5 years of the 20-year period was 28% less with planned anticipatory care. Ranked by Townsend Index of social deprivation, both communities were among the worst 10% of 55 electoral wards in West Glamorgan County.  Ranked by age-standardised mortality, the community receiving planned anticipatory care was 3^rd from the top, while the community receiving only good demand-led care was 32^nd.

Personal care can work, as long as it is applied rationally, systematically and with foresight to all of the people, all of the time, in communities whose doctors share the common culture and experience, and know how to integrate wants with needs at a pace tolerable to both staff and patients – above all, with respect for continuity.

Thirteen years later, Richard Smith left the BMJ to become Chief Executive of European section of UnitedHealth, the largest corporate provider of primary care in USA.  Blame the system, not the man.  His move was unexpected to many.  The title of his paper today provides an explanation: “public plus private trumps either alone”.

Well, he may have convinced himself, but he needs to recognise that conflicts of interest apply as much to him as to everyone else.  For care of whole populations, private business can’t prosper without state funding.  To care for all the really sick people, and to help everyone so far as possible to stay healthy, private needs public to stay in profitable business.  It’s a parasite, which, however bloated, can’t survive without a tax-funded host.

In states designed and maintained to support business, unless public service for needs keeps its distance from business for profits, business ethics will always displace the ethics of public service.  “Business ethics” – what an oxymoron!  As absurd as “Military intelligence”!  In the BMJ two weeks ago, Nigel Hawkes, health editor of The Times, wrote an article headlined as follows:

“The NHS stifles the entrepreneur in us all: managers in the NHS do not innovate because there is nothing in it for them.”[16]

The corrupted civil service he now takes for granted would have been unimaginable before Margaret Thatcher began to run history backwards.  The irresistible forward movement of science and technology is concealing our slide backwards even from such doubtful social justice as we had already achieved.  While things still move forward faster and faster, people, and the relations between people, move backwards with equal speed, away from solidarity, back to the war of every man against every man.

Within us all is an innovator, a thirst for discovery, ambition for real achievement in making the world a little better when we leave it, than when we arrived.  That thirst for innovation, discovery and effective participation in progress toward justice, comes under assault as soon as we enter the world of adults, hammering us into shape as combatants in a perpetual war in which winners are always fewer than losers.  To realise our natural capacities as innovators, we are forced either to become entrepreneurs, or marginalised revolutionaries.

The Times, Richard Smith MkII, and all these true believers in capitalism are wrong.  They fail even in their own terms.  NHS administrative and transaction costs were between 2 and 6% until so-called reforms started in 1990.  Since then they have more than doubled, well on the way to the 25% to 30% or more now prevailing in USA.[17] [18]

Health care can most usefully be analysed and understood as production, with measurable inputs, outputs and efficiency.[19] [20]  Without that understanding, health economics is no better than religion, resting not on evidence but faith, beyond criticism but also beyond verification.  But it doesn’t follow that it can only be commodity production.  Health professionals who love their work, and value their roles as agents of justice, don’t produce health care so as to sell it for profit, either for themselves as independent entrepreneurs, or as servants to corporate employers.  Of course, those who choose to produce care as a commodity, in entrepreneur boutiques or corporate factories, can easily do so.  As matters now stand, they may be well rewarded, but they will not thereby work more effectively or efficiently.

The results we got in Glyncorrwg were founded not only on a planned approach to rational, evidence-based production, they also required levels of mutual trust and shared, continually updated and carefully and critically recorded information, which in turn depended on sustained continuity of care and shared community experience.  It was a life work, and had to be, there’s no other way it could have been done.  But what has been the main consequence of forcing the NHS back into the market place?  Discontinuity, insecurity, disruption, competition, league tables, commercial secrecy, hidden rewards so huge that insider dealing has become customary and corruption is inevitable, and intimidation of staff now too scared to declare publicly what they think. 

In UnitedHealth USA, one chief executive has already had to resign because of massive fraud against the state,[21] just one of many others in US “public plus private” business culture.  Americans are used to this, so they have much tighter regulation than we do.  We shall soon see our first cases of the same sort of fraud.  Above all, we have seen destruction of continuing relationships, particularly in primary care.

Wales is different.  Wales has been the birthplace of collectively organised and collectively funded personal health care, first from coal and slate miners’, steel and tinplate workers’ medical aid societies, then from Lloyd George’s National Insurance, finally from Aneurin Bevan’s NHS.  Many of our most important communities have been left derelict by collapse of heavy industry, but throughout Wales we have more community left than anything visible in south-east England, its ideological heartland.  We have a Welsh Assembly with devolved powers over education and health, which we have used to defend our comprehensive schools, and are now using to renationalise the NHS.  We have Edwina Hart, an Assembly Health Minister who knows where she’s going, can take effective decisions, and could flatten any media interviewer.  Behind her we have the most loyal and imaginative Chief Medical Officer in the NHS, Tony Jewell.  We have already abolished prescription charges, we have brought our hospital cleaners and cooks back into the NHS, we shall have no more Private Finance Initiative contracts, secret for 30 years while they bleed our children and grandchildren dry to pay for services we may soon neither need nor want, and we are on the way to ending the purchaser-provider split on which the whole neoliberal strategy depends.  I’m sorry no UK national newspaper tells you any of this, but it’s happening, and it’s what a huge majority of people want and are beginning to understand.

So watch this space.

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