Impact of NHS policy on the health of people in Wales

Julian Tudor Hart

External professor, Welsh Institute for Health & Social Care, University of Glamorgan, Pontypridd

Paper presented to Conference “Fitting the pieces together”, University of Wales College of Medicine, Cardiff May 4, 2000.

What impact does the NHS have on health?  Medical care is an insatiable consumer of resources, but hard evidence of health outputs proportionate to work input is less obvious. John Bunker’s work has stood essentially unchallenged since it was published six years ago.[1]  Reviewing evidence from USA and UK, he showed that between 1950 and 1994, both countries added about 7 years to average expected life.  Of these 7 added years, roughly three were probably attributable to medical care.  The other four he attributed to other social changes.  He also concluded that, if care had been universally available to a high standard, we could have gained another two and a half years. 

Of the total potential gain of nearly 10 years, more than half could have come from good medical care had it been fully available.  Of this still unrealised potential, most probably lies in better control of chronic disorders such as diabetes, high blood pressure, chronic lung disease and so on – tasks for continuing anticipatory care in the community.

Historically, struggle to improve the quality and availability of medical care for all of the people has gone hand in hand with struggle to raise wages, improve housing, and get education for life rather than servitude; in other words, the main course of modern Welsh history.  Resistance to these reforms, finding limitless reasons why they’re impractical, unnecessary, or bound to have results opposite to those intended, has gone hand in hand with support for two-tier health care, with quality care bought as a market commodity.  In USA, such resistance has resulted in about 15% of the population having access only to emergency care, side by side with gross overprovision for relatively trivial problems for the rich.

Jane Hutt, our Assembly Secretary for Health & Social Service, has set out a programme for advance in Communities First.[2]  This recognises the uphill task we face in starting at last to address causes of ill health, as well as their consequences.  Hitherto isolated professionals must now learn how to form effective working alliances with colleagues, patients and local populations.  Anticipatory health care and action for public health are not alternatives, but convergent pathways to the same objective, measured health gain.

The NHS in Wales now has 15 health gain targets, set out in the Assembly’s Better Health Better Wales.[3]   We already have the six most essential tools for reaching these targets and verifying what we have done:

1.      We’ve a robust popular belief that economic decisions can use human judgements of what’s most socially useful, rather than market judgements of what’s privately most profitable.  We work towards a society based on co-operation, not competition between winners and losers.  Our NHS provides daily proof that work can be planned and done more efficiently when motivated by human needs, than when motivated by profit.

2.      Our NHS includes our whole population.

3.      Our NHS is rationally divided between a foundation in primary care, staffed by teams led by generalists, and a superstructure of referred secondary care staffed by specialists.

4.      Our local populations are registered with their personal NHS professionals, so that primary care teams know the names, addresses and phone numbers of all the people for whom they are responsible.

5.      Our NHS patients have continuing care.  This generates cumulative continuing personal medical records, recording events throughout their lives, so that clinical decisions at any level can be taken and understood rationally, in context of whole life stories.

6.      Our NHS patients could relatively easily be developed as co-producers of health gain for everyone (including themselves) rather than consumers of care as a private asset.

All these six principles are essential to future progress of the NHS as an affordable, cost-effective and evidence-based service.  Simply to mean well is not enough; we have to do well.[4]  So-called “experts”, their brains washed and pockets filled by two decades of Thatchery, denounce these principles as dogma, derived from naïve faith rather than hard experience.  This is not so. 

For me, the value of these principles, above all the first and the last, has been confirmed by experience of actually delivering care under initially atrocious conditions, to a population bearing exceptional burdens, and after 25 years, raising objective health indices to match those in areas of least need.[5]  Using these principles, our team reversed the Inverse Care Law.[6]  Others can do the same. Those of my medical and nursing colleagues who worked hardest, most self-critically, most effectively, and with greatest willingness to learn from each other and from their patients, were committed to the culture of co-operative public service, not the culture of competitive business.  Their attitudes to the populations they served were inclusive, not exclusive.  They recognised both their own limitations as community generalists, and the limitations of hospital specialists, seeking new working relationships of co-operation rather than hierarchy.[7]  They recognised continuity as the only way to cope responsibly with clinical decisions made within constraints of time and staffing suffered by all doctors and nurses at the deep end.  The only way you can achieve or maintain elementary decency at the deep end of medical care, of school teaching, or of social work, is to know the patients, know the pupils and parents, and know the clients, so each contact can build on the last.

The sixth principle, that patients (and pupils, parents, and clients) can and must become transformed from passive consumers of medical or nursing care (and of education, and of social assistance) into active co-producers of health (and of education, and of civil society), is least understood today, but in future it will provide our main foundation for progress.  It’s the key to democratisation of the service, and to closing the huge moral gap in the NHS which made it vulnerable to Thatcher’s attack in 1989.  Patients preferred being valued as consumers in a market, to not being valued at all.  From 1948 to 1989, the NHS was at best paternalist.  At worst, it approached the attitudes of the Poor Law.  If the future society we want is of socially responsible citizens in a participative democracy, where better to start than with staff and users in the NHS?

The distinguished team led by Glyn Jones Elwyn at the Department of General Practice at the University of Wales, Cardiff, has led the rest of the UK in developing what they call narrative medicine.  This implies that patients’ life stories provide the safest, most efficient and effective foundation for reaching optimal clinical decisions.  Their research started in 1979 with Nigel Stott’s and Robert Harvard Davies’ classic paper on “The exceptional potential in each primary care consultation”.[8]  The Department’s recent review concluded that: “future developments in this area depend on increasing the time available within consultations, require improved ways of communicating risk to patients, and an acquisition of new communication skills”.[9]

My only criticism of this cumulative analysis is that so much remains implicit promise, rather than explicit commitment.  The review cites David Tuckett’s book Meetings Between Experts, published in 1985.[10] His research compared actual consulting behaviour of GPs with and without intensive training in patient-centred medicine through Balint groups.  GPs with Balint training had volunteered for this demanding and unrewarded additional work, totally committed to a patient-centred view of clinical decisions.  The control group was randomly sampled from their more ordinary local colleagues.  Comparing what GPs actually did rather than what they said, Tuckett found no significant difference between GPs with and without Balint training and attitudes.  Both groups virtually ignored patients’ own ideas about their problems. 

I think the Cardiff group still underestimates the capacity of most power-holders to change what they say, without changing what they do.  The rhetoric of change may be accepted, if this seems the best way to keep power in the same hands. Development of doctors and nurses as co-producers rather than providers, and development of patients and local populations as co-producers rather than consumers, entails redistribution of power and property.   Almost all doctors, most nurses, and many patients still believe that knowledge and skills brought by health professionals to clinical decisions are not just different from the knowledge and skills of patients and local populations, but immeasurably superior and more important.   We have plenty of evidence to show this is not so.  To apply new medical knowledge effectively, the knowledge and skills required from patients go beyond the limits of our traditional provider-consumer paradigm.[11] [12] [13] Given a new paradigm recognising more complex human values, redistribution of power, property and responsibility could enrich all main stakeholders, but such understanding cannot and will not be reached without struggle, without challenging the old provider-consumer paradigm, born of traditions of medical trade which have been obsolete in the UK since 1948.

The Cardiff group has always tried to avoid confrontation, with either Welsh professionals, or the then unelected Welsh Office.  I understand there’s more than one way to skin a cat, but sooner or later, our old enemies of professional arrogance, complacency, and hierarchy have to be engaged and defeated.  To mobilise the large professional as well as public majority potentially available for this task, we need to admit to ourselves that we are engaged in struggle, and that progress never has and never will come altogether without pain or risk.

The Going for Gold [14] strategy posed these issues in just such challenging terms.  Supported by the Assembly Secretary, it variously encouraged, provoked or compelled valley GPs of widely different views to devise some alternative, more acceptable to GPs wanting to maintain their personal ownership and control of primary care.  This challenge has now been met, and splendidly met, by Dr Chris Jones of Pontypridd, with imaginative but realistic proposals for rapid redevelopment and reorientation of primary care for the 54 000 people of Cynon valley.[15]  The Cynon Valley Primary Care Development Project is supported unanimously by all 31 local GPs, by the Bro Taf Local Health Group and Health Authority, and by the Assembly Health & Social Secretary. 

The Cynon Valley Primary Care Development Project includes virtually all initial features of Going for Gold except one, namely transfer of ownership from the hands of GPs to the hands of the public. This ultimately vital difference is of little immediate importance.  What hands does the public possess?  Except for the delegated power of elected government and even less directly accountable power of bureaucrats, none whatever.  We’ve hardly begun to develop the real instruments of participative democracy.  The Cynon valley project could provide exactly the means we need to develop the public hands we need, to help doctors to become the socialised staff our socialised NHS has hitherto too rarely possessed.   In practice (though ignored in theory), GPs throughout the UK are redefining what they mean by professional autonomy, their values moving away from freedom to own profitably, toward freedom to do effectively.[16]  The most demoralising feature of valley practice was not that the work was so hard, but that it’s health outputs were so obviously trivial.  Launched down the path of teamwork for continuing care, GPs will find for themselves the advantages of relating to the NHS in the same way as their nursing colleagues.  The important thing is not where we start from, but where we’re going.

In the same way, nurses and nursing will find new and much larger roles in primary care, adopting and adapting the healthy “can do” attitudes developed by the most innovative self-employed GPs, without their arrogance of ownership.  Medical and nursing traditions have always operated with entirely different clocks.  Doctors were compelled to take decisions in minutes, which nurses then had to apply in hours.  For a great deal of primary care, nursing clocks are more appropriate than medical clocks.  The Cynon valley plan leaves GPs in the driving seat, but for the first time, their public vehicle will have an agreed destination – to produce better health, safer births, happier lives, more timely deaths, and to reverse the Inverse Care Law (a listed objective on p.6 of the plan).  This destination will ultimately determine who drives and how.  The most important thing is to agree where we’re going, and to make a practical start.  I think we are now about to do just that.

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