Like most healthcare systems in the developed world, the British National Health Service is under constant scrutiny. However, such scrutiny is just the beginning of a much larger debate likely to exercise the whole developed world in the near future; are current health services sustainable?
Irrespective of whether funding and services are provided by the State or private sectors, a number of challenges are coalescing in such a way as to resemble a ‘perfect storm’, and all will need to be addressed if we are to avoid such a cataclysm.
These challenges have to be seen in the context of the countries involved: populations are reasonably stable, average incomes are well above subsistence levels, and population health (in terms of basic needs such as housing and nutrition) is good. Deaths from infectious diseases are low and life expectancy is high, but the negative impacts of affluence (such as obesity and diabetes) are growing. In such countries, several truisms can be highlighted:
The population demography is changing: as life expectancy in the developed world rises and birth rates slow, the demography alters, putting the emphasis of health services onto older people, who have the greatest demands; the increasing prevalence of long term conditions, co-morbidities, and rising hospital admissions all put increasing strains on health services.
Moreover, most health systems (both state and privately run) depend on the insurance principle: the ratio between those paying ‘premiums’ and those make ‘claims’, and that ratio is changing for the worse as older people pay less and claim more.
Medical technology is accelerating: medical science has become steadily more capable over the years, with a growing ability to treat ever more conditions. Some are life threatening and affect millions of people (the improvements in cancer diagnosis and treatment come to mind), some are extremely serious but affect very small numbers of people (the ‘orphan conditions’ such as Gaucher’s and Tay-Sachs Diseases), and some (the so-called ‘life style conditions’ such as baldness and erectile dysfunction) are changing our attitudes to health care so that ‘dis-ease’ of any nature is increasingly being seen as ‘disease’.
In addition, there are other influences for change that may be less direct, but are often as powerful.
Rising expectations reflect the increasing medicalisation of health problems, fuelled politically and commercially; politicians generally win elections by promising more services rather than fewer, and commercial companies survive by marketing their services to generate business. Expectations have risen in terms of what services may be available, as well as where and when they may be delivered (the so-called ‘choice agenda’). Results are expected to be virtually guaranteed, and there is a growing emphasis on improving the healthcare experience as well as its outcome.
Comparisons are drawn between the delivery of health services and commercial ones such as banks or restaurants, even though these latter are self funded (with built in brakes once they become unaffordable), whereas health services are usually funded by third parties (at least in part), making the disincentives to demand much less visible or effective.
The way in which rising expectations have been driving demand exactly mimics the developed world’s wider consumerist philosophies: economies depend on growth which requires increasing demand, driven in turn by the public’s hunger for more goods and services, delivered more quickly, more cheaply, and with greater choice. Thus, just as next year’s smartphone has to be better than this year’s, so next year’s antidepressants have to be more effective, with fewer side effects, than those available now.
However, since health care is enormously emotive, and usually largely funded by third parties, the ‘can I afford it?’ question is rarely asked, either by individuals (for whom health is beyond financial measure) or by funders, for whom the penalties of reducing expectations and disappointing their clients (electoral defeat for politicians, and lost business for insurers) outweigh most possible future problems. As a result, efforts to manage expectations downwards have been few, and have generally failed to make much progress; experiments in prioritization, such as those in Oregon, have had little impact, so the only serious control mechanism to have been generally invoked is that of increasing efficiency: getting more bangs per buck.
The reality is that, whilst there is always room to improve efficiency in large systems, the pressures are such that society will have to challenge what services are provided as well as improving how they are provided. Genuine rising need, growing expectations, and medical technology’s ability to provide more, are creating a Tsunami of rising costs; once increasing risk aversion and reduced investment are factored in, then the notion of the perfect storm begins to make sense, a disaster that can be foretold but not avoided.
So are there ways of avoiding the storm? There are, but they assume that the human propensity for short term fixes can be overcome, which may be an assumption too far. Firstly, reducing public expectations would help; understanding that healthcare resources are limited, and that some things are more important to treat than others, would be an excellent start.
How one does that is harder to prescribe; raising awareness of the real cost of services may help, even if these were not actually charged. The UK ‘GP budget holding’ experiment in the 1990s was partly intended to increase cost awareness, and the current development of Clinical Commissioning Groups is an extension of this, but the funding mechanisms mean that the there is little alignment between effort and reward.
Actual charging, on a co-payment basis, is used in countries such as France and New Zealand to demonstrate the link between usage and costs, but this would currently probably not be acceptable in the UK. Creating ‘tiers’ of services has been partially implemented countries such as Canada, where everyone is guaranteed basic services, but more ‘luxurious’ products have to paid for separately; thus for example, basic cataract surgery is free, but the fancier lens implants are not.
Service rationalisation, as mooted by David Nicholson, is inevitable if hospital economies of scale are to be realized, and the risks of low volume services are to be mitigated, but this is an efficiency gain, and not the paradigm shift that is actually required. To achieve that, the obvious variables that could be adjusted are the availability of services, or their price; changing the third variable, demand, would require our societies to bring back a more collective ‘communitarian’ response to public need, which would imply a radical adjustment of the balance between ‘me’ and ‘society,’ a utopian aspiration, but unlikely to come in our lifetimes.
This is an expanded version of a piece published in The Conversation on 20 August 2013 at http://tinyurl.com/n62gloc