Q: What is the difference between God and a surgeon?
A: God doesn’t think he is a surgeon.
CONSULTANTS ARE an arrogant and stroppy lot, independent-minded, stubborn and clever. The biggest problem that successive governments have faced in reforming the health service has been the attitudes of its senior medical staff. At the NHS’s very inception, Nye Bevan told how he had to “stuff their mouths with gold” to persuade them to go along with it. All the cards were left in their hands, so that if you are a consultant, especially in the larger hospitals, you can act like something approaching God: you don’t see patients, you graciously receive them.
This Godlike status was conferred not by the particular brilliance of our medical experts but by the pressure on the service they supposedly served. The shortfall that there always was in NHS funding and the lack of serious competition — together with a shortage of specialists, partially manufactured by the royal colleges, that limited training places so everyone always had jobs — ensured that consultants could pretty much do as they pleased.
Labour changed that, by introducing a contract that for the first time gave hospital managers some control over the output of consultants, who only agreed it in return for a large pay increase — which is where many of the NHS billions have gone. The Government also opened privately run treatment centres, staffed where necessary by foreign doctors, to break the NHS consultants’ monopoly.
How the consultants squealed (and still do, claiming sub-standard treatment from foreign doctors; some nerve, given the profession’s refusal to reveal its own individual success rates). But they have lost that fight; patients vote with their feet for quicker treatment at the fast-track centres, no matter who is running them, rather than “better” treatment at the hands of Sir Gerry Fatfingers who can squeeze them in in eight months’ time.
All of which is a very long-winded way of introducing the point that I wouldn’t trust a consultant’s opinion on how to reform the health service. So, what are we to make of some 800 of them, Doctors for Reform, calling for a more “flexible” healthcare system? Where were these radical reformers when the Government was fighting to set up new treatment centres, to offer patients the flexibility and choice that the NHS couldn’t provide? The only choice doctors tend to be keen on is their choice of how and when to treat patients.
But I am putting off having to admit, painfully, that actually Doctors for Reform has a point. The NHS, as elegantly argued by Professor Karol Sikora, a leading Doctor for Reform, on this page yesterday, is going to face a widening gap between supply and demand and will have to choose which services to provide and which to leave to the open market, ie, for the rich.
Look at the pressures that will be wrought by an ageing population: in 1950, with the NHS barely a year old, there were more than five people of working age for every pensioner. By 2050 there will be just two. Then look at the potential (and cost) of new genetic technology. If a genetic test, for instance, could show that I have a 4 per cent higher than average chance of developing Columnist Repetitive Argument Pharyngitis, and should therefore, for my health, avoid opinionating in newspapers regularly, ought I to be allowed to have the tests to discover that on the NHS?
Say that a test, for which you may have to pay yourself, shows that you have a 15 per cent chance of developing a particular cancer, where the norm would be 3 per cent — should the NHS give you preventive treatment that would reduce your probability of contracting the disease to the 3 per cent average? Even if it costs tens of thousands of pounds?
When David Cameron declared in January that the Conservative Party now believes in a taxpayer-funded NHS free at the point of need, he embraced the cost of new genetic treatments as well as new cancer drugs. “The NHS can no longer ration these treatments as it used to,” he declared. Really? Who is going to pay for them? With both main parties playing politics for idiots — you ask, we give — there is no check on consumer demand for the NHS. And consumer demand is limitless: it started with basic healthcare, grew to embrace mental health and fertility and now slimness, and would, given half a chance, stretch to beauty and energy as well. Permanent blondeness? Why not? Look at the expensive things people are prepared to pay for privately with only a slim chance that they might make a difference to their health — from reflexology to cutting-edge cancer drugs — and then ask yourself whether you want to fund all this on the NHS.
So, yes, Professor Sikora is right: the days of an exclusively tax-funded health service are numbered. But then they always were. What the NHS provides was limited from Day 1, and demand has always outstripped expectations. In its first year of operation, 1949, Bevan estimated that the NHS would cost £176 million; it actually cost £437 million. A year after its launch, a shilling prescription charge was introduced, both to raise money and to reduce the “cascades of medicine pouring down British throats”, in Bevan’s words. Two years later, dental and optical charges had to be introduced. The rich always have and always will be able to buy a more expensive range of healthcare.
What Doctors for Reform seem to be demanding (it isn’t entirely clear) is a completely different European-style funding system for the NHS, and it isn’t necessary. What we do need is greater realism from politicians about the limits of the system, less encouragement from populist ministers to act like children demanding more sweets from the sweetie shop, and a serious attempt instead to decide where the lines should be drawn in future.
Doctor, doctor, I think I'm suffering from déjà vu!
Didn’t I see you yesterday?
