A Neurosurgeon’s thoughts on the NHS
On Wednesday 17 January, Henry Marsh CBE FRCS came to The Perse to deliver the Lent 2018 Community Lecture.
When the NHS was created after the Second World War it was thought that it would save the government money, as universal free healthcare would make the nation so fit and healthy that it could go on working indefinitely. Now, stories of an NHS funding crisis pervade our screens and newspapers. Is it worth saving? Marsh’s immediate response to this question is ‘yes’, although he is acutely aware of the many challenges the system faces. He wryly observed that one of these is having a three letter acronym – ‘NHS’ is a useful catch-all term for the media to blame when one aspect of the healthcare system falls short. In reality, the NHS is a huge organisation. A single district hospital will carry out on average 845 different procedures, beyond which a significant amount of care and treatment is carried out in the community.
On the day of Marsh’s lecture there had been extensive press coverage of the number of nurses leaving the profession, while disillusionment amongst junior doctors is a widely reported problem in the NHS. Marsh is sympathetic to their cause, and believes that the support structure that existed for him in the early years of his career has largely fallen away. When he trained in the 1970s, the hospital was like a ‘firm’ run by senior doctors, and staff knew one another personally. While he worked very long hours, this was mitigated by a sense of belonging and mutual support. Moreover, today’s multiple pyramids of authority within the hospital structure mean that a lot of doctors’ time and energy is spent negotiating to be able to carry out treatments and operations. When a surgeon arrives at work in the morning, they may not be able to operate until the afternoon due to a lack of beds – a ‘bed’ in this context meaning not just the physical bed itself, but also three nurses and all the equipment and resources needed to care for the patient. Thirty years ago, the surgeon decided to operate and everything else had to fit in. While this system had its failings, it did make it much more straightforward for doctors to get on with treating patients.
Despite the negative headlines, the NHS actually comes out very well in international comparisons of healthcare systems. However, it shares a fundamental challenge with almost all healthcare systems across the world; health spending outstrips economic growth and the healthcare budget takes up a larger and larger proportion of government spending. Governments inevitably face a dilemma about where to draw the line on health spending, because it really is a bottomless pit – after all, it could spend every penny of its income on healthcare and the whole population would still die. The problems facing the NHS are not peculiar to the UK: an ageing population, and the resulting increase in instances of cancer; advances in medical technology creating expensive treatments, in particular for cancer; increased expectations amongst patients who demand access to expensive treatments and more frequent litigation, which costs the NHS £1bn per year, 40% of which is on legal fees.
The question of litigation in healthcare led Marsh to discuss the controversial recent case of Simon Bramhall, a surgeon who signed his initials on a liver he was transplanting. This did not cause any physical harm to the patient, and was only discovered when the transplanted liver was removed by another surgeon, after failing for completely separate reasons. While Marsh considers the surgeon’s actions ‘silly’ and does not defend them, he does believe that this sets a worrying precedent. A doctor could now face a criminal record for doing something that causes distress to a patient, but does not physically harm them. The narcissistic element of this case led Marsh to consider how doctors, as fallible human beings, have the confidence to carry out difficult procedures under challenging conditions, sometimes in the face of impossible patient expectations. While Bramhall clearly took self-belief and arrogance too far, doctors do need to be able to pretend that they have more experience and confidence than they really do if they are ever to take on a challenging new case. Their duty to the patient in front of them must be balanced with their duty to become a better doctor for their future patients. When combined with our society’s reluctance to admit that doctors sometimes make mistakes, this can require a little bravado. After all, no-one wants to hear their doctor say ‘I’ve never really done this before’.
How to provide universal free healthcare in spite of an ageing population, expensive procedures and increased expectations is inevitably a politically charged question. The Griffiths Report in 1983 proposed that management was the answer, and Margaret Thatcher envisaged this would make the NHS so good that no-one would want to go private. Subsequently, there have been attempts to use competition to improve the NHS, but Marsh is sceptical about the degree to which the principles of free market economics can be translated into healthcare. A ‘good’ market is more efficient, producing more of the desired output with minimal input. But how do you measure efficiency of output in healthcare? A danger is that this comes to mean simply doing things more cheaply, rather than providing better care. Another obstacle is how to combine a single payer system, where healthcare costs are covered by one public system, with market competition. Solutions to this dilemma have included payment by results and the purchaser provider split, through which Clinical Commissioning Groups can ‘shop around’ different hospitals for treatment, so hospitals are incentivised to get more patients through their doors to increase their funding. However, Marsh believes this is flawed, as there is no link between the work of clinical staff and making or saving money – it is the last thing they are thinking of when treating patients – and there is no realistic prospect of a hospital going bust in the same way as a business. Creating a market in healthcare also runs the risk of creating supplier induced demand. This would not necessarily be deliberate. Our judgement of probability is coloured by emotion, for surgeons as well as patients, and there is a danger that a stronger link between treatments and the practitioner’s income would lead to unnecessary procedures.
Marsh began his lecture stating his belief that the NHS is worth saving, and his reasons for this are largely social. He agrees with Nye Bevan’s belief that ‘no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.’ A great virtue of the NHS is that it is a source of equality in society, and losing it would only widen the gap between rich and poor. So, if it is worth saving, how do we pay for it? Possibilities include co-payments, where patients provide some contribution towards their care, increased income tax or, Marsh’s preferred option, a hypothecated health care tax on top of income tax. He believes that the problem is financial rather than cultural but governments shy away from tackling this, fearful of their electoral prospects if they raise taxes. Benjamin Franklin is famously quoted as saying that nothing in this world is certain except death and taxes. The stark reality for the NHS is that we cannot have less of the former without more of the latter.
The Perse holds termly Community Lectures, open to all in the community, whether or not they have a link to the School. Information about upcoming lectures can be found here.