Robert Baker: Do we really want patients to choose their healthcare?

There is a law of diminishing returns; piling in money will mean more of the same, only more costly
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The Independent Online

The really odd thing about the NHS is how, despite the pillorying it has had over recent months, it remains so popular. Rather like the royal family, it doesn't seem to matter how many scandals emerge – ultimately people just can't imagine ourselves without it. Defying Wanless to suggest funding our last experiment in socialism other than by direct taxation makes you about as popular as Tom Paulin in a synagogue. The public, in recent opinion polls, have welcomed the money. But they have also, perversely, said that they do not expect anything to change.

The really odd thing about the NHS is how, despite the pillorying it has had over recent months, it remains so popular. Rather like the royal family, it doesn't seem to matter how many scandals emerge – ultimately people just can't imagine ourselves without it. Defying Wanless to suggest funding our last experiment in socialism other than by direct taxation makes you about as popular as Tom Paulin in a synagogue. The public, in recent opinion polls, have welcomed the money. But they have also, perversely, said that they do not expect anything to change.

Viewed from the shop floor as doctors, do we agree? Is this £40bn really about to give the British the best insurance scheme in the world? Doctors love to profess cynicism about such matters. "Not another meddling bureaucratic reform; you can't expect change to occur after so many years of underfunding; the money's a good thing, but can't they leave us alone to get on with our work?" are the three most frequent responses among my colleagues.

The engine for change seems to be greater patient choice – an end to the top-down, government-led bureaucracy of old. Seventy-five per cent of the budget is to be placed in the hands of primary care providers. But it isn't the same as the Tory internal market – definitely not, that was an abject failure.

It is superficially hard to argue with the idea of increased patient choice, and demand being driven from the bottom up. It is edifying to observe how first-rate services arise due to politicised and articulate patient demand – HIV care, for example. Except that putting choice in the hands of patients may not always be the right thing to do.

There are some circumstances, of course, where it is ideal. Doctors, on average, wash their hands after only 14 per cent of examinations. The correct figure should be 100 per cent. The one intervention that has been shown to increase that figure is getting patients to boss them into doing it. So far so good, but how about patient choice for MMR vaccination? Are parents really the right people to make a scientific public health decision?

Besides, what choices are we really giving people by allowing them to pick their own hospital? It isn't even Pepsi versus Coke, more Ovaltine versus Horlicks. Supposing we were to give patients choices about what the NHS should be for. This issue has been examined in something called the Oregon health priorities experiment. Voters in Oregon were asked to prioritise state-funded health care. The results were surprising. The top five priorities were " preventive" care, long-term nursing for the elderly, and critical care for children.

Only 15 per cent voted in favour of state funding for expensive interventions such as organ transplants. In 1987, Oregon's state legislature decided to stop paying for such transplants, except for the kidney and cornea, for Medicaid clients. Would we obtain similar responses in this country? If so, whole flagship NHS transplant departments would have to close down or seek private funding.

Besides, what is the NHS really good at? Until now, its great strength has been in providing adequate health care cheaply. People who work in it – and even external observers – often say the Americans spend about twice as much of their GDP on health care as we do, yet theirs is certainly not twice as good. At least we just about manage to provide cover for everyone, no matter how poor, even if rather sluggishly. There is inevitably a law of diminishing returns in health care, and piling in a load of money will probably mean more of the same, only more expensive.

Gordon Brown argues that the money doesn't matter, because a well-funded NHS will mean a healthier and more productive workforce, and the drain on the Exchequer will cancel out. There is almost no evidence to support this view. Healthcare systems may be justified on the basis of humanitarian help for the sick and disadvantaged, but not on economic grounds. Overall, your health is determined by genetics, relative wealth and social circumstances. Not by your GP or local hospital.

So what is the NHS bad at, and what should the money be put towards? The great issue confronting all Western health systems is one of quality. Recent, if contested, figures suggest that 70,000 people die each year in the NHS from medical errors that are probably avoidable. Two hundred thousand, or one in 10, are harmed in some way during an admission to hospital. In other words, the NHS is one of the nation's leading causes of premature death. This is partly due to staffing levels – particularly patient: nurse ratios. It is partly due to defective infection control – 25 per cent of patients who die in hospital do so with infections they acquired there. Furthermore, with a few honourable exceptions, there are hardly any universally accepted, standardised national protocols for care of most illnesses.

You could, usefully, deal with these problems, but my view is that Gordon Brown has shied at the wrong coconut. The obvious question is: "How can we ensure optimal health for the greatest possible number?" is something that may not have much to do with the NHS. Instead, what has been addressed is: "How can we deal with the NHS in the most popular way possible?" In other words: "How can we win the next election?"

The author is a doctor in a London teaching hospital

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