Robert Baker: Huge injections of money won't improve the health service

'Massive injections of cash would wreck the things the NHS relies on: excuses and martyrs'
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The Independent Online

It's turned out busy for the NHS this week. Gordon Brown's pre-Budget report was published yesterday and promised increased health funding – and now there's Wanless to worry about.

The inquiry of that name, chaired by ex-NatWest Chief Executive Derek Wanless, has just presented its interim report estimating health service budgets for the next 20 years. The report says the NHS remains seriously underfunded and it looks as though either compensatory tax increases or cuts in other budgets may be on the way. That's all right then, because there's one aspect of the NHS that everyone can agree about – if only it was properly funded, then it would be rightfully restored to official "envy-of-the-world" status.

Everyone agrees with that, don't they? Well – actually, I don't. It is my view that massively increased funding for the NHS as it stands would destroy the very things at which it is particularly good.

A perfect metaphor to illustrate this is a car. Not just any old car, but a special one. A Morris Minor, in fact. Not just any old Morris Minor either, but a Traveller. One of those Tudor-style estates with a wooden frame, the sort favoured by social workers, often to be seen with a "Nuclear Power – Nijn Danke" sticker on the back.

Morris Minors and the NHS share a birthdate. 1948. Both will get you to your destination more often than not. Both are rather quaint if actually slightly ugly and naff in the way the British seem to prefer.

Both are practical, workmanlike and rather uncomfortable for longer jouneys. Both are, unaccountably, rigidly fixed Cliff-Richard like in our national affections. But the key thing about Morris Minors is that you can pay huge sums restoring one, particularly if the wood has been neglected by previous owners. And at the end of the day you still end up with a Morris Minor, a rather slow and draughty machine designed for motoring in another age and left standing by every other car.

The best way to own one is to either replace it with something more modern or not to spend any money on it at all. Because the great thing about Moggies is that they are dirt cheap, so you can run them into the ground then get another.

So it is with the NHS. The amazing thing about the service is not that it is so bad on its budget, rather the opposite. The Government currently spends just under 7 per cent as percentage of GDP on health. This compares to an average of 8.6 per cent for other Western countries, 9.6 per cent for France and 14 per cent for the US. If only we were to match them, our poor old NHS would be so much better – wouldn't it? The US system, although better, certainly isn't doubly good.

Anyone who knows anything about the NHS will tell you that it isn't inefficiency that is the problem – it's over efficiency. The system operates at approximately 100 per cent capacity most of the time, and at (relatively) such a bargain rate.

Massive injections of cash would wreck the other things the NHS relies on, which are excuses and martyrs. "Look at me, I'm working so hard; If only we had the money!" is the refrain of many health workers.

If we did have limitless money and spent it on the NHS we still wouldn't correct the lag between us and other European nations in death rates, particularly from cancer and heart disease.

If you really want to improve the health of the population then the National Health Service – more properly termed the National Illness Service – is probably the wrong place to start.

If you want the greatest Benthamite, utilitarian good for the greatest number, then public health, social egalitarianism and preventive medicine are the way to go. Wealth and social justice determine health outcomes, not frantically overworking doctors.

That aside, the reason the NHS is a bottomless pit for money is not inefficiency. It's lack of clear, planned national goals and outcomes. This results in a skewed provision of services between regions, where some have massively expensive world class units for rare diseases and others have little access to specialists for common conditions like heart disease and breast cancer.

Big swingers in major specialist units are very skilled at diverting resources in their direction. Without a proper plan for provision for this is likely to continue. The key phrase here is a service fit for its purpose, not the fatuous current buzz term "clinical excellence".

What is needed is a debate about what that purpose is. Do we really need "clinically excellent" units in London when there is such a longevity gap between North and South, rich and poor? Do we want to provide intensive care facilities for 90 year olds' when the money could be used to make people healthier by improving social equality?

To return to the car metaphor, maybe it would be healthier to manage without a car at all, and start walking again, or even buy everyone a bike.

robert.baker@ucl.ac.uk

The author is a practising doctor

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