How might the NHS end?

I stumbled across this editorial I published in the BMJ 18 years ago while searching for something else, and I found it intruguing to read. We’ve been talking about the end of the NHS as long as we’ve been talking about the end of the novel, and neither seems to happen. Indeed, in some ways both are stronger than ever.

Yet what I wrote in 1999 could almost be published today, although then I wrote “Ministers are trying to reverse the fragmentation of the health service by introducing more central control and direction,” whereas the last reorganisation tried to do the opposite. In fact there has always been considerable central control of the NHS, and Cyril Chantler, one of the wisest observers on the NHS, thinks that it’s one of the NHS’s biggest problems.

My (I must say typical) advice in 1999 was to lower expectations, which is not the way of politicians. Nevertheless, we do now have Realistic Medicine, Prudent Medicine, and Slow Medicine, all of which are about recognising the limitations of medicine.


Uwe Reinhardt, the American health economist, thinks that all health systems may eventually converge to a three tier system that offers high quality, fee for service care to the very rich; insurance based managed care to the expanding middle class; and rough and ready care for the poor. The United States and much of South America already have such a system. Could it happen in Britain? The current media frenzy over the latest NHS crisis prompts speculation on how the NHS might end.

Most institutions on the scale of the NHS end not with a bang but with a whimper, and the current “crisis” will probably pass like so many before it as the media move on to other stories. The NHS will not simply collapse. Nor is any government in the foreseeable future likely to seek a radical solution and privatise the service. But one possible endgame is that the middle classes lose confidence in the service and begin to make other arrangements. If comfortable Britain begins to seek health insurance and private care on a large scale resources will shift from the NHS and so, crucially, will political attention. Preserving the NHS at all costs will not be the political imperative that it is now. It could become a rump service. We would then arrive at Reinhardt’s prediction.

And why would the middle classes lose confidence? Most probably because of problems with access and quality. People are unlikely to migrate in large numbers because they have to wait to have their hernias repaired, but they will worry about finding it difficult to see their general practitioner and if they think that casualty may not be able to cope when they have their heart attack, that they (or, worse, their children) won’t have access to an intensive care bed when needed, or that they are being fobbed off with a generalist when they should see a specialist. If the middle classes decide that they want immediate access to paediatricians or gynaecologists then the NHS will struggle to cope. The middle classes are also becoming much more concerned about the quality of care. Increasingly they do not believe that one surgeon is as good as another: they want the best. There is also increasing concern about the quality of communication and the non-clinical side of care.

The government recognises the demand for quality and is giving priority to attempts to raise quality. Unfortunately it may be underestimating the difficulty. Ministers are trying to reverse the fragmentation of the health service by introducing more central control and direction, but, as those knowledgeable about quality improvement remind us, telling people to do better will not improve quality. Nor will keeping scorecards improve quality. The NHS is a huge organisation, and nobody knows how to encourage the spread of best practice. The monolithic nature of the NHS may yet be part of its failure.

People’s expectations may rise much faster than the ability of the NHS to deliver, particularly when expectations are stoked not only by the media and access to the internet but also by politicians themselves. Ian Morrison, the Scottish Californian futurologist, has a joke that in Glasgow death is viewed as imminent, in Canada as inevitable, and in California as optional. If a large number of Britons grow to have the expectations of Californians then a service that pretends to be comprehensive, free at the point of access, and high quality runs into serious problems. The Californians may ultimately be discouraged by the bills they have to pay, but the aspiring Briton encounters no such deterrent—and certainly won’t elect a government that proposes to raise taxes. The demise of the NHS may lie in this mismatch between expectation and provision. And now the law is increasing the tension by insisting that the NHS must provide long term care and that blanket bans on particular treatments are illegal.

One group that suffers from the mismatch between expectation and provision is NHS staff. They are caught like hamsters in a wheel that must go faster and faster. Instead of being compensated for pay that is generally poorer than in the private sector by the feeling that they are doing an important job well, they are now conscious of increased pressure and of failing to deliver an optimum service. They have low pay and disappointment. So nurses and managers migrate to other sectors, and doctors begin to think about providing services outside the NHS. Wholesale demoralisation of the staff may be an important component of the endgame.

Can I end this editorial optimistically? I think so. A mismatch between expectation and provision can be approached in two ways. Clearly it’s necessary to improve the provision, and politicians always promise such improvements. But it would also seem sensible for everyone—politicians, researchers, clinicians—to work on the expectations: death is inevitable; most major diseases cannot be cured; antibiotics are no use for flu; artificial hips wear out; hospitals are dangerous places; drugs all have side effects; most medical treatments achieve only marginal benefit and many don’t work at all; screening tests produce false negative results; and there are better ways to spend money than on more healthcare technology. “The best healthcare system in the world,” which politicians in every country promise, will not be one that provides everything for everybody but rather one that determines what that society wants to spend on health care and then provides explicitly limited, evidence based services in a humane and open way without asking the impossible of its staff.



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