Avert the tragedy of the commons in the NHS

In the cash strapped and workforce strapped context of today’s NHS, we hear more and more about the need for Britain’s people – more or less every one of which has been, is or will be an NHS patient – to consider reasonable and appropriate use of the NHS.

Posters tell us “don’t go to A&E or call 999 unless it is life or death”. Newspapers expose the boroughs that are “rationing” expensive referrals into hospital outpatient services.

A nationwide review of prescribing hit the news headlines in autumn 2017 to resolve the significant NHS spend on often cheap, over the counter medicines. In short, there are lots of people who are living longer and not always healthier, and the money and workforce can no longer stretch to meet all our needs and wants all the time.

When considered objectively and strategically, this feels like an efficient and reasonable response within said context. Yet, stories of poor families struggling to buy lactose free baby milk, and missed cancer diagnoses due to lack of investigations, and people with mental health problems detained in police cells, make us all worried about the risk of going too far with rationing.

British culture and identity is often one of fierce pride that we have a health system that is free at the point of use and does not make value judgements about our worthiness as users. We British do not need to take out health insurance to survive, and the system does not let us die because we are poor, or an ethnic minority, or are too sick already.

Our pride is a feeling that we do not want to jeopardise or adulterate, lest we start along the slippery slope of losing something precious. Yet in 2018’s Britain, with 65 million people of which one in 12 people are aged over 75 years old, is the nobility of the NHS a sustainable option?

Tragedy of the commons

In 1968, Garrett Hardin wrote an article for Science journal called “The Tragedy of the Commons”.

Quoth he, “Picture a pasture open to all. It is to be expected that each herdsman will try to keep as many cattle as possible on the commons. Such an arrangement may work reasonably satisfactorily for centuries below the carrying capacity of the land. Finally, however, comes the day of reckoning. At this point, the inherent logic of the commons remorselessly generates tragedy”.

The commons land becomes no longer able to support life, the cattle die and all the herdsmen suffer.

Hardin was describing an analogy for overpopulation and environmental degradation that is also relevant to today’s NHS resources; if each person prioritises his or her own needs over a wider appreciation of the demands on the system, then the NHS will continue to be at risk of worsening quality, unsafe care and eventual collapse.

 There are lots of people who are living longer and not always healthier, and the money and workforce can no longer stretch to meet all our needs all the time

This is no critique of the population. It is perfectly reasonable that people want to access healthcare for themselves and their loved ones, at the time they have a problem, and to have their problems treated to the fullest extent, as soon as possible.

Surely, that is why we pay our taxes and loathe those who do not; that is why the NHS is there, part of the furniture of 20th and 21st century Britain; and that is what sets us apart from the American health system?

Finding a sustainable solution

But, the NHS is struggling. People have not done anything wrong in wanting and thinking these things, but they will do if, as a society and as individuals, we do not adapt to our circumstances and change how we think and behave. There is not enough money and there are not enough staff.

Increasing funding is not a sustainable solution. It might put a finger in the metaphoric dyke for a while, but after a short time, the increased level of funding will no longer be enough either. And in any case, we cannot generate more qualified and dedicated staff from thin air, especially post-Brexit.

Hardin’s concept of “mutual coercion” suggests that people’s use of resources can be controlled, for the good of society, by agreed laws, taxes and other devices for limiting their free use

Hardin’s conclusions are bleak. He asserts that there is no technical solution to the tragedy; only a “fundamental extension to morality” can resolve the dilemma of the sustainable use of the commons. Hardin’s concept of “mutual coercion” suggests that people’s use of resources can be controlled, for the good of society, by agreed laws, taxes and other devices for limiting their free use.

My question to 2018 Britain is, if we are now at the day of reckoning for the NHS, a much loved institution that from cradle to grave has cared for us without discrimination, is mutual coercion the only way forward? Or can our population, as stakeholders in the NHS, evolve from self interest towards a morality of mutual protection of NHS resources?

Can we each stand up and say “we will make the effort to learn how to best use the NHS, to avoid waste as if the costs were my own money (because they are), and to only seek help for myself and my herd when I have done everything I can first”?