open space

In 1972, Archie Cochrane observed that the 'NHS... is subject to a severe inflation, with the output rising much less than would be expected from the input.'1 More than 25 years later, despite his pleas for more attention to efficiency and effectiveness, the situation appears to have worsened to hyperinflation. A state of almost uncontrolled demand accepted as need now exists, in which those waiting for treatments of unchallenged effectiveness usually wait longest.

Counselling, screening and treatments of borderline benefit are provided with less delay and reluctance than joint replacements, cataract removal, heart surgery and prompt emergency treatment.

With crumbling medical resistance to aggressive marketing by pharmaceutical companies, and capitulation by major purchasers in the face of unpopular decisions, all seems almost lost. And the government - elected partially on the expectation that it would 'save' the NHS - appears to have painted itself into a very tight corner. Unwilling to concede or negotiate any of the three founding principles of the NHS - comprehensive care, free at the point of need and funded out of general taxation - it can surely only be a matter of time before one principle is lost.

Many believe the solution is simple: increase the percentage of gross domestic product devoted to the NHS. We are repeatedly told that the 6.9 per cent of GDP the UK devotes to healthcare is almost the lowest in the global league of affluent nations. What we do not often hear is that no other health service secures significantly more from state sources, and other countries' higher percentages are the result of private healthcare contributions.

And then we have the 'rationers'. For them the answer is also straightforward: namely a combination of prioritisation, core services, citizens' juries and public debate about what the NHS should no longer try to do. Unfortunately initiatives like Oregon and QUALYs have proved unworkable on a large scale. In any case, if rationing is defined as delay or denial of effective treatment then it already exists widely in the NHS. Despite an army of globetrotting health economists, the rationing solution remains elusive. It also conflicts with founding principle number one.

Everyone must hope that the National Institute for Clinical Excellence will prove its effectiveness in acting as a breakwater against the entrepreneurial activities of those advocating the latest interventions for the oldest diseases, usually of uncertain effectiveness and hugely expensive when applied to populations. But the real test for NICE will be ending investment in interventions of unproven or borderline effectiveness, for which it will not be short of choice. Most are sponsored by vested interest groups with powerful lobbies.

The suggestion that tangible links should be restored between money paid and benefits received also keeps surfacing. Payments for hospital meals and GP services are often mentioned. The former would require considerable bureaucracy, including means testing. GP charges would mean political disaster at the death of the first child whose poverty-stricken patients could not afford to call the doctor. Charges for non-urgent needs such as sexual dysfunction should be considered, but witness the recent furore. Insurance-based charges for road traffic and sports injuries also need to be pursued further. After all, prescription, dental and eye-test charges were all established a long time ago. Which brings us back to principle number two.

The private sector already relieves the NHS of 20 to 30 per cent of all elective surgery in the UK by 'cherry picking' commercially attractive and effective treatments, leaving the NHS to deal with the mass of incurable and uninsurable chronic illness. The NHS would be swamped if this growing volume of elective surgery were to return to the fold. Should the trend continue, access to this type of healthcare will effectively have been privatised. Bang goes principle number three.

Finally, the oft-repeated credo that all would be well if only there were fewer managers and administrators. The need for many more effective managers would be easier to argue in the light of current NHS inefficiencies.

Archie Cochrane regarded the NHS as 'a favourite child showing marked delinquent tendencies'. What would he think now? I find it hard to believe the NHS can survive another 50 years with the same basic principles intact. Continued fudging and drifting are the likely result of continued inaction, disguised by fashionable terms like 'partnership' and the 'third way'. 'Thinking the unthinkable' about introducing extra charges cannot be postponed much longer.