Thirty years ago when I was a student of healthcare organisation we were taught that the ideal healthcare system in the world was the NHS.
It seemed clear that once America had universal coverage (Medicare and Medicaid had recently been enacted and many bills for national health insurance had been introduced into Congress), a national health service would be the next logical step. It was not a surprise when Congressman Ron Dellums from Oakland, California introduced a bill to create a national health service in the United States in 1975.
By the end of the 1970s, press reports about the long waiting lists for elective operations and the lack of new diagnostic technology such as CAT scanners and MRIs began to raise questions about the quality of the NHS.
Perhaps the coup de grace was the publication of The Painful Prescription by Aaron and Schwartz in 1984, which laid out the informal yet widespread basis of rationing of specialist care within the NHS. The response to this book was that whatever problems the US healthcare system had, the answers were not to be found in a national health service.
Moreover, it was at this time that the closest US analogues to the NHS, the Veterans Health Care System and large municipal public hospital systems were under increasing attack for low quality and low productivity.
Americans concerned with improving healthcare took to alternative paths. Those who believed in the gospel of the market began to advocate for privatisation of healthcare, while those who believed in the benefits of social insurance have pushed a single-payer model based on the Canadian healthcare system.
Today, when American students are taught about the NHS at all, it is only that it has been severely underfunded for the past 20 years, it rations care, and there is little innovation.
I expect the implementation of the NHS plan will begin to change all that. The plan is so comprehensive and far-reaching that it will utterly transform the NHS as it exists today and again make it the paragon for health systems in the world. But there are several issues that seem worrisome.
There is no question that the NHS must do significant catch-up before it can become a 21st century healthcare system. I can think of no other healthcare system that has committed the large amount of money that Britain intends to infuse into the NHS. Yet it is possible that as it struggles to catch up, it may find itself falling farther behind the exponential growth in medical care. In the quest to make up for shortfalls in the past, is it possible that the new programmes of building hospitals will ultimately give the NHS a system more suitable for 1990 than 2010? Would it not be better and more ambitious to create a new style of healthcare delivery that eliminates historical artifacts such as hospitals and separations between primary and consultant care?
The plan states that the vast majority of operations in the new NHS will be same day surgeries, following a trend that has occurred in the rest of the industrialised world. Why not build ambulatory surgery centres or equip surgeons offices to do procedures rather than more expensive hospitals?
Perhaps the most serious question is: will the NHS be able to build the new buildings, find, train, and hire the new staff, and implement all the new procedures in the timetable that is provided? One of the great advantages of the old NHS was that people did not expect much from it and accepted its shortcomings with seeming equanimity. But the publicity around the new plan will lead to raised expectations. The new funding comes from a government committed to improving the NHS and a good economy, but what happens if either changes? Will the British public accept any less of a NHS than they have been promised? And how will the system be able to increase its spending to account for new technologies, procedures, pharmaceuticals and other changing aspects of health and medical care that will come into place as it is upgrading?
I was surprised to see no mention of the Internet and its potential to improve patient education and co-ordination among health workers.
While the plan says that there will be phones and TVs available at all patient beds, why not have wireless Internet access available as well so patients can e-mail friends and relatives, perform administrative tasks, and get health education?
The NHS plan will lead to a revival of a great institution and many around the world will be watching to see how this process goes. The affirmation of government provision of healthcare as a right to all citizens, particularly in a time when the market seems to rule, is a wonderful and encouraging development. Let us all hope that the plan is successful so that it will once again show the world how healthcare should be delivered.
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