With the UK's enduring love affair with the NHS feeling the financial strain of a meticulous Chancellor, Prof Karol Sikora asks whether the voting public can stand more tax rises?
Costs are spiralling out of control in every healthcare environment. Ageing populations with a wide range of medical problems are using vastly increasing amounts of care costs. New technology - drugs, procedures and machines - are powerful inflationary drivers in an information-rich, consumer-oriented world. Direct-to-patient marketing, using advertisements and subtle public relations activities to generate positive press stories about medical innovation, are the increasingly used marketing tools of the pharmaceutical and medical device industry.
Different healthcare systems are using a variety of approaches to dampen demand. Rationing, both overt and covert, inevitably leads to inequality. Britain's NHS is undergoing a slow reform process. Huge variations still exist in the way patients access its services, depending on their location, education and socio-economic background. There are also major differences in prioritising services by those responsible for their payment.
NHS spending is at unprecedented levels, with over £90bn being spent this year alone. Yet, on the basis of objective standards such as cardiovascular and cancer mortality, surgical waiting lists and timely specialist referral, the quality of service provision and the ability to provide new technology simply does not match that of the Europeans. Access to medical innovation is much slower in Britain and there is now evidence that the UK is falling further behind.
Increasing the total budget spent on the NHS is only one solution. It is clear that a massive increase in spending has not been accompanied with improved productivity. As the tap runs dry, the NHS will enter financial limbo. The Wanless report suggests that, for the five-year period from 2008, the NHS will require funding growth of approximately 5%. The last Budget indicated that, starting in 2008, public expenditure growth will only be around 2%. The omens for the future of tax-based healthcare funding delivering all that is needed are not good. A report from the think tank, Reform, suggests the UK is already committed to an £11bn funding gap by 2010 - and that is without any new technology.
There are several options on the table for healthcare financing:
n Doing nothing
Maintaining the proportion of taxation spent on health at predicted post-2008 levels will fall far short of the Wanless and Reform projections for what the NHS will need. This will stimulate new private healthcare markets for those services not available from public providers who will have no incentive to improve their service offering. Co-payments and top-up insurance plans will rapidly emerge to meet this new demand. Doing nothing will simply lead to rationing by delay and denial. This has a two-pronged stalling effect on progress. Firstly, it gives the false impression that all will eventually be well, while, in reality, services will not be affordable for everybody. Secondly, it prevents alternative, entrepreneurial providers from entering the market.
n Increased taxation
Increasing taxation could be used to generate funding for innovation. But increasing tax by one pence in the pound on every person generates only £3.5bn a year. The problem for politicians is that the elderly and high-cost healthcare consumers are voters but not high taxpayers. The younger, high taxpayers do not see why they should pay for the healthcare of the grey vote. How far would the average British voter be prepared to tolerate increased taxation for better healthcare? Probably not a great deal.
n New insurance schemes
Converting to a European social insurance-based system of universal coverage and access would be the most radical approach. Payments would be made through mutual but competing organisations commissioning public, private and independent sector providers for healthcare. Co-payments would be possible for certain interventions that are not judged to be value for money. Such interventions would be delivered by the same staff in the same hospitals and billed directly to patients. A policy of partial co-payment could be examined, but this is probably too big a concept for politicians to convey to the public and still retain their confidence. A stepped option would be to allow the Primary Care Trusts (PCTs) to compete for insured lives whatever their location and then open it all up to the private sector.
n Co-payment
Services would be provided by a direct payment at the point of care: a co-payment. This would be met by the patient. Insurance plans and individual health savings accounts could be used to reduce the immediate impact of such payments. Despite the lack of debate, this option is, in reality, already being selected by stealth. Indeed, insurance products designed specifically to cover co-payments are about to emerge.
A prerequisite of any reformed system is to strip away bureaucracy to reduce costs, and there are plenty of examples of that in the NHS. Another key component is to encourage clinicians - whether doctors, nurses or others - to configure services directly to patients without the current cumbersome structures. It is time to open the debate about whether the NHS should be able to provide, not just a decent core package of services, but to allow patients to contribute financially for improved services for themselves and their families. This would reduce the inequity resulting from the current confusion, where some patients have to receive all their care privately and not just the upgrade they seek to achieve. The latter is simply unaffordable to many, who have, after all, paid their tax-based insurance premium for the core package. Being open about the possibilities could lead to a set of innovative insurance products to pay for specific options for a range of diseases in later life. This will herald an era where real patient choice will drive quality upwards. While it is unrealistic to expect costs to fall, this mechanism would almost certainly act as a constraining effect on excessive healthcare inflation.
Defining the core
For co-payments to work effectively, the NHS core service must be clearly defined. The problem is huge regional variation in what is provided and the time to treatment and access to a specialist. The NHS core package may, for instance, be based on the treatments and interventions that the National Institute for Health and Clinical Excellence (NICE) deems to be safe and cost-effective. So, in this way, anyone who decided not to co-pay would still be guaranteed a quality, though not always cutting edge service. This may be a lifestyle choice that some wish to make.
NICE standards would be regarded as a minimum, not a maximum standard. These standards would need to be enforceable - not advisory, as they currently are. For those that see conforming to NICE directives as a step downwards, they should be aware that many trusts and PCTs do not offer treatments that NICE guidelines suggest should be offered. This regional lottery must be addressed. Any efforts to improve equity and access to care will be constrained by the current political reality of all major parties. There is simply no support for the wholesale re-organisation of healthcare funding.
CancerPartnersUK believes that, in view of this, it must at least legitimise co-payments. They are all too often the unspoken and unrecognised barrier to accessing high-quality, timely healthcare. Making co-payments official would allow people to save tax efficiently for them, or insure for them, and provide those on lower incomes the incentives and support to help to pay for them. This would go a long way towards closing the yawning gap left by taxation-based healthcare funding. Significantly, it would harness money for the benefit of patients that would allow investment not only in services provided by the independent sectors but, for the first time, also by the NHS. The NHS needs to be explicit about what its core package will provide and make this rightfully available. High-quality health technology assessment by NICE is an essential component in deriving the contents of the package and needs to be speeded up.
Conclusion
The UK is now leaving an economic Garden of Eden. The British public has a long-standing love affair with the NHS - almost like a religion. How much is it really willing to pay for an extra year of good quality life is going to be a key question for the baby-boomer generation. How will it allow individuals to contribute to their care in an equitable way? Consumerism and social solidarity are not natural bedfellows, yet, the very core of NHS doctrine is being impinged on - care given freely on the basis of medical need and not ability to pay from cradle to grave. Its high priests are very worried and do not encourage further analysis. So, instead, a system of stealth co-payments has emerged, but the tipping point is coming. There are no right or wrong answers but the NHS can certainly never return to an age of innocence in the sacred garden. It needs to discuss these issues openly.
Professor Karol Sikora is medical director of CancerPartnersUK
