What Thatcher Did To British Health Care

...Health authorities and hospital trusts are obliged to "consult" the public as part of their decision-making process, but consultation can be more or less meaningful, depending on who is consulted and how...

...This is supposed to be good for patients, whose GPs act on their behalf and (allegedly) in their interests...

...Thatcher avowed at election time that the NHS was safe in her hands...

...Traditionally, they have been low in the pecking order—humble yeomen who must defer to the rich and powerful consultant aristocracy...

...Seventy percent said community relations had remained the same or worsened since the reforms and one third said staff morale had deteriorated...

...But the United Kingdom's crisis has a special character because of the history of its National Health Service...

...A team at York University has suggested that rationing be guided by a computerized formula, based on the length and quality of life (or "qalys") that can be anticipated as a result of a clinical intervention...

...Patients should therefore never be given information about [health] districts and contracting, and GPs should only be given information on these grounds where absolutely necessary...

...Most weeks there are stories in the media about people dying because their operations have been delayed...

...In the new quasi-market, the newly independent GPs have begun to consider which patients make better business...

...Only one in ten said information systems were adequate for their needs...

...How, indeed...

...Freed from the old bureaucratic constraints, yet disciplined by new budgetary ones, some managers and professionals may have begun to think more creatively about how to respond to patients' needs...

...We need them for this...

...His face appeared on the front of every newspaper, grinning cheerily...

...This might have been a useful move, had planning not been locked into a hazardous embrace with the function of purchasing health care...

...A government survey published in July this year revealed that almost 90 percent of adults in England have one or more of the four main risk factors for heart disease and stroke: high blood pressure, raised cholesterol, smoking, and lack of physical activity...

...The consultants had been hired to advise the authority on cost cutting...

...The saving grace is that there is less public deference toward managers, less blind faith...

...Patients are more often asked what they think of the way they have been treated...

...They can produce thicker glass and stronger locks, and try to catch the burglars...

...But that is a highly optimistic view and it shouldn't in any case divert attention from problems that persist within the service itself...

...Mismanaged computer contracts by another health authority in southwest England led to spectacular losses of public money—up to £63 million, according to the newspapers that investigated the scandal...

...they become independent purchasers of hospital and other specialist services for their patients, rather than using the contracts issued by health authorities...

...Members of the public have no way of finding out whether one doctor kills more patients than another, or even whether one doctor works more to the satisfaction of patients than another...

...More and more people are coming to the view that their only hope of ensuring satisfactory health care is to take out private insurance...

...they lack the clout of the fund-holders to bargain with consultants or to get the best and quickest treatment...

...Hospitals are encouraged to compete with each other for contracts from health authorities and GPs...

...Public utilities were privatized and central government hacked away at the powers of local government...

...Between 1979 and 1989, public spending on health grew in real terms by an average of 2.71 percent per year...

...Some of this information is known to health care purchasers but withheld from the public...

...The British public has become accustomed to the idea that its National Health Service (NHS) is "in crisis...

...In the United Kingdom and the United States, life expectancy has slipped as the gap between rich and poor has widened...

...Toward the end of Margaret Thatcher's final term of government, in 1990, the NHS and Community Care Act was passed by Parliament...

...No one batted an eyelid, although there had been quite an outcry when Thatcher "went private" a few years ago...

...Hospitals are no longer run as fiefdoms of senior doctors and surgeons ("consultants...

...So rationing, which might have passed unnoticed in a previous era, is now, perhaps mercifully, a hot potato...

...But the Patient's Charter, which is part of a broader Citizen's Charter issued by the prime minister, has helped put the idea into people's heads that they should have more power and more say in decisions about the health service, even though they do not...

...All this is probably for the good...

...casualty patients lined up on trolleys unattended, waiting for an empty bed...

...or ambulances failing to respond to emergency calls...

...In February it came to light that the Department of Health had ordered hospitals not to tell patients how long they would have to wait for their operations...

...we can consult their expertise...

...Even now, doctors' and hospital bills are not spiraling upward as in the United States...

...Health authorities are appointed, not elected...

...She had meningitis...

...It's the same with Health Service personnel...

...Now, with their new muscle in the marketplace, they are beginning to find the consultants deferring to them...

...Some hospitals and authorities genuinely want to render themselves accountable to their local communities, but are hard-pressed to work out how to do this in an institutional framework geared to avoid any meaningful dialogue...

...It is now widely held that money can buy better health care...

...From the late seventies onward there has been a growing unease about the public sector, and inevitably some of this has rubbed off on the health service...

...The government's Patient's Charter promises treatment "no later than two years from the day when your consultant places you on a waiting list...

...This, of course, is an anxiety shared by most Western governments in the 1990s...

...In 1991 it issued a Patient's Charter, declaring that all citizens had ten specific National Health Service Rights...

...with the money they earn from contracts, they employ or subcontract for the services they require to carry out the work, on whatever terms they can negotiate...

...There is ample evidence that income and social status are the main determinants of health...

...But some serious problems have remained unresolved...

...The government's NHS reforms have failed to turn around the priorities of policy making, WINTER • 1994 • 53 What Thatcher Did to focus on the promotion of good health...

...Scarcity and Decision Making There is little evidence that the reforms have helped to check rising costs of health care...

...Equity and Choice In the long run a successfully coordinated health policy might reduce claims on the health service...

...Politicians, managers, and health "experts" have been shuttling over to Oregon and returning unenlightened...

...One of the least controversial and easily camouflaged forms of rationing is to hold patients in lines...

...Equality came in a poor third at best...

...Depending on your point of view, this is a valiant attempt to empower the public or a neat exercise in public relations to camouflage a deteriorating service...

...This information is not collected—so health care purchasers are almost as much in the dark as the public...

...The danger of this approach is that it can obscure highly contentious social and ethical questions under the guise of scientific precision...

...In fact, there is no forum for public debate...

...and the reforms introduced over the next three years...

...In the 1980s, Margaret Thatcher's government delivered a powerful message: free the market, roll back the state, cut taxes, and let individuals look after themselves...

...One hospital wrote to consultants explaining: "We have been asked by the NHS Management Executive and [health] regions not to involve patients in discussions about contractual issues...

...Virginia Bottomley, WINTER • 1994 • 55 What Thatcher Did secretary of state for health, has admitted that rationing is inevitable, but has passed the buck to health authorities and health service staff to decide how to do it...

...Promotion and Prevention The NHS remains a huge machine, spending many billions and employing many battalions...

...The boy's father challenged the decision in the High Court but failed...

...Decisions have to be made about how to ration scarce resources...

...This summer (June 1993) Michael Heseltine, flamboyant cabinet minister and failed contender for the Thatcher succession, had a heart attack in a Venice restaurant...

...The United Kingdom was in fact spending a far smaller proportion of GDP (Gross Domestic Product) on health care in 1987 than the United States (6.1 percent compared with 11.2 percent) and only slightly more on public health care (5.3 percent compared with 4.6 percent in the U.S...

...Nevertheless, the Thatcherite Tories, enthralled by the Reaganites, turned to the United States for inspiration...

...Didn't we all...

...He hit the headlines when he was denied life-saving treatment earlier this year because of the closure of a bone-marrow transplant unit at a London hospital...

...A third world experience" is how one friend of mine described her eight-hour wait on a trolley in the corridor of a south London hospital casualty unit...

...But that would be anathema to the antistatist tendencies in John Major's party...

...So the health authorities, who are both planners and purchasers, have their minds fixed upon shopping for hospital and GP services, not upon planning or health gain...

...But when she needed an eye operation she nipped into a private clinic, explaining afterward that she wanted to be able to choose when and where to have the treatment...

...Even a prime-time television drama series, Peak Practice, features doctors in rural middle-England tussling heroically with unfamiliar budgeting and managerial regimes...

...So why the crisis...

...they may 54 • DISSENT What Thatcher Did offer a more limited service...

...But that is not going to solve the more serious problems that beset health policy in the United Kingdom...

...Yet it is almost entirely unaccountable...

...Patients have no idea which drugs have which side effects, unless a doctor cares to tell them...

...It would have to resume responsibility for economic and social planning, to promote a more equal distribution of income...

...But consultants can delay the moment when a patient's name goes on to the list...

...They include a right to be registered with a GP and a right to receive treatment within two years of being placed on a waiting list...

...There were 52 • DISSENT What Thatcher Did compelling economic reasons to try to pummel the NHS into a more cost-effective shape...

...The health service is a huge and rampant spender of public funds...

...Undoubtedly it would help if the Government were prepared to raise taxes and put more money into the Health Service...

...The principle on which the NHS was founded, and which still underpins most health care systems in Europe, is that there should be equitable deployment of available resources for the benefit of the whole population: equal access to available care and equal quality of care for all...

...There is even talk at government level of admitting some "alternative" therapies to the charmed circle of clinical respectability...

...But even more important is the ordering of priorities...

...Entrusting doctors, nurses and health managers with the job of enhancing the nation's health is rather like giving the job of preventing burglary to glaziers and locksmiths (or indeed, to the police...

...The degree of cooperation between the two depends in each locality upon the strength of political will to pursue a cooperative approach against the odds...

...A Regional Health Authority in the Midlands spent £4 million on consultancy fees, including the rent of houses in London, the hire of aircraft, and lavish entertainment...

...it is part of the bedrock of British democracy, in that it helps (or should help) to guarantee a basic human right...

...But health authorities are constitutionally quite separate and different from local authorities...

...So much for choice...

...In some corners of this quasi-marketplace, the new rules may have unleashed previously untapped energies...

...Patients witness it daily: paint peeling off hospital walls...

...Planners and deliverers of health care, previously part of one big happy family, were separated and made to deal with each other on contractual terms, as customers and suppliers in a quasi-marketplace...

...In Britain, babies in the poorest families are twice as likely to die as babies in the wealthiest...

...Some unscrupulous doctors have refused to admit patients from certain "problem" housing areas: they are well aware of the correlation between social deprivation and ill-health...

...One of the main boasts of the NHS reforms has been that more competition between service providers will increase the "customer's" power to choose...

...The reforms have triggered a managerial revolution...

...but their business depends, to a large extent, on a continuing demand for new windows and new locks, and a continuing supply of burglaries to investigate...

...But that is not the main business of prevention, which must be concerned with the environment (pollution, working conditions, road safety, urban planning, and so on), with human behavior (smoking, diet, exercise, hygiene, safe sex), and, most important of all, with social and economic relations...

...It dominates policy discussion and policy making...

...The reorganization itself has been expensive, and the new market ethos has brought new opportunities to waste money...

...The power to choose is unevenly distributed—not only among individual patients but also among doctors...

...Complaints procedures are being polished up...

...Universal and free to all who need it, the service has been in place for nearly half a century, since it was introduced as part of the postwar welfare state by Clement Attlee's Labour government...

...56 • DISSENT...

...They found Alain Enthoven, business professor at Stanford University (and today a leading proponent of "managed competition" in U.S...

...The epidemic of media scandals about the NHS is an expression of this changing mood, and the scandals in turn lend momentum to the change...

...In the reformed NHS, the planning function (working out the health needs of the population and how to meet them) has been separated from the provision of health care...

...For forty years, there were no conspicuous cases of sick people like Rhys Daniels being excluded from essential care...

...Those whom they reject must seek another doctor...

...now they have managers and accountants crawling all over them, issuing "mission statements," making sure they meet the terms of their contracts, looking for new business, balancing budgets, and so forth...

...Most, though not all, of the current crisis has emerged from a radical program of reforms introduced by Conservative politicians anxious to curb public expenditure...

...A recent survey of senior executives in fifty hospitals across the country suggested there was less sharing of information between hospitals than in the past...

...In other words, the gap between rich and poor within one country will affect that entire population's life expectancy: it will be higher where income distribution is more egalitarian and lower where it is less so...

...At a local level, health planners would need to work closely with local government, so that all aspects of local planning, on environment, education, and services, were geared toward health...

...increasingly these would be concentrated among older people and among those with chronic and progressive illnesses...

...General practitioners (GPs) were encouraged to become "fund-holders": this means they are given some control over their own budgets...

...In the old days, such decisions would have been taken, for better or worse, by senior doctors behind closed doors...

...So much for "equal quality of care for all...

...That would require a far more imaginative and courageous approach...

...Indeed, the picture was altogether bleak...

...Power to determine these points remains in the hands of the consulting bodies...

...Health policy), who in 1985 had advocated the introduction of an "internal market" to the health service...

...While costs continue to rise, while claims on the service increase, and while the government remains committed to curbing public expenditure, something's got to give...

...All the reforms of the NHS have taken place against a background of steady decline...

...or patients being kept in the dark about their health or how long they will have to wait for treatment...

...Now the managers are on to the case...

...The health care cart has been put before the health policy horse...

...they are unelected and they even have different boundaries...

...However well-intentioned they might be, however committed to making people better, their jobs depend on people being sick...

...If they want to keep mum about what they are doing, they can usually get away with it...

...The more health care providers are involved in rationing what is supposed to be a universal service, in order to meet their new contractual obligations, the more they are going to want to do so in secret...

...Fund-holding GPs, for their part, are more powerful than ever before...

...Public enthusiasm for the principle of a national health service remained quite passionate...

...Large, monolithic state-owned bureaucracies have become increasingly vulnerable to criticism that they are inefficient and waste public money and that they serve the interests of bureaucrats more than those of the customers...

...The reformers can accommodate the notion of prevention as a clinical activity (vaccinations, body-scanners, and so on...

...they know nothing about the past effectiveness of any particular drug...

...They, too, take decisions behind closed doors...

...And individual care plans have not been distorted by an industry trying to maximize profits...

...Nearly 80 percent said they did not believe the NHS objective of creating a quasi-market within the NHS was being achieved...

...But public confidence in the nature of the organization was severely shaken...

...Since they get an annual fee for each individual on their register, it doesn't take a genius to work out that fit, middle-class people will be less of a liability than those who are poor or chronically sick or disabled...

...These "old-fashioned" GPs are the poor relations of primary health care: they tend to operate alone rather than in multimember practices...

...It is paid for out of taxes...

...This sorry arrangement is failing quite miserably to proceed along the road...

...The health service reforms must be judged by those standards...

...water dripping through leaking roofs...

...Health authorities, which used to be responsible for planning and administering health services, became purchasers of care, entering into contracts with suppliers of care (hospitals, community health services, local doctors, and so on...

...We therefore should not expect them to be the best people to tackle the root causes of theft...

...Furthermore, international comparisons suggest that life expectancy is affected by relative as well as by absolute income levels...

...When he returned to England he went straight into a private clinic...

...GPs who are not independent fund-holders are less likely to turn them down, because they don't have to think or behave like entrepreneurs...

...or vast sums of money disappearing into black holes created by inept managers...

...Market and Choice were the horses backed by the Tories...

...The government has, for complex reasons, encouraged such truculence...

...Yet the government has steadfastly resisted pressure to ban tobacco advertising or to put serious money into health education...

...or doctors having to make "tough choices" about allocating resources...

...A service that is supposed to be universal and that spends such large amounts of taxpayers' money must be made more accountable to the public...

...soiled laundry left in piles because there are not enough staff to collect it promptly...

...The "rights" are largely a sham—you can't enforce them, you can only complain if they are not upheld and receive a "full and prompt reply...

...The ideology behind the reforms has been openly hostile to equality...

...Worse than that, the NHS trailer, which ought to be behind the cart, has been put before the cart and the horse...

...The balance of power is further distorted by an information gap...

...At the national level, a government that seriously intends to improve the nation's health would have to acknowledge that this depends far more on its economic policies than on its health service reforms...

...Last but not least, the cost of health care was rising while public resources were shrinking, thanks to expensive new medical techniques, an aging population, and (by the late 1980s) a deepening recession...