Revolution

Like Mao’s China, Britain’s National Health Service exists in a state of permanent, institutionalised revolution. Underneath it all, the very peculiar relationship between health and money is to blame. But this has also given rise to a world-leading experiment in health rationing.

The NHS’s endless turmoil can look messy. Currently we have centralisation of services in ever larger and more specialised hospitals. But we also have decentralisation of hospital services into community “polyclinics”.

At the same time the commissioning of services is being turned on it’s head. Giving “bottom-up” control to GPs and breaking up the Primary Care Trusts created in the last, barely completed revolution. Whatever the outcome this too will no-doubt soon by erased by the next breathless revolution.

Part of the cause is political – the NHS is a part of every general election campaign.

It is also the extraordinary advances in medicine that make it difficult for the NHS to sit still. It is an organisation with the scale and inertia of a giant utility firm, trying to cope with technological change like a cutting-edge Silicon Valley start-up.

But even more fundamentally, underneath this confusion, lies health’s big problem with money.

Most goods and services are either essentials or discretionary. The essentials, like food and heat, consume all our resources when we are poor, but as we get richer we reach a point where we have enough. They take a shrinking proportion of the country’s wealth as the economy grows.

The slack is taken up by the fun stuff – leisure, entertainment,
fashion, holidays – once we have enough of the essentials, we spend an
increasing proportion of our income on these luxuries.

But health doesn’t work like either. It is an essential, but one we can never get enough of. Poor or rich, we spend whatever we can if our life depends on it. And the richer a country gets, the more of its money goes on health.

In a country like the UK, where health spending is channelled through the state, that means that over the years the state will have to grow, taking an ever bigger slice of national income. This is something never acknowledged by those who call for a smaller state.

It also means that the NHS will never have enough money. Hard choices will always have to be made, and much of the turmoil is an attempt to deal with this problem.

In response, England and Wales have quietly pioneered a bold experiment in utilitarian health rationing, under the reassuring acronym NICE.

An apolitical body set up by the last Labour government, the National Institute of Clinical Excellence is at best unknown here, and at worst it is occasionally blamed in the press for “unfairly” withholding drugs from desperate patients.

But internationally, it is both admired and copied for its rational approach to deciding which new treatments are worth funding. It looks at the evidence for how many “quality adjusted” years of life a drug or procedure will save, and asks the unusually sensible question – would we save more lives spending the same money on something else?

Sensible, but deeply controversial. When Obama suggested something similar in the US, he was accused of creating “death panels” to decide who should live and who should die.

In a sense this was true, but when health resources can never meet all demands, these choices have to be made. And the best way has to be through an analysis of the costs and benefits, however cold this may seem. The result is a rational allocation of money in health that benefits patients and taxpayers alike.

So successful has NICE been that more than forty countries have sought its advice and it has even set up an international division to spread the word further. Some countries have placed so much faith in NICE that rather than create a similar institute of their own, they simply adopt the guidance NICE publishes.

We should be grateful that the NHS benefits from NICE’s work to draw those difficult but unavoidable lines. And we should hope that it stays relatively obscure, working away as the unending NHS revolution continues to rage above it.

Jeremy Bentham, the 18th century father of English Utilitarianism, must be quietly smiling in his cupboard at UCL at the thought of the bold utilitarian experiment going on just round the corner at NICE’s Holborn headquarters.