NHS at 70: Can the ‘free’ healthcare model survive?

Nurses do the rounds at the Royal Infirmary of Edinburgh. Picture: Greg Macvean
Nurses do the rounds at the Royal Infirmary of Edinburgh. Picture: Greg Macvean
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As the 70th anniversary of the NHS approaches, the perennial question around the sustainability of the service has reared its head again, with political parties of all persuasions seemingly reluctant to address the issue.

The “free at the point of delivery” service cherished by so many has never been under greater scrutiny, with daily tales of chronic underfunding in the face of an ongoing recruitment crisis set against the backdrop of an ageing population.

Dr Catherine Calderwood, the chief medical officer for Scotland, believes the NHS is sustainable but says there is a “burden of over-treatment” that can be reduced by providing people with the information they need to make the best decisions about their care.

She said: “In its 70-year history our NHS has continued to evolve as the needs of our people have changed and medicine has advanced.

“I know that we, as doctors, sometimes find it easier to err on the side of caution.

“We recommend one more test, one more referral, one more procedure. I also know that it can be difficult, as a patient, to speak up and ask for more information.

“But clinicians need to be aware of the times when we might be doing more harm by over-treating people without a beneficial outcome; and we need to encourage everyone, professionals and patients, to feel comfortable in reaching treatment decisions together.

“By doing this, we can not only sustain the NHS but see it continue to improve and meet the needs of the people of Scotland well into the future.”

Her warning came as it emerged the NHS in England is to cut back on a number of treatments, including breast reductions and operations to stop people snoring, to prevent more than 100,000 “unnecessary procedures” taking place annually.

Prime Minister Theresa May’s recent announcement of £20 billion of funding to be made available to the NHS, with £2bn of that coming to Scotland from a so-called “Brexit dividend”, has been predictably criticised by her political opponents as nothing more than a “sticking plaster” for the health service.

However, are alternatives to the general taxation model supplemented by National Insurance contributions, which the NHS relies on for the majority of its funding, any better or worse than the systems adopted in other countries?

A range of alternatives have been touted, including the much-lauded French model largely financed by government national health insurance, which requires residents to register with a health insurer.

The fact is that most countries rely on some form of user charges to pay for a proportion of overall costs, from charging for prescriptions to paying for GP appointments.

In Germany, for instance, workers pay around 8 per cent of their gross income to a non-profit insurance company called a sickness fund, with employers matching what they pay.

Mark Dayan, a policy analyst with the Nuffield Trust, said he doesn’t see why the NHS would be any less sustainable in Scotland than it would be anywhere else in the UK or “indeed the western world”.

Dayan believes the problems faced by healthcare are not unique to Scotland. “In fact they’re not even particular to countries who have an NHS-style tax-funded system,” he said. “What is true is that in recent years there has been a lot of financial pressure on the NHS in Scotland and there’s been some staffing pressure.

“This is basically as a result of the dynamic where the population is getting older, people are getting more complex diseases and the health budget isn’t rising quickly enough to keep up.”

Dayan highlighted flaws in other healthcare systems throughout the world, including in the US, where tension has centred around the introduction of Obamacare and initiatives by private companies that push down costs.

“There’s an element of wishful thinking creeping in,” said Dayan, “and people go: ‘Well, if we scrapped the NHS and got some other system, through some mechanism we’re not totally sure about – that would get rid of all our money worries.’

“But in fact most countries have these money worries almost regardless of what the system they have is, and it’s not obvious that changing the way you pay for health services will somehow address problems of cost-effectiveness.”

Dayan believes initiatives introduced by the Scottish Government such as “Realistic Medicine”, which is based on a multi-disciplinary approach that would see greater use of pharmacists, for instance, are the way forward.

He cited the work being done by the Scottish Medicines Consortium in terms of trying to prioritise spending on the most cost-effective drugs.

“That’s not always popular, in particular when they’re ruling out some drugs that do actually work but are incredibly expensive,” he admitted. “Frankly, I think what they’re doing is probably a good idea. You have to be realistic – the money is always going to be limited and you want to make sure that it’s being focused on things that do as much good as possible.”

Dayan said the long-term thrust of Scottish Government policy was based on doing more outside of acute settings to stop people going to hospital. He described this as “the right direction of travel”.

Chair of BMA Scotland, Dr Peter Bennie, said a rapidly increasing funding gap, along with long-standing medical recruitment and retention difficulties, meant that without action the sustainability of the NHS in Scotland will be “seriously undermined”.

“With sufficient long-term investment in the health service and action to 
address the real-terms fall 
in pay we have seen year 
after year, there is no reason why these twin problems cannot be addressed,” said Bennie.

“But as a society we cannot afford to put off the big decisions on how we will fund this any longer.”