“DNA,” she drops the notes onto the end of the desk, and I sigh: she’s not referring to deoxyribonucleic acid. Here, in this clinic room, DNA stands for ‘did not attend’.
“Your eleven o’clock is here early though. Shall I bring him through once I’ve weighed and measured him?”
“Yeah, thanks. That’d be great.”
She glances at the mess of toys and crayons scattered over the giant city plan play mat, before noticing the fire engine that now stands in watchful readiness under the furthest recesses of the examination couch. It’s her turn to sigh as she considers tidying everything up in a couple of hours. She stoops down and removes the Tyrannosaurus Rex from the roundabout in the middle of the mat, placing him carefully in the corner, before leaving the room. The T-Rex looks thoroughly discombobulated perched atop the preprinted post office, arms and legs wildly splayed after encountering my last patient. I go and straighten the poor king of lizards up; he’s no match for a six year-old with ADHD.
Before my next family come in I try to give the parents of the family who haven’t attended a ring. I’d wanted to see Noah. He’s recently been started on medication for his diagnosis of ADHD, and I want to know whether he’s managing any better at school. One of the possible side-effects of his new medication can be a rise in blood pressure; and so talking to his parents over the phone isn’t enough: at some point I need to examine him.
Noah’s mum picks up after a few short rings. I start by making sure Noah’s well, before asking how he’s getting along. I’m pleased to hear he’s doing well. She informs me his teachers are telling her Noah’s a “changed boy”, and he’s concentrating much more in the classroom. I tell his mum that I’ll need to seem him soon and she apologises they didn’t make it today: she forgot.
It’s estimated that, each year, missed appointments at GP surgeries and hospital clinics, cost the NHS around a billion pounds. Nigella Lawson’s dad, back when he was counting the nation’s coffers, famously said that the NHS is “the nearest thing the English have to a religion”. In that context, what I’m about to say might be considered blasphemy, but I’d ask you to bear with me, and hear me out: I don’t necessarily think that the NHS is the best way of funding healthcare.
Now, before I’m excommunicated, let me point out that I only say this because I believe that, if the NHS’ founding visionary, Nye Bevan, were around today he’d be throwing over tables in Her Majesty’s Treasury and driving out the ‘money changers’ (or, in our scenario, mild-mannered policy wonks evangelising ‘internal market’ economics), to borrow another religious metaphor. Allow me to explain.
The idea of healthcare that’s ‘free at the point of use’ is laudable. It is one of the single greatest achievements of post-war Britain, and it is something I’m proud to be a part of. But, like every other method of delivering healthcare, it’s not without its flaws.
In the United States, several years before the introduction of ‘ObamaCare’, the state of Oregon ploughed money into an expansion of its Medicaid program. In the US, Medicaid is a government program that helps provides health insurance to people, and families, who might otherwise not be able to afford it. Unfortunately, the state of Oregon didn’t have enough money to offer Medicaid to everyone who might now qualify for assistance under their program’s expansion: so they held a lottery.
Put aside, for a moment, whether you think that the idea of offering healthcare by raffle represents the very best of pragmatic innovation, or is just plain odd, and you can see that a pretty perfect scientific experiment had started. Suddenly, you can compare two similar populations; one group with, and one group without, healthcare: the so-called ‘Oregon Medicaid healthcare experiment’ was born.
Data from the study was published in renowned scientific journals: Science; and the New England Journal of Medicine. Economists were as excited as it’s possible for economists to be. Two years after the study started there was no significant difference between the health of those with, and those without, health insurance. But those who did have insurance were much more likely to see a doctor: in particular, they were 40% more likely to attend an Emergency Room.
As always, people used statistics from the study to justify their particular beliefs. Those who believed in the expansion of healthcare coverage pointed out that those with insurance had much better rates of diabetes detection and management, as well as a much lower likelihood of depression. Those against, pointed out the increased healthcare expenditure of those with insurance, for small gains.
The study was short, and it would be possible to spend a long time talking about its flaws, but it is interesting that those people who had insurance used ERs more than those without. After all, it seems like common sense that you’re more likely to schedule a routine appointment with a doctor if you have health insurance. But an emergency is an emergency: surely, if people are attending ERs for a genuine emergency they would be equally likely to do so whether they’re insured or not (in the US, ERs are legally obliged to treat you in an emergency, regardless of your insurance status). The way that people with insurance used emergency care seems to imply that cost might be a useful deterrent of unnecessary attendances in Emergency Departments. As A+Es up and down the country face increased strain, it’s at least worth bearing in mind.
So, back to the NHS.
Successive governments, Conservative and Labour, have opened up an internal market within the NHS. As of 2012, that means that ‘any qualified provider’ can be paid to provide NHS services to patients. These patients still receive treatment that’s ‘free at the point of use’, just as they always have, but, increasingly, that treatment, or service, might be provided by a private company wearing an NHS logo. The idea is that these private companies drive down costs by undercutting NHS providers. Win win, right? Sounds like the very best of free-market capitalism, utilised for the benefit of all the consumers of our egalitarian healthcare system. Well, no, actually. Turns out it’s almost the worst of both worlds: so much so that, in 2010, a Health Select Committee described the whole thing as “twenty years of costly failure”.
The idea that the NHS is unaffordable is nonsense. As a percentage of GDP, the UK spends less on its healthcare than the EU average, or the OECD average: it spends 7-8% of GDP. By contrast, the US spends around 16%. Despite that, the NHS is consistently ranked as one of the best healthcare systems in the world.
When I said that I didn’t necessarily think that the NHS is the best way of funding healthcare, I meant it. But, oh my, it is very far from the worst. As the Oregon healthcare experiment shows, the single greatest failing of the NHS is that it might not be utilised by people cost-effectively. It risks DNAs and inappropriate ED attendances. But it is extraordinarily good value for money.
Looking at the merits and pitfalls of healthcare systems across the globe is probably a lifetime’s work. Every system will have plenty of both. In these financially straightened times it seems that the NHS is increasingly described as unaffordable; the implication being that, at some point in the future, it will have to change. But could we ever do so?
Before his no-show today, the last time I saw Noah was the school holidays. He and his mum visited me, along with his three other delightful siblings. I know that Noah’s older sister has been very sick, because, coincidentally, I looked after her on one of my recent shifts in the hospital. I also know that Noah’s dad recently lost his job, and the family are struggling. So, when Noah’s mum tells me that she forgot her appointment, I can more than understand how that might have happened.
However you provide healthcare, you’re dealing with people’s lives. Any system has to account for the fact that Noah is a child who isn’t able to be responsible for his own health or financial situation. Noah’s family aren’t independent of the society they live in: his father lost his job because there’s a tough financial climate. That might be considered as much of a public health issue as ensuring clean air and water.
And so, as my next patient runs into the room and starts daubing crayon all over the long-suffering T-Rex, I think about how the NHS might not be the best way of funding healthcare: but for Noah and his family, it is so very far from the worst.