People need to be asked what the NHS should provide
The call for a public debate about what the NHS should provide (and what it should not) in order to create a high quality and sustainable health service for the 21st century has come from many quarters. This includes the Chair of NHS England, the CEO of NHS Providers, the BMA and me .
Politicians, however, have been reluctant to take up the challenge, fearing the wrath of public opinion should it turn upon them. Two recent medical articles side by side in The Times suggest that the debate should not be delayed for much longer. They reflect the increasing confusion at a policy level on how the increasing crisis of the NHS should be addressed. Although not apparent from the titles, both refer to the National Institute for Health and Care Excellence (NICE), the main national body assessing value in the NHS. Both appear to deal with rather dense methodological research – the left-hand article is based on Carl Klaxton’s work (A Health Economist from York) and addresses what NICE’s ‘threshold’ for assessing the value (cost-effectiveness) of new drugs should be (he thinks it is too high); the right-hand article refers to a study assessing how likely country-specific cancer guidelines are to recommend innovative treatments. In fact they both go to the heart of the debate of what the NHS should be for and its underlying values and priorities. In summary, the left-hand one is saying that NICE is too lenient in its assessment of new interventions and the ‘opportunity’ cost of this means that people are dying as a result. It goes on to suggest that other parts of the NHS are using a different threshold to NICE, which will result in institutional variation and differing standards of care. The right-hand article concludes the opposite, that NICE is too restrictive and is stifling innovation. To ask which one is right, is to ask the wrong question. The more important question is what do the public want from the NHS? With an ageing multi-morbid population and the speed of medical technology development, it is no longer possible to have a comprehensive service, free to all and of high quality. Something has to give – at present it is quality that is feeling the strain.
The only way that politicans will initiate such a debate is if they consider that the public has the appetite for a good look at the NHS. The public needs to be fully informed, not with headlines and soundbites, but with real information on what is possible and what the implications are of the different scenarios for tomorrow’s NHS. How this is to be initiated will be difficult. But a first step could be to support the public in understanding and participating in health prioritisation decisions at a local level. While Clinical Commissioning Groups are legally required to consult with the public, the emphasis on openess and transparancy seems to have dimmed with the new Sustainability and Transformation Partnerships and Accountable Care Systems. New ways of informing the public of the need to prioritise health services and to encourage them to get involved are needed. As part of my research I have just developed a new prototype website. While describing my research on social values over the last six years, its main aim is to encourage the public to share examples of how they have been affected or have participated in difficult healthcare prioritisation decisions. By the use of stories, films and video, it may be a small step on the way to triggering the national debate that the NHS so desperately needs. The idea emerged out of my recent 2018 Rockefeller Academic Residency at their centre in Bellagio, Italy.
Surrounded by artists, authors and practitioners I realised another book on the issue was futile – much better to encourage people to tell their own stories and use these to explore the issues. The prototype website can be found here: https://people4health.com
What do you think?
Professor of Public Health, Kings College London