In February 2001, the NHS is once again under scrutiny. Politicians
and commentators have periodic spasms of interest, but nothing seems
to change. Why is this? This paper adresses some of the root causes.
It covers some of the ground developed in Bills of Health.
HEALTH ECONOMICS: SUPPLY AND DEMAND
In the 20th century, policy makers tended to look only at the supply
side of the NHS equation, that is, the provision of medical, nursing
and paramedical services. In the 21st century a new approach is
required. If we are to create a health service that comes anywhere
near to satisfying demand, we must look at the whole picture - both
the supply of, and the demand for, medical services.
It is undeniable that the NHS is under funded in comparison with
similar countries, but as well as calling for increasing resources,
we must also argue for a decrease in demand.
DEMAND ON THE HEALTH SERVICE
Rising demand is caused by a number of factors. They fall into
two main groups, which might be termed the classical, and the politico-economic.
CLASSICAL CAUSES OF INCREASING DEMAND ON THE NHS
· Increasing age of the population
· New medical technology
· Increasing Patients' expectations
· Increasing practice of defensive medicine by doctors due
Charter and increasing litigiousness of users .
· Increasing incidence of chronic (longstanding) illness
POLITICO-ECONOMIC FACTORS THAT PLACE INCREASING DEMAND ON THE
· Poor housing,
· environmental conditions
· Breakdown of social cohesion
HEALTH IMPROVEMENT THROUGH POLITICAL REFORM
THE CASE FOR THE MEDICAL PROFESSION'S INVOLVEMENT
Politico-economic are well recognised by academic researchers, but
substantially ignored by health policy makers, possibly because
they are regarded as belonging firmly in the domain of politics
and economics, and therefore out of bounds to medical thinkers.
Such demarcations are a recipe for intellectual stagnation, and
also for a continuation of the unsustainable state of health services,
particularly in areas of high unemployment, social exclusion, poor
housing. By surveying - or, indeed as some will see it, invading
- the wasteland of unemployment, pollution and poverty that politicians
and economists claim sovereignty over, medical profession may be
able to bring about some clarity of thinking and even some useful
change. Dr John Snow was not a qualified water pump engineer, but
his action on the Broad Street pump brought about more health benefits
that any amount of learned papers on the causes of cholera.
Politicians used to lay the sole responsibility for health improvement
on individuals. The results of this policy are extremely limited.
POLICIES FOR HEALTH
The scope of Government scope to improve health is great. It will
be even better when Government begins some joined up thinking.
The argument that the BMA should pursue is summarised as follows:
· 1/5th of NHS spending (~£8bn/y). (16-22% to be exact)
is wasted in dealing with illness caused by unemployment, poverty,
poor housing and pollution.
· Unemployment is the root of these factors, since it causes
a loss of social cohesion, brings about poverty, and through opportunity
costs, allows poor housing and pollution to persist.
· There are 1-2 million jobs waiting to be done in pollution
prevention, house renovation, community work and many other socially
and environmentally beneficial activities, many of which will bring
about health improvements.
· The present benefit system exacerbates unemployment.
· A Wage Subsidies Bill would enable socially and environmentally
constructive work to be done, creating a more just, sustainable
and healthy society.
· This policy would be economically possible and advantageous.
BILLS FOR HEALTH
Bills of Health proposes four Parliamentary Bills to address the
problem of structural or politico-economic causes of ill health.
WAGE SUBSIDIES BILL
1. Changes to the benefit system that will abolish 100% marginal
taxation that is currently applied to benefits at the point in time
that the claimant finds work.
2. Minister sets up register &c.
HOUSING FINANCE BILL
3. A Bill that introduces the concept of Mortgage to the Treasury,
which will enable homelessness and substandard housing to be brought
to an end.
POLITICAL PARTIES (FINANCE) BILL
3. A Bill to prevent political parties from benefiting from corporate
AN UNWANTED EFFECTS RESTITUTION BILL
that will cause producers pay for the any adverse health effects
of their products.
4. Commercial products - for instance, tobacco, alcohol, sugar,
saturated fats, pesticides and solvents - cause a great deal of
illness. At present the onus is on the victim to "prove"
that s/he has been poisoned, and the causative agent is innocent
until proved guilty. It would be better if the producer should assume
the responsibility for paying (at arms length) for the cost of researching,
monitoring and making restitution for any adverse health effects
of their product. For instance, this would lead to a sugar levy,
hypothecated to the NHS dental service; a cholesterol tax on butter
and milk to pay for cholesterol lowering drugs, and so on.
ROAD TRAFFIC REDUCTION BILL
The medical profession should add its weight to the broad alliance
of NGOs pushing for a reduction in volume and speed in road traffic.
Reduction in traffic would carry the following health benefits.
1. It would result in a reduction in air pollution which will reduce
the number of episodes of
§ respiratory diseases
§ coronary thrombosis.
2. Reduction in noise from speeding traffic, which will result
in less stress overall.
3. Reduction in direct physical threat from speeding traffic, which
will result in less stress.
4. Greater ease of walking and cycling in the community (more exercise)
with more opportunities for interaction between citizens - gain
One in two people do not have routine access to a car. These are
therefore a disadvantaged group, which it is the Government's overt
policy to help.
With increased provision of public transport as part of the traffic
reduction package, the isolated rural disadvantaged will gain.
5. Lower burden of MVTA's on the NHS - less accidents - giving an
indirect gain by freeing up services.
6. Lower burden of bereavement caused by less road traffic related
deaths (currently running at some 4000 p.a.) leading to a gain in
7. The work created in traffic calming structures, cycleways and
footways will reduce unemployment, with resultant reductions in:
§ mental ill health (especially suicide and parasuicide )
§ GP consultations,
§ alcohol consumption,
§ illicit drug use
§ weight gain,
§ physical inactivity
© Richard Lawson