ANALYSIS
• National and local arrangements for priority setting, which are sometimes in conflict, and permitting the development of waiting lists to ration and delay access. • Managing resources through evidence based practice and protocols, and introducing new technologies largely through professional education and the National Institute for Health and Care Excellence (NICE) and its equivalents in the four countries. These provide a policy framework. However, the NHS and its clinicians and managers need constantly to adapt to the situation on the ground, make judgments, and manage politics and their patients ’ expectations. Alternatives to a comprehensive service The alternative to a comprehensive service is to limit the services either to a particular range available to everyone and/or to limit them to a part of the population. This would be typical, for example, of an insurance policy which had a defined set of benefits provided only to its policy holders. People would then have to pay for any additional services either directly or through an insurance system if they could afford to, or go without them. Defined benefits A defined benefits system has several drawbacks. The benefits package may be eroded over time to become a minimum safety net of services. Cash strapped governments might exert pressure to reduce benefits (austerity is a recent example) and commercial interests are likely to promote more expensive options as alternatives to the basic package. A safety net service is likely to lead to stagnation and poor services as innovation, development, and investment move into other areas with higher profitability. Inequality is likely to increase because poorer people can ’ tpay for additional services, and service quality and health outcomes may suffer if only some needs are met. A comprehensive system, in contrast, promotes innovation in the services available to everyone. We argue that a comprehensive service should remain as a vital aspiration that will constantly force planners and commissioners to consider how best to achieve it. It is a spur to progress, but it will only work when there is transparency and trust. Today ’ s NHS can best be described as a comprehensive service with some limited exceptions where resources are managed through waiting lists and other practical means such as NICE guidance and protocols. This needs to be publicly acknowledged together with a public commitment to making it as comprehensive as possible, adding new services as evidence of their effectiveness and value is demonstrated and resources permit. Priority setting will remain essential and must be conducted through public, visible, and accountable processes with everyone — patients, staff, and the public — having good information about what can or cannot be provided at any given time. Trust and transparency are essential. Health workers, who have to make decisions about treatment, as well as patients, will benefit from greater transparency in decision making. Defining benefits might be perceived as bringing certainty, but this is not entirely true. Difficult and disputed decisions will still need to be made. Defined benefits need to change as practice advances and, for example, insurance based systems that take a defined benefits approach spend a great deal of time and money on disputes about contracts and coverage.
The greatest anomaly in the English system is that social care, on which a lot of healthcare depends, is the responsibility of local authorities, is mostly means tested, and varies enormously between areas. Shared health and care management, as occurs in Scotland, Northern Ireland, and Manchester, offers a partial solution, but this approach is not widespread. The problem is beyond the scope of this paper. On the subject of clinical need, practice has become more sophisticated with, for example, patients and their advocates increasingly involved in clinical decisions through co-creation and informed choice. What matters to patients can be as important as what is the matter clinically. Similarly, assessing the health needs of populations and communities has become more comprehensive and needs to involve patients and citizens who can identify issues not recognised by professionals. Charging patients at the point of care Another alternative would be to provide a comprehensive service by charging patients for using some or all services through co-payments. This takes us to discussion of the NHS being free at the point of need. Aneurin Bevan, in his book In Place of Fear , argued that “ no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means, ” and describes the difficulties people had without a free health service. 12 The establishment of the NHS eliminated the catastrophic economic impacts that illness often had on an individual and their family. In contrast, two thirds of bankruptcies in the US (where services are largely insurance based) result from medical costs, and medical debt affects enormous numbers of people. 13 Charging for care might be expected to reduce unnecessary health service usage, affecting poorer people more acutely. The RAND Health Insurance Experiment, a randomised controlled trial conducted in the US between 1974 and 1982, was designed to assess the impact of cost sharing between the insurer and the patient, or co-payments, on people ’ s use of health services. 14 It showed that cost sharing reduced “ appropriate or needed ” medical care as well as “ inappropriate or unnecessary ” medical care. This had minimal impact on health status, except in people who were poor and sick, where the reduction was on average harmful: “ The projected effect (from having no charges) was about a 10% reduction in mortality for those with hypertension. ” 14 A recent report that considered these issues concludes that user charges are not an effective way of directing people to use health services more efficiently. It finds that people do not value interventions more highly when they have to pay for them out of pocket, and that even relatively small user charges can deter people from using needed healthcare. Such charges can reduce adherence to essential medicines and other forms of treatment, increase the use of other health services, lead to financial hardship, increase the use of social assistance, and adversely affect health, particularly in people with low incomes or chronic conditions. 15 One option would be to give exemptions to charging, as currently happens with prescribing, optometry, and dentistry. About 40% of the English population has exemptions, but almost 90% of items prescribed are exempt. 16 This is unsurprising given that older, younger, sicker, and poorer people, who are largely exempt, are more likely to need prescriptions and services. If the same exemptions were agreed, charges would be paid only by a small part of the population and would need to be high to make a material difference to the NHS budget. 17
the bmj | BMJ 2024;384:e078903 | doi: 10.1136/bmj-2023-078903
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