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Introduction

Almost everybody agrees that the UK National Health Service (NHS) is in need of radical reform, so let's start to spell out what that reform might look like. Other countries manage to deliver prompt and effective healthcare: it's not impossible. But we have to want to do it, and we have to believe it is possible.

Details

Aim

For a start, we need to change the primary aim. The NHS currently aims to deliver cost-effective treatment, but it should aim to deliver prompt and effective treatment.

The current system seeks to maximise the effectiveness of the NHS resources, which are primarily the people - that is, the NHS people. What this means is that outside every Doctor's waiting room there is a queue of people waiting to see the Doctor. This ensures that the Doctor is never waiting to see a patient, never under-utilized. It means that the Doctor is constantly working as hard as possible, which produces burnout and early retirement, or a move to a country which treats its Doctors more humanely. And it means the patients have to wait - wait for an appointment, and then wait in the queue; it delays treatment, which often results in the condition getting worse (and thus more expensive to treat), and also results in the patient experiencing a reduced quality of life and often a reduced performance at work as well.

In seeking to maximise the effectiveness of the NHS, we inevitably create many other costs which are carried by the individuals who are suffering, and also by society as a whole in lost production - all the people sitting in queues in the hospitals and Doctor's Surgeries could be doing something useful with their time, if they were not forced to sit and wait for their name to be called.

The current system aims to be cost-effective, but it is measuring cost-effectiveness the wrong way: it is looking at resource management, when it should be looking at service delivery: sickness imposes a cost, to the individual and to society, and we should be seeking to minimise that cost. We should be focussing on prompt and effective treatment: making people better in the most effective way, as quickly as possible.

The cost of delivering the service is irrelevant: what matters is the real cost - which includes both the cost of delivering a healthcare system and the cost of sickness. According to the Financial Times, in February 2024, sickness cost UK businesses £138.3bn in the previous 12 months - and this is only one part of the real cost. People leave work or cut their hours to care for a sick partner or child, the self-employed simply don't work; neither the sick people nor those caring for them generate as much economic activity as they would - they don't have the money to spend, they don't go out for meals or to the pub, or cinema, or theatre. And then there is a further opportunity cost of what the sick people could be adding, in work, in volunteering and in other activity: sick people don't start up businesses, write books, compose songs, paint landscapes, or care for children and other relatives as well as they could. And that is before you start to think about the actual human cost, including all the unnecessary suffering.

Physical and Mental Health

Governments have long been promising to put mental health services on a level playing field with physical health services, but this never happens. The reasons for this are complicated. One aspect is that you can't measure a mental health problem, and if you can't measure it, you can't manage it - not with the tools we choose to use.

Partnership

The downside of a national health service is that it tempts people to stop taking responsibility for their own health: I can eat what I like and exercise as little as I like, and if I get sick it's the job of the NHS to make me better.

Scope

We need an honest discussion about the scope of the treatments which the NHS should provide. An effective NHS does not have to provide every treatment which people want, and there must be some restriction in the provision of expensive and unproven treatments: these are difficult questions, but they don't get easier by ignoring them.

Infertility is one obvious area to consider. It is clearly a dreadful problem for many people, but do we actually have a right to produce genetic offspring? And cosmetic surgery may make a person feel better - for a short while, at least, but it is arguably counter-productive in terms of helping people grow and develop as human beings. Are there other areas we need to think about here?

The Bigger Picture

We cannot tackle health problems - whether physical or mental - if we only look at the individual. People who do not have somewhere suitable to live are sitting in hospital beds, as are people who do not have the support they need at home or in their community. People are made sick by bad housing and polluted air. They need good homes, families, communities, jobs, leisure activities.

We can blame the individual for their addiction, but addiction is largely the result of living in a sick society: people generally become addictedd because they are either seeking pleasure or avoiding pain, and there are much better ways of achieving both these ends.

There is little point in getting better at fixing people, if we do nothing about the things which are breaking them.

I take your point that the cost of healthcare can be measured not just by the cost of provision but by the cost of not providing it - the reduced productivity of people who are unable to work due to illness or the need to care for someone who is ill. The trouble is that it would take a brave government to increase health spending and gamble on getting it back from people being more able to contribute to the economy. Many consumers of the health care do not contribute economically in any case - the elderly, and children, for instance. Health policy is already increasing it's emphasis on prevention, by education and by vaccinations and screening. Having just reached 65, I have been offered vaccinations for shingles and pneumonia, both of which must cost money in the hope that I won't get admitted to hospital and cost even more money because I become ill with one of those conditions.

Regarding mental health: it is not entirely true that it cannot be measured in the way that a physical illness can. There are various questionaires that rate the degree of a person's symptoms of an illness, such as the Beck Depression Inventory, and in my work we were asked to rate people in these ways before and after treatment. This could be used, for instance, to determine the effectiveness of types of medication and of talking therapies (and ideally of a control group). But it also true that mental illness is less predictable than physical illness and so it does not work to base spending on the projected length of time for which they should be in hospital. If a person has a Personality Disorder as well as a formal mental illness, it can totally throw a spanner in the works of planning: but PD cannot be ignored as the suicide rate for PD is higher than for most forms of mental illness.

If cutbacks, or at least re-prioritisation of health spending, is necessary, then possibly the fertility treatments and cosmetic treatments that you mention could be deemed a "like to have" rather than a "must have". But this would prove controversial to say the least - and as for gender reassignment treatments, let's not go there!

Adrian

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Comments

Adrian Roberts May 5, 2025 at 10:41pm

Paul

I take your point that the cost of healthcare can be measured not just by the cost of provision but by the cost of not providing it - the reduced productivity of people who are unable to work due to illness or the need to care for someone who is ill. The trouble is that it would take a brave government to increase health spending and gamble on getting it back from people being more able to contribute to the economy. Many consumers of the health care do not contribute economically in any case - the elderly, and children, for instance. Health policy is already increasing it's emphasis on prevention, by education and by vaccinations and screening. Having just reached 65, I have been offered vaccinations for shingles and pneumonia, both of which must cost money in the hope that I won't get admitted to hospital and cost even more money because I become ill with one of those conditions.

Regarding mental health: it is not entirely true that it cannot be measured in the way that a physical illness can. There are various questionaires that rate the degree of a person's symptoms of an illness, such as the Beck Depression Inventory, and in my work we were asked to rate people in these ways before and after treatment. This could be used, for instance, to determine the effectiveness of types of medication and of talking therapies (and ideally of a control group). But it also true that mental illness is less predictable than physical illness and so it does not work to base spending on the projected length of time for which they should be in hospital. If a person has a Personality Disorder as well as a formal mental illness, it can totally throw a spanner in the works of planning: but PD cannot be ignored as the suicide rate for PD is higher than for most forms of mental illness.

If cutbacks, or at least re-prioritisation of health spending, is necessary, then possibly the fertility treatments and cosmetic treatments that you mention could be deemed a "like to have" rather than a "must have". But this would prove controversial to say the least - and as for gender reassignment treatments, let's not go there!

Adrian

This reply was deleted.

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Reforming the NHS