Historical Perspectives On Contemporary Issues

I’d like to thank the speakers for two really stimulating talks. With such provocative material, it’s a pleasure to respond. As my fellow commentator, Dr. Alex Mold, points out in her excellent piece, “Shopping for Health” looks, in some ways, very different from the perspective of the United Kingdom, with its universal health provision free at the point of need. The “internal market” notwithstanding, the UK’s National Health Service (or more accurately, its four separate national health services – NHS England, NHS Scotland, Gig Cymru in Wales, and Health and Social Care in Northern Ireland) is rarely perceived or culturally represented as a marketplace. And while the UK has a flourishing medical marketplace for over-the-counter, alternative, complementary and health-related products and services, these are rarely considered in the same light as medically mediated goods and services, whether they are prescription drugs, professional services or expert consultations. Indeed, other than in dentistry, privately purchased medical services, as opposed to services commissioned by the NHS from private and corporate providers, are and are likely to remain a minority concern for most British citizens. In the most recent figures available (for the year 2016), 79.4% of all healthcare spending in the UK was paid for directly from government coffers – and thus from general taxation. To date, UK citizens need not carry identification to access these services, and even with my noticeable US accent, I have never in almost 20 years of living in Britain been asked to prove my right to use these services. Implicitly or explicitly, consciously or unconsciously, in this country, access to medical treatment is regarded as a right for all residents.[1]

This view of healthcare has had profound effects of the British medical marketplace, marginalising many forms of health consumerism that have flourished in the USA. Private medical insurance offers one such example. Even at its peak in 2008, only 12.4 percent of British citizens (some 4.35 million people) carried any private health insurance for use in the UK. Even with concerns about Brexit prompting more companies to offer their employees private cover, the most recent figures available suggest that just over 4 million Britons have any private health insurance. Since over 3 million of those receive that insurance as a workplace perk, it is clear that the consumer appetite for pre-paid access to purely commodified medical care is limited. Individual subscribers – that is, people paying for health insurance themselves – make up only 952,000 of the policies in the latest figures available, though some of these will include cover for dependents.

There are a number of reasons for this low uptake. Private policies cost on average some £650 per year for healthy individuals in their thirties, escalating to some £2300 for individuals in their 70s, who are much more likely to claim.[2] This is seen as an unaffordable luxury for many, particularly since the NHS, for all its flaws and waiting lists, is perceived as reliably excellent at providing both emergency and acute care. In fact, while critical attention to failings in the UK’s national health services has been an abiding feature of the British news media since 1948, and has expanded rapidly in the wake of both cost cutting and with the rise of an ever-larger elderly population with complex needs, so too have cultural representations of a heroic, high-tech, and above all compassionate health service. British contemporary culture abounds in such imagery, perhaps most powerfully via wildly popular reality/documentary programmes including “24 Hours in A&E” (14 series and two special broadcasts so far); “GPs: Behind Closed Doors” (now showing its sixth series); “Ambulance” (in its fourth series); and “Helicopter Heroes” (in its eighth series of covering what are in fact only partially public, NHS-funded air ambulance services). The health service is also portrayed, largely positively, through historical and dramatic programmes ranging from the very popular and now internationally distributed “Call the Midwife” series to the wealth of historical documentaries recently produced to celebrate its 70^th anniversary. It is perhaps worth noting that these historical representations often include unflattering (and not always entirely accurate) comparisons between access to care under the NHS and in pre-NHS Britain, while the proliferation of US medical dramas on UK television ensures that UK audiences are acutely aware of the frightening limitations of wholly marketised, for-profit medicine for all but the most affluent.

Practical as well as cultural factors are important in curbing UK consumer demand for medical services on an insurance or fee-for-service basis. Private hospitals notoriously and controversially rely on NHS-trained medical staff, and beyond London patients are likely to see the same specialists whether in an NHS clinic or its private equivalent. No UK insurers cover emergency or primary care, and few offer cover for two of the non-emergency services most likely to be used by their 30-64 year old customer base: maternity and mental health care. Best current data suggest that truly “comprehensive medical insurance” simply is not available to UK consumers, precisely because it is not needed. Private general practice does exist in Britain – indeed the right both to practice medicine and to purchase medical care beyond the NHS was guaranteed in the 1948 Act that established the NHS in England and Wales (and in the separate Acts for Scotland and Northern Ireland). However, uptake is vanishingly small as compared to the use of NHS primary care services: the most recent data suggests its extent to be some 7 million private GP consultations, less than 3% of the total.

The NHS very publicly struggles, and in almost every region, fails to meet public demand for mental health services, so US readers might expect a different picture of “shopping for health” in this sector. But while the private mental health care sector earns its providers over twice as much as private family practice (approximately £1.1 billion as opposed to £500 million per annum), 87% of its consultations are in fact paid for by the NHS, and only 7% were purchased by individual consumers. In fact, children, adolescents and the (retired) elderly are all but invisible in the in any case unimpressive ranks of the privately insured in the UK, making its provision very profitable, but culturally almost irrelevant. In essence, when people talk about healthcare in the UK, they mean the NHS. And in the NHS, equality of access, if not of outcomes, is both assumed and fiercely cherished.

One site in which this difference becomes very clear relates to local and regional variations in health service provision. This is an increasingly pressing topic for national as well as local policy makers in the current economic and political climate: as austerity drives cuts in health service provision, sharp regional divides – economic, social and political – prompt loud calls for greater local and regional autonomy. Yet one of the most enduring and pervasive critical discourses pertaining to the NHS, at least since its proto-marketisation in the 1980s, addresses the much decried existence of a “postcode lottery” in access to services and treatments.

As one US observer wrote, evaluating the NHS at its 10^th anniversary in 1958:

The logical difficulties of [national health] planning … inevitably lead to psychological tensions which may become quite unbearable in a period of serious scarcity. To decide between the relative weight of an improvement of the mental health versus the tuberculosis service, or between the demands of the Newcastle versus the Manchester region… may try emotional stability as well as the calculating intelligence. (Eckstein, 1958, p. 272).

This has certainly remained the case. Far from offering a solution, the loosening of top-down guidelines and homogeneity initially encouraged by the advent of the NHS internal market and the deployment of “GP fundholding” (a policy from 1991-1998 which granted some general practitioners greater control over their practice’s share of the NHS budget, and allowed them to commission services independent from national health objectives) produced greater strains. Neighboring primary care practices, local areas, and regions of the UK funded different packages of services for their patients, based on expert assessments of need, local health priorities and often-vague notions of “community standards”. This might have been seen as opening a space for local consumers to act on the health service, and to allow demand to drive provision. But instead, when members of the British public found themselves denied a treatment offered to a friend or acquaintance, or described as available by the media, they were infuriated. In a national health system, funded by general taxation, not local or regional hypothecated taxes, local variation was read straightforwardly and consistently as iniquitous – as a “lottery of care” undermining the equality that was perceived as a fundamental feature of Britons’ right to medical care. This model has been subsequently recapitulated – with much the same disputatious effects -- by the current dispensations of “Clinical Commissioning Groups” and regional devolution.

As the levels and range of services available free at the point of delivery in the NHS expanded to include treatments intended to improve as well as to preserve life – for example, fertility treatment, smoking cessation, addiction prevention and treatment, “psychologically necessary” plastic surgery, gender reassignment surgery, gastric band and other weight reduction modalities, even wheelchair provision – and a wide range of expensive new chemotherapeutic and pharmacological interventions, local decision-making became ever more problematic. Alan Milburn, the first Labour Health Secretary for 18 years, argued in 1997 that, instead of opening the door for a more consumer driven and responsive health system, market-driven NHS reforms were perceived as setting “hospital … against hospital, doctor against doctor and patient against patient. … In the two-tier health service, access to care depend[ed] on the lottery of patients' post codes and their GP practices.” (Milburn, Hansards, House of Commons, 25 June 1997). Markets and the variations they produce were and are simply not readily understood or accepted in the area of healthcare. And while Britain’s consumers were more than happy to shop for over-the -counter pills and potions, skin treatments and vitamins (to the tune of £2.6 billion in 2017-18 alone) and an ever-growing array of health-related products – from “slimming aids” to medical devices (accounting for an estimated additional £810 million per year) – they were far less enthusiastic about the concept of choice driving service availability in the NHS.[3] In terms of healthcare, “never enough” in the UK context is balanced by “never unequal,” at least in the public imagination.