Our healthy future

Thursday, December 1, 2016
Dr. Rupert Beale


Conservatives must rediscover and apply authentic conservative principles if we are to win public trust over the NHS, explains Rupert Beale

Primum non nocere- first, do no harm - is the foundation of all good medicine; it is also the great conservative principle. Why then should we allow the political Left to have the whip hand in matters pertaining to health? I’ve no doubt that a future Conservative government could make the NHS the best healthcare system in the world; but it must first rediscover conservative principles. I emphasise rediscoverbecause economic liberalism, powerful as it is, has little useful to contribute to front-line healthcare. That of course does not mean that the NHS can learn nothing from best practice in commercial enterprise, far from it, but rather that the NHS at its best is an institution like the army or judiciary: something that the UK indisputably does brilliantly despite, rather than because of, a lack of consumerism.

The fundamental problem with consumerism in healthcare is what might be called ‘information asymmetry' by economists, or ‘doctor knows best’ by everyone else. We have to be able to trust our doctor when we are at our most vulnerable; it’s important for all concerned that they don’t even indirectly have profit as a motive. You might hope that a doctor would not expose a patient to danger and prescribe an unnecessary drug or suggest a futile operation purely for financial gain. But even assuming all healthcare professionals uphold high ethical standards, is it so wicked to recommend a test of marginal diagnostic utility, or consult a variety of colleagues (each billing for their expertise) about a relatively trivial problem? There’s plenty of evidence that this drives up the costs and decreases the efficiency of healthcare in the US, and we cannot afford this creeping into the UK.

Doesn’t a lack of consumerism entail ‘producer capture’, a healthcare systemdesigned around the needs of healthcare providers? This particular ‘producer’ finds that hard to credit though undoubtedly changes to increase flexibility of the NHS workforce would be welcome. Increased flexibility would improve both staff morale and organisational efficiency (although there is an issue with healthcare unions, who represent their members’ interests rather poorly). Despite this, the NHS compares very favourably to marketbased and mixed-provision models of healthcare across Europe and across the Anglosphere. We score highly for efficiency, and poorly for what might loosely be termed ‘customer service’. This suggests the NHS operates on a benignly paternalistic basis, which we on the Right should have no problem with whatsoever.

Is it possible to construct a free market in healthcare? Could this not increase efficiency? After all, we trust supermarkets to deliver food, and the motor industry to make cars - clearly the government couldn’t take on these roles - isn’t the NHS the Trabant of the west? The evidence suggests otherwise: Trabants were awful, by any sensible international comparison the NHS does pretty well. Furthermore, even allowing that it might be theoretically possible to have a market-based system that actually worked, as conservatives we have to be deeply suspicious of trying to fix something that isn’t particularly broken. “Wouldn’t it be lovely if...” doesn’t constitute the proper basis for policy; we can safely leave that kind of nonsense to the Left - I’m thinking especially of the kind of Utopianism so rampantly on display from the ‘Yes’ side in the recent Scottish independence debate. We have a socialised system of healthcare, it works fairly well, it is the settled wish of the British people that it should remain socialised, and it is frankly not realpolitik to wish to change this.

If the NHS is doing well, do we simply rest on our laurels, secure in the knowledge that innovation will take care of itself, and that no reforms will be necessary to cope with the burdens of an ageing population and higher expectations of healthcare, whilst at the same time not increasing the share of GDP allocated to health? Obviously not – but the last point is important. We can’t simply throw money at the problem; even if we had that money to throw it wouldn’t guarantee much of an improvement. The only viable solution is to concentrate on exporting and expanding best practice, from those parts of the NHS which function well to those that don’t. How?

In my own speciality, nephrology, a great deal of care and attention is lavished on kidney transplantation. A group of very dedicated physicians, surgeons, immunologists, nurses, dieticians, pharmacists and other healthcare professionals work together cohesively and cooperatively. Data on outcomes is collected meticulously, and compared to other centres both nationally and internationally. Problems are anticipated as well as merely identified, unnecessary expenditure is carefully avoided, and a constant desire to improve things for patients underpins everything that’s done. It’s hardly a surprise that outcomes in kidney transplantation in the NHS compare favourably to anywhere else in the world. The challenge is to export this highly academic ethos to other parts of the NHS: the less glamorous work of caring for the elderly should have no less dedicated staff.

It’s not a question of throwing monetary resources at the problem. In fact, we waste a huge amount of money providing inappropriate drugs to elderly patients when what we should be providing is good quality basic care. It’s bad enough that we should spend money inefficiently, but worse is that we may well be spending money and causing harm. A lack of proper data about whether what we are doing is actually leading to positive health outcomes cripples our ability to appropriately allocate resources. An academic ethos – by which I mean a focus on research and teaching, subject to peer-review – is the best guard against poor data, poor scrutiny and poor outcomes.

Exporting this academic ethos requires an extension of academic medicine from the confines of teaching hospitals to those parts of the healthcare system currently most distant from it, and it also must include appropriate training and mentoring of junior and middlegrade staff. This latter group constitute perhaps the most disaffected group of NHS workers; they have been very poorly served by New Labour reforms, and the coalition has perpetuated many of these errors. It should be a particular focus of future Conservative administrations to enthuse and empower junior medical staff. We should enable them to be unafraid of the charge of ‘elitism’ . We want them to be unashamed to be excellent, nobody wants a mediocre doctor, and in a system of socialised medicine the only real driver of improvement is to ensure we have excellent and highly dedicated staff.

I’ve set out some general principles by which I think a future Conservative administration should improve the NHS: use the existing excellence within the NHS to drive up the standards across the board, avoid any privatisation of frontline services, collect meaningful data and use it to allocate resources and avoid causing harm. There are probably a variety of concrete policies that might coalesce from these principles, but there’s only one which I think must be unavoidable: a future administration will have to grasp the NHS IT nettle. It may well be desirable to do this on a regional, rather than national, basis in the first instance – and, in sharp distinction to frontline care where the NHS has genuine internationally recognised strength, this will absolutely require the private sector, as well as some of the sharpest minds in the public sector.

There are further benefits of sticking to conservative principles on the NHS. By properly enshrining public ownership and public benefit of the NHS as a core Conservative policy, we would allay fears of healthcare professionals and patients, as well as preventing a potential line of attack from the Left. As an illustration of the power of this line of attack, it was bogus scaremongering over the NHS that propelled the Scottish Nationalists to within an uncomfortably close distance of success in the Independence Referendum. This was despite the fact that the attack made no logical sense whatsoever, given the devolved nature of the Scottish NHS!  We have to believe in a publicly owned NHS in our hearts and minds, and we have to prove that we mean it.

Dr. Rupert Beale is a consultant physician working in London

This article was originally published in Crossbow, the Bow Group Magazine - Conference 2014 on 27/09/2014. Published online 01/12/2016