Clinical Need, Not Ability To Pay


London, England 1992: An NHS Midwife in the East London home of a new mother. NHS midwife’s provide help, care and instruction from prenatal, through birth, and on for several weeks there after. This midwife clients included immigrants, working class whites and several affluent families who had begun to move into her Docklands service area. Photo copyright: Robert Gumpert 1992

The pressures on the NHS’s resources are enormous and at the same time the austerity imposed by the Conservative Government means that staff have had a pay freeze that has seen the value of their salaries drop by 10% over a decade. And further, Brexit puts into doubt the position of 130,000 European doctors, nurses and technical staff who work in the NHS. Morale is at a pretty low ebb.

The British love their NHS, it offers fundamental peace of mind; security in the face of the worst-case scenario and no one has to worry about the cost, it’s free at the point of use. While naturally enough some Hospital Trusts are better managed than others and some doctors are better than others, everyone is, in theory at least; able to choose where they want to receive their treatment and care.

It’s first two founding principles where and are:

1. The NHS provides a comprehensive service available to all.
2. Access to NHS services is based on clinical need, not an individual’s ability to pay.

These principles established by the Labour Government of 1945, are still held onto and are doggedly maintained. The NHS is paid for out of general taxation and at the time of writing the annual budget was around $150 billion making average costs for a family of four in the UK around $10,000 per year compared to $25,000 per year for a family of four in the USA (Forbes May 15th 2015).

So what do you actually get? Knowing some of the issues that have affected American friends and their families here is a far from complete list: all maternity care, pre and post natal, hospital or home deliveries, ‘c’ sections, neo-natal care and after care are provided free. All childhood vaccinations, dental plan to 18 years old, eye tests and glasses are provided free. Everyone has a right to join a General Practitioners surgery and receive free examinations and consultations and referrals; these practices are pro-active and call patients for examinations and assessment at key life points, which get more often as one gets older; for example regular smear tests and mammograms, tests for bowel cancer, cardiovascular revues, flu shots, all this is free. If you, or any member of your family or anyone, has an accident, whatever it costs: ICU, surgery, nursing care and rehabilitation, the NHS pays. If you have a long-term illness, preexisting congenital defect, or you’re struck by lightening, the NHS will aim to give you the best treatment and care available, and yes it’s free.

It’s true that some areas are limited, or that you’ll need to show special need to get in a programme, but fertility treatments, some cosmetic surgery procedures and gender reassignment treatment are all available on the NHS; yes for free.

Ten years ago a friend of mine in the US was diagnosed with liver cancer. He had a number of major operations paid for by the medical plan at his place of work. After a year or so and close to a million dollars worth of health care, his insurers decided there was a problem with his insurance and withdrew his care. There was still a lot of treatment needed. When he threatened to sue they said go ahead, knowing full well he’d be dead before the case was settled. Luckily he was an UK citizen though he hadn’t lived here for decades. He returned to the UK and the NHS took up his care. He lived a further 5 years. I asked once what the difference between the US system and the UK system was? He pondered a moment and replied, “The American doctors’ waiting rooms are nicer.”

Come to the UK, open any newspaper, any day of the week and you’ll almost certainly come across a horror story about the NHS. Over crowding, long waiting times, mad or bad doctors, or shortages of trained staff. Of course, 99% of people, or more, are perfectly happy with their treatment from the NHS, but in an organisation that employs 1.5 million people and treats 65 million, there are always going to be horror stories.

However generous you want to be there are practical limits of a nationalized health service and defining those limits is a complex ethical as well as financial problem. A few years ago an American Republican nominee made some remarks about the terrible healthcare in the UK, that the NHS had ‘death panels’ groups of people who would decide if you lived or died. He was picking up on an organisation with the rather ironic acronym N.I.C.E, that is, the National Institute for Clinical Excellence. In the NHS, someone has to decide on the efficacy of treatments and drugs, against their costs. Stories involving NICE often revolve around a person with a terminal illness who has read on the internet that a new drug might give them another six months of life, unfortunately the treatment costs thirty grand a month and is effective in less than 40% of cases. Of course if it was you, you’d want the chance, but what is an NHS supposed to do? It’s tough, but of course some arbiter has to exist; you can check out NICE here. It’s a highly ethical, transparent organization that does a hell of a job, but do they make mistakes? Well, probably, but would I rather they or an insurance company decided the need for an expensive drug or procedure? What do you think?

There is no denying the strain being felt on the NHS at the moment. Supporters point out that if we increased our per capita spending to just the average of other main European states’ public health services, it would solve many of the outstanding problems. John Appleby, Chief Economist with the Kind’s Fund estimates that the UK would need to invest another £16 billion, about 10%, just to keep pace with growth and an increase of 30 % or £43 billion just to achieve the average spending of the top 14 European countries.

In Britain at the moment there is a movement towards the position that austerity is not the only way to balance the budget as has been suggested by the Tories; that taxing the richest in society can help bring stability and growth to the economy. People are realizing that the world class health service they were told they had, doesn’t quite measure up. The only way to achieve it will be through further taxing and spending and even the Tories are beginning to realize that is going to have to happen.


About the author

Neil Burgess

Neil Burgess has worked as an agent, editor, curator, and publisher within the field of contemporary photography for more than 30 years. He was the founding director of Magnum Photos London and bureau chief of Magnum New York. Since founding *nbpictures, an international photographer's agency based in London, he has represented the work of some of the world’s leading photographers, including Sebastiao Salgado, Annie Leibovitz, and Don McCullin. View all posts by Neil Burgess →

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