by Peter Watt
Yesterday saw the publication by NICE of their latest guidance on the use of IVF by the NHS. It said that women should be able to access IVF quicker (ie younger) and also that the upper range of women able to access the treatment rises from 39-42 in England and Wales. This has to be seen as a good thing, a reflection of the continued advances in medical treatment. What was in the past impossible becomes possible.
Except read the small print. What NICE are doing is providing advice to NHS Trusts as to what they can do if they choose to. As Dr Sue Avery from the British Fertility Society told the BBC:
“It’s good that there’s the possibility there, but the funding does not match. I can’t see any prospect of it happening immediately. Our biggest concern is hanging on to the funding we’ve got.”
Now quick declaration of interest here; my wife Vilma and I underwent IVF. Initially we had treatment on the NHS and then went privately. We were successful and have a beautiful daughter as a result. But at the time we were incredibly lucky that where we lived was still offering treatment on the NHS. Plenty of others no longer did or offered a much more limited service. Because the reality of the NHS is that on a whole variety of fronts it rations treatment.
On Tuesday there was a story about a man who had had a gastric band on the NHS but who was left with large amounts of excessive abdominal skin. His local health service had refused to pay for his apronectomy and he was facing a bill of some £15-20,000.
Or just think about the people refused cardiac surgery unless they lose weight or stop smoking. In some areas you can get some types of cosmetic surgery and in others not. In some areas certain services and procedures are available pretty quickly in others there is a longer period of waiting.
Across the Country there are debates about where maternity and A&E departments are sited with no area wanting to give up ‘theirs’ even though we don’t need as many as we have. In dentistry and optometry the NHS offers a fairly limited service by comparison to what is available privately. And all of that is before you get to the social care rationing which, depending on where you live, is contingent on what services you can access and at what point you are deemed weak enough.
Rationing in the health and social care sectors is a reality and has been so with increasing impact for many years. Politicians may decry the “post-code lottery” but it is a dishonest slogan. The notion that all decisions about what to deliver and in what way can be determined in Whitehall is clearly nonsense.
So over the years decisions have rightly been devolved; and if you devolve decisions then you should expect choices to be made! Now all of that was the case even when Labour decided to turn on the money tap.
Spending on the NHS has increased ten times since 1948. In today’s money we spent about £9 billion in 1948 and the 2012/13 budget is £108.9 billion. And labour massively increased spending so that from 1995 to 2006, the NHS annual budget more than doubled from £39 billion to £89.7 billion. Years of infrastructure underinvestment meant that the money was soon swallowed up. But it didn’t stop the rationing.
It certainly didn’t mean an end to the abuse and unnecessary deaths that the Francis report and others have exposed. In many ways, increasing spending that much and that fast without the requisite reforms of the NHS was one of the biggest mistakes of the Labour government.
As the Tories have shown, even pledging to ring-fence the NHS budget when other departments face cuts is not enough. An aging population and the onward march of technology, new drugs, treatments and staffing costs means that freezing the budget is an effective cut. If you then add in a need for huge efficiency savings then the results are there for all to see. But carrying on as we are is not an option. We simply cannot continue like this. At what point does the NHS have enough money? Is it £120 billion? £150 billion? But no one yet seems brave enough to say it.
Instead we get the doublespeak of efficiencies, local commissioning decisions and NICE. In government, Labour planned efficiencies and would not have ring-fenced the NHS budget. Now in opposition they decry the cruelty of the governments cuts. In opposition the Tories marched to save their local hospitals and slammed the government. At some point this has to stop.
People are not stupid whatever politicians may think. The only way that we can possibly begin to tackle the structural deficit in this country is to be honest with people about what is possible and about what is not. They can see that spending on some things will have to be curtailed and choices made. They can see that they will need to make some decisions themselves about their own lifestyles and priorities. They are quite capable of being part of a grown up discussion about this. But politically we don’t seem to be prepared to do this. We seem more comfortable demanding an end to the postcode lottery – until we are in government of course and it becomes local commissioning decisions again.
Peter Watt was general secretary of the Labour party
Tags: cuts, IVF, NHS, NHS rationing, Peter Watt, postcode lottery
All caused by having the insurer and the supplier being the same organisation.
Similarly the 40,000 avoidable deaths in the NHS is largely down to the regulator and the supplier being the same.
So what about honesty on the finances?
Why have you hidden 5,300 bn of pensions debts off the books?
Let me tell you. If they were on the books people would realize they aren’t going to get the 20p in the pound you pay for the state pension. They would end up not paying tax because it would be handing money over to fraudsters.
So you keep it a secret.
So why structural deficit? Why not the deficit?
I agree that political parties need to be honest about rationing and I think that it is for Westminster politicians to lead the debate on this issue. Leadership – a strategic vision – is what we expect of elected MPs; management – operational efficiency – is the what the civil service is for.
I personally think that there is a need for Westminster to say what should and what should not be available through the NHS. IVF is a good example of this; because it is medically possible for people 40 and over to conceive using IVF does not mean that the NHS should pay for it. An offshoot of this issue is whether the NHS should pay for IVF for homosexual couples to conceive; as I heard one medical commentator say – homosexual couples do not have a fertility problem, they have a conception problem.
The issue of which drugs and treatments should be made available on the NHS is a strategic matter; absolving responsibility for decision making in Westminster is (partially) what has lead to a postcode lottery. I know there is an argument for allowing individual trusts to allocate budgets regarding local need, however there are some treatments that simply aren’t appropriate for public money.
I appreciate that there are numerous ethical dilemmas; particularly with cancer and dementia drugs that extend life but offer no cure. The issue of quality of life is a subjective one and will vary from person to person. But as Peter states the money is not inexhaustible.
I do not agree with the statement “Across the Country there are debates about where maternity and A&E departments are sited with no area wanting to give up ‘theirs’ even though we don’t need as many as we have. In dentistry and optometry the NHS offers a fairly limited service by comparison to what is available privately.” I don’t have all the information to make an objective judgement but I think that local maternity and emergency care are an important service and both of these require spare capacity to efficacious. It may not be cost-efficient to run spare capacity but if people are to have the service they require when they need it most then there needs to be some allowance for peaks and troughs. You can’t plan to have 4 beds in a maternity ward because the average number of births per day is 3.7. On the day that 7 babies are born then 3 people either give birth in a corridor or are driven across the county in an ambulance.
The statement that closes that paragraph I do agree with ” And all of that is before you get to the social care rationing which, depending on where you live, is contingent on what services you can access and at what point you are deemed weak enough.”
For me one of the major issues affecting the NHS is the price of pharmaceuticals; the big pharma companies could amost be accused of racketeering. They make huge profits that far outweigh the risk that they take in their R&D expenditure. This is another industry where the risks are socialised and the profits are privatised. Drugs only comprise 10% of total outlay so reducing this expenditure is no panacea but it does not mean that we should allow rampant profiteering.
I agree with you Peter. I too watched the interview with the man who wanted apronectomy following surgery for obesity. To be honest, I had no sympathy for the man – he will just have to save up if he wants it done. It is not life threatening and really a consequence of his own lack of discipline in allowing his weight to get out of control. I also abhor homeopathic treatment being funded, plastic surgery for cosmetic purposes (it often occurs if someone can persuade a doctor that their small breasts (eg) are causing them psychological problems) etc etc.
I think we are spreading the limited resources too thinly. I fail to see why hospital patients do not have to pay for their food – this happens in other European countries. I do not agree with every new mother having a visit from a midwife. One midwife can have an open clinic if people need help. We are trying to do too much and as a result some of the things that matter such as surgery delayed and often life saving drugs not forthcoming. Sorry Peter, I do not agree either with IVF being funded by the taxpayer. I am old enough to know – it was not available during my child bearing years and in my opinion it is not an illness. I am not against all these treatments but should they be provided by a struggling NHS?
We have allowed the notion of the State will provide in every situation and somehow lost the concept of personal responsibility. Our Doctors have encouraged this too although I do detect a shift somewhat. At one time, we were not able to choose any treatment, medical conditions were not discussed with us, records the property of the NHS (still problems in this area). Look at how much routine work GPs are delegating to nursing staff and other non trained medical staff. I had a recent blood test and was surprised that it was taken by a former receptionist who had undergone a training course. This was not a problem for me but it does reflect change. Increased technology means that we are better informed about medical conditions and therefore was are a more challenging clientele to the medical profession. We need to continue to push this change to the users of NHS services. We have a responsibility to look after our own bodies – we have had enough education on health and diet by successive governments.
Rationing will always occur in the NHS. We could however rid ourselves of many procedures which although making life “nice” are not life threatening. At some time in the future we will have to look at what the NHS does provide and what can be reasonably stopped.
Finally, I have had experience of other health systems so am not blinded by politicians and others praising the NHS. It is not a wonderful organisation in all parts of the country, and some of us live in areas of the country that are unable to attract high quality medical staff. My own Trust is being investigated for high mortality rates – these were first reported in 2011 in Dr Foster and CGC reports. I have never been in hospital (will no doubt happen as I am of mature years) but fear ever being admitted as I think they would likely kill me. As to be expected, the same surgeons are now writing to journals (BMJ) blaming management for the death rates.
At some time we will need to ask the public what services the NHS should provide within allocated funding and allow us to make these decisions. We cannot rely on medical staff as their first priority is quite rightly to protecting their income. Will it happen – probably not in my lifetime as all politicians are frightened of upsetting the electorate. I think politicians are wrong. Stafford is not an isolated case although it is extreme. More and more of us are questioning the health model.
For once I entirely agree with Peter (though he is rather flippant about the “rationalisation” of A&E and maternity services). Whatever the budget, some form of rationing is inevitable, and the more rational and objective it is the better which is why NICE was an excellent creation.
I do think that a critical argument which Peter misses, however, though it is touched on by Robin Thorpe, is the role of pharmceutical companies, but it’s not just about “racketeering” (though there is some of that). Pharmas spend too much developing “me-too” drugs and not enough on more innovative drugs – a market failure if ever there was one which ought to justify more money going into academic medica research). As a result of that, and their need to satisfy shareholder interests, they often sell drugs at inflated prices which are simply poor value for money in comparison with other uses.
Pharmas have a financial interest in encouraging patient demand for these poor value drugs, which they engage in in various nefarious ways which can be politically difficult to counter especially in the case of end of life treatments. It would be much better for politicians to proactively defend inevitable rationing than simply to fire-fight the understandably emotive appeals by people in, for example, the advanced stages of secondary cancer.
I do not agree with Jane, however, that we should write off whole areas of treatment. What is meant, for example, by “cosmetic surgery”? Does that include cosmetic reconstruction after a mastectomy? I think not! In fact, NICE deals with these things quite well too.