The National Health Service: A Cultural U-Turn

Contemporary Britain has redefined and extended the roles of the National Health Service from simply treating illness to its prevention, educating the masses and extending life. In its plight to meet all of these criteria, or face torrents of criticism, the NHS has reached a stalemate on its 70th anniversary. Despite receiving £116.4bn in funding (2015/16), it is under fire for shortages of staff and beds as well as prolonged waiting times.

Now, there are calls to modify the NHS from the likes of Mark Pearson (the OECD’s Deputy Director of Employment, Labour and Social Affairs). Others, such as Dr Kristian Niemietz of the Institute of Economic Affairs, have advocated the complete discontinuation of the NHS and its replacement with universal healthcare. The latter may not be necessary if significant changes are made to British attitudes towards health and the norms and practices within medicine.

Increasing the accountability of British citizens by adopting an insurance-based healthcare system is a possible solution to the high demand hospitals face, especially the pressures felt during the winter months. If people have to make insurance payments to receive treatment, the financial commitment is likely to cause a shift in British attitudes towards health, i.e. people will be more compelled to maintain their health without professional medical intervention.

Lifestyle-related illnesses in particular would see a significant decrease. Giving people more personal responsibility for their health could be the key to increasing general health by establishing a more health-conscious culture in Britain, reducing long-term costs to the NHS.

Switzerland exemplifies this: each individual pays insurance premiums worth up to 8% of their annual income. As of 2014, Swiss people are spending an average of 6% of their income on healthcare (this is predicted to increase to 11% by 2030) compared to 5.7% of taxable income in the UK. The system is aimed at promoting health, reducing costs, and encouraging each individual to be responsible for their own health.

Right now the NHS is hampered by the mantra that it is truly “the envy of the world” and any reform from its current model would amount to dismantling Nye Bevan’s legacy.  If this idea is maintained, an insurance-based system will be politically infeasible.

This is not to say that paid healthcare, co-pay or insurance systems would result in a utopian society in which nobody is sick - for instance, diabetes is equally prevalent in Switzerland and the UK (approximately 6%).

But sustaining life is arguably the most vital function of health services, and it appears to be a greater strength of insurance-based healthcare. Switzerland has one of the highest life expectancies in the world and one of the lowest mortality rates in Europe. Notably, the 2015 Euro Health Consumer Index described Swiss healthcare as excellent.

In light of this, the extent to which the NHS can be considered “the envy of the world” becomes questionable. Comparisons with Switzerland and other European nations suggest that British healthcare may not even be the envy of the continent, let alone the world.

At this point in time, the state of the NHS is undeniably inadequate and therefore cannot continue; adult five-year cancer survival rates in the UK are often lower than the European average. For colon cancer, rates were up at 58% by 2007, whereas in the UK, rates were at 52%. Even if sweeping reforms currently lack support from the government, the question of the possible changes that could be implemented in the meantime remains. There are various incremental reforms that could significantly improve outcomes. A starting point for this could be rectifying attitudes and practices deeply ingrained in clinical settings.

Perceptions of accountability must be revised among medical staff. Matthew Syed’s Black Box Thinking addresses the issues of failure and blame at length. Syed makes pertinent comparisons between the industries of healthcare and aviation. While the Aviation Safety Network has reported 2017 to have been the safest year in aviation history with only 44 fatalities in 10 airliner accidents, a report has found that medication errors alone could be causing over 22,000 deaths in the NHS as of 2018.

Syed attributes this difference to the stark contrast between the procedures following accidents in the two industries. When a patient dies unexpectedly, this is met with blame and back-covering; Syed used the real-life story of a woman who died in a routine operation as an example of this. When a plane crashes, while the media reacts with blame and outrage, the aviation industry itself responds with a full analysis of the jet’s black box and body. In fact, Syed goes as far as to suggest that aviation investigators welcome mistakes, which might sound morbid, but he is referring to the opportunity to improve a system when its flaws are exposed.

Elsewhere this approach is going to become more and more important. When cars crash because of human error the tragedy is personal but few people learn lessons from what went wrong. When an automated car crashed in February killing a pedestrian the entire fleet of self-driving cars learned lessons.

This is applicable for our healthcare system; the NHS needs to establish a climate in which staff are able to come forward with their errors. Those very same mistakes, if exploited fully, are the route to improvement. But only if the incentives are right.

Another area for cultural reform in the NHS is the need for an openness to openness, if you will. Interdisciplinary collaboration can prove to be crucial in the progression of any organisation. For instance, the use of graded assertiveness, also known as the P.A.C.E. model of communication, is now commonplace in nurse training. P.A.C.E. (which stands for Probe, Alert, Challenge, Emergency) addresses what social psychologists call the legitimacy of authority - in the hierarchy of staff in a hospital, nurses are liable to see doctors as superior to them and therefore obey them unquestioningly, irrespective of what they think. Graded assertiveness provides them with a method of communication that can enable them to overcome the intimidation they may experience when attempting to express themselves with urgency in high pressure scenarios.

Introducing P.A.C.E. required honesty from the healthcare industry regarding the existence of a hierarchy and the fact that under pressure, doctors can become error-prone. Similarly, a candid evaluation of the predictive value of the NHS is required.

Open Healthcare has been proposed as a method of increasing the predictive abilities of patient records by combining them with data from healthtech companies and giving patients greater access to their personal records. It is thought that patterns can be drawn from the collated information, giving a greater insight on the causal relationships between genes, lifestyle habits, and illnesses, which could better inform future diagnoses and treatments. We could live longer and happier lives. With the ONS estimating 24% of deaths could be postponed through lifestyle choices, Open Healthcare (and openness in healthcare) could be key to allowing people to make better informed decisions over their own lives.

Spending more and more on an inefficient system in the hopes of achieving miraculous change is comparable to adding water to embers and expecting an inferno. Funding is imperative if some semblance of the NHS is to continue, but there has to be difference in the way everyone (from patients to bureaucrats, from doctors to contractors) approaches healthcare in the future.

Nonetheless, the necessary change may not be as drastic as some suggest, particularly critics advocating the total dissolution of the NHS. It is more than likely that the seemingly insignificant things, like nurse-doctor interactions, can collectively overturn an entire system, yet leave the elements people want – free services at the point of use – intact.

Fadekemi Adeleye is a research intern at the Adam Smith Institute.