NHS rationing: we need honest politicians to tackle the taboos

I’ve just taken part in a discussion on BBC Radio Kent on the emotive topic of IVF on the NHS. No one can deny, including myself from personal experience, that trying to conceive for some couples is an emotional rollercoaster. The current concern in Kent from infertility consultants is that new guidelines will reduce the availability of IVF to couples in Kent. Before we dismiss this with a ‘they would say that, wouldn’t they’, it is vital to look at the bigger picture.

There are two interconnected big taboos on which politicians owe it to the public to open up the debate, but which most seem to regard as the third rail. The first taboo is being honest about NHS funding. The second is deciding what the NHS covers. Demand for healthcare always has and always will outweigh supply. How many times have we heard politicians say that the NHS has, and always will be ‘free at the point of demand’, and will provide the ‘best’ healthcare? It’s not true. We are victims of our own success: research and innovation have yielded ever more treatments, techniques, and interventions leading to greater public demand, raised expectations and an increase in longevity, (the latter resulting in our being more susceptible to diseases of old age such as dementia and age-related macular degeneration). For many, glasses, medicines, dentistry, wheelchairs, certain specialised drugs are items that you either pay for or can contribute to. If someone wants the best focusing lens implant when they need their cataracts removed, they can’t have it. It’s not available on the NHS. Nor could they have the latest prosthetic robotic arm if they lost their own in a car accident. As a system of limited resources, it is both totally disingenuous and illogical to promise that the NHS will provide the best of everything.

The projected funding gap for the NHS by 2021/22 is of up to £54 Billion if funding is held flat in real terms, which in the face of the bigger economic picture, and healthcare to date having been ring-fenced, seems a realistic scenario. We cannot divorce the NHS from the national economic reality. We are still drowning in debt; only Greece, the Netherlands, Portugal and Cyprus currently have more private debt (excluding the banking system) than us, and combined UK private and public debt (again excluding the balance sheets of City banks) reached a record of 298% of GDP at the end of last year, higher than the Eurozone average of 268%. To put this in further perspective, at the end of the second world war in 1946, UK debt was 250% of GDP. Added to this, the number of people aged over 65 is estimated to increase by 51% between 2010 and 2030, and the number of people over 85 will double over the same period. We are living way beyond our means, and that includes our tax funding of health.

Part of what has driven this spending is the second taboo: not all conditions that we are able to treat should truly be classified as ‘illness’ or ‘disease’. More and more of us are being turned into patients when our ‘condition’ is just a variation of human normality. Researchers writing in the BMJ last year described us as being ‘over-dosed, over-treated and over-diagnosed’. On the one hand we have increased diagnosis, or what is known as ‘diagnostic drift’: screening programmes that detect early cancers that will never cause symptoms or death; tiny “abnormalities” picked up by sensitive diagnostic technologies that will never develop; the widening of criteria for being given a diagnosis and genetic testing that gives us a very dubious ‘risk’ rating, both of which can cause anxiety and possibly lifelong testing and treatments for no benefit.

On the other we have an ever increasing number of differences, what were once regarded normal human variation, now labelled as medical conditions. Witness the recent controversy around the American DSM-V bible of mental disorders which includes sadness, shyness, distress, and (as do previous editions) also admits ‘the difficulties inherent in drawing a precise distinction between normality and psychopathology’. Infertility, the sensitive subject covered in this morning’s radio programme, is a relatively common difference between adults. Yes we have medical treatment, and undoubtedly it is a clinical ‘want’, but a clinical ‘need’ on which we should be spending tax-payers money?  (And I have to mention here the 80,000 children in care and thousands of babies waiting for adoption; it’s not the case that you can never have a family). I am sure someone could make a good ‘anxiety’ case for having their teeth whitened on the NHS, but we don’t fund this, even though they could claim their discoloured teeth are ruining their confidence and life-chances.

There will be many different opinions, but the point I am making is that we need an honest public discussion: we can’t afford everything, so what do we guarantee will remain free at the point of delivery? There is an appetite and willingness to spend our own money on our bodies, as demonstrated by the £2.3bn Britons spent on cosmetic procedures in 2009 (it could be nearer £4bn now), and the £500m already spent privately on IVF, as well as other private procedures and consultations. I am not saying this will be easy, or painless, but we owe it to those with serious illness now and in the future the certainty that their needs will be met. And to those feeling that they are facing a postcode lottery for whatever reason, to have the uncertainty removed and know exactly what they can expect from the NHS, no matter where they live. It’s high time to tackle these taboos.