I did not always grow up having the NHS in the background to fall back on. I was born and brought up in Malaysia, and only migrated here for the latter part of my secondary education, medical school and eventually junior doctor training. Malaysia, whilst having a socialised healthcare system, has severely limited government funding in comparison, and waiting lists are significantly longer than what the British public are used to on the NHS.
Therefore, many citizens who are able to afford it opt for private healthcare, which, albeit cheaper than in the UK (due to cheaper labour forces and the market rules of demand and supply), is still expensive. During medical school, I also spent a month in Bihar, one of India’s most impoverished states, where healthcare was provided by various charities, and private healthcare is beyond the reach of vast swathes of the population; and another month in Ohio, USA, where every patient in clinic had the name of their private health insurance provider printed on the front of their case notes. Having experienced four different healthcare systems across the world, I am proud to work for the NHS and to be part of all that it has achieved.
In addition, events in December 2014 provided me with the unusual privilege of being both a patient and doctor in the NHS with a major illness for the first time, for I was diagnosed with a congenital brain cyst requiring complex neurosurgery. Just one year prior to this, my own otherwise healthy mother, living in Malaysia, had also been diagnosed with cancer of her tongue and required radiotherapy. Comparing our experiences in two very different healthcare systems led me to realise that the benefits of the NHS lie far beyond the fact that it is free at the point of use. Unless one has been on both sides of the fence - as doctor and patient - and has been through more than one healthcare system, few fully realise this.
1. Although it is only the tip of the iceberg, the greatest thing about the NHS is that it is, of course, free.
Most members of the British public want to retain the NHS in its current state simply for this reason. We all take it for granted, but many like me are fully grateful for it simply being available when we need it. When one is unexpectedly struck by major illness, especially when one still feels young and “productive", not needing to think about the financial impact is a true godsend. When my mother was diagnosed, I could see her thinking about how much her healthcare was going to cost her (£10000 for radiotherapy, on top of a £400 annual health insurance premium), and she continues to have to pay for her follow-up scans annually as these are not covered by her insurance policy. My parents are fortunate enough to be financially comfortable, and to be able to afford health insurance premiums. Not all are that lucky - Malaysian newspapers are routinely filled with charity appeals for less fortunate patients to help fund life-saving treatments (e.g. bone marrow transplants, chemotherapy) for which they cannot wait upon an extremely over-burdened public healthcare system. This is something we rarely see in the UK. A free NHS also reduces the economic divide with regards to healthcare access, and therefore improves public health as a whole.
2. It is cheap.
The Commonwealth Fund has found the UK NHS to be the most cost-effective in the world. Contrastingly, USA’s insurance-based system was found to be least cost-effective. There is good reason for this - fully fleshed out in this video - simply because a profit-making, insurance-based system only serves to drive the costs of its products and services ever higher. Cost-effectiveness in the NHS is driven particularly by the national guideline development body the National Institute for Health and Clinical Excellence (NICE). NICE guidelines are used by doctors and other healthcare professionals up and down the country to guide their decision-making, and one of the criteria for a treatment or service to be included in a NICE guideline is whether it is cost-effective. The question NICE asks is: “If drug A does the same job as drug B but for a fraction of a cost, then why should we not just use drug A?”. Conversely, the question insurance providers ask is: “If drug B is more expensive than drug A but does the same job, why should we not just use drug B so that we can charge more for insurance premiums?”.
3. Its doctors and health professionals can actually be more ethical.
As a doctor, I can tell you that one of the greatest freedoms of working in the NHS is not having to think about what my patient can or cannot afford. Because my patients do not pay me for my services, I am free to advise and provide treatments that have been shown to work, not ones that I know that you can pay for. It means that when I advise parents to vaccinate their children, it is not because I profit in any way from prescribing the vaccine, it is because I know that it is best for your child. In my field - paediatric endocrinology - hormonal treatments are largely exempt from NHS prescription costs. I therefore am able to treat all my patients - rich and poor - the same. One does not have to look very far to find cases of American patients not completing their chemotherapy simply because they cannot afford it and their insurance policies will not cover it. In the USA, investigations and treatments are routinely planned based on “what the insurance policy covers”. In India, doctors regularly choose cheaper but often less effective drugs because “something is better than nothing”. My mother would have been in the same situation if she did not have the means to pay for her healthcare. And while we may think these countries are worlds away from the UK, if the NHS were to be privatised, remember that some 20% of our population live below the poverty line and are unlikely to be able to afford “best evidence-based” healthcare if they had to pay for it themselves.
The converse is also true, and nowhere is this exemplified more than in the management of death. I once spoke to a German professor who admired the NHS because one of the questions UK doctors are trained to do, perhaps better than in many other healthcare systems, is to ask the question: “What are the risks of investigation and/ or treatment?”. Today’s medical technology allows us to sustain life artificially beyond what many would have deemed a natural death. Decisions regarding withdrawal of life support are some of the most difficult to make in healthcare and are majorly distressing for both families and health professionals alike. In places such as the USA and Malaysia’s private healthcare system, such decisions are often placed in relatives’ hands, and is spurred partially by the fact that they are, in fact, paying for the life support. Doctors working in such situations are often placed in difficult ethical dilemmas in the face of relatives who feel too guilty to make the decision to let their loved ones go (I personally know of a family who went through this). Relatives who make the decision often then live with the guilt of having possibly “killed” their loved ones in the grieving period afterwards. Contrastingly, in the UK, the legal decision is taken out of relatives’ hands and ultimately placed with the healthcare professional, who act in the best interests of the patient in discussion with the relatives. The lack of financial interest means that decisions about withdrawing life support can be made entirely on a clinical basis. The media however is always quick to portray doctors making decisions to withdraw life support as a way of the NHS “saving bed spaces”, but in my entire career I have yet to witness this. I would argue that healthcare professionals are at their most humane in the presence of a dying patient - our training has taught us to emotionally distance ourselves from patients and to be objective, but in death families are often seen grieving alongside healthcare professionals. Personally, were I to be ever faced with a similar situation with a loved one, I am absolutely clear who I want making the decision - and I certainly do not want it to be me.
4. It is united and self-governing.
Multidisciplinary teams (MDTs) comprise a multitude of professionals who help make complex decisions about healthcare, particularly in situations where there is a lack of evidence-base for best treatment, or more than one specialist needs to be involved. They are such an intrinsic part of the NHS that most patients do not even realise they exist, working in the background to decide on the best management plan for them. For rarer disorders such as ones I encounter in my clinics, there are often regional and national MDTs bringing together specialists from across the country to exchange knowledge and expertise on conditions where little is known about optimal management. Whilst local MDTs exist within private healthcare systems such as in the USA, wider networks of specialists working across different healthcare organisations (who may be in competition) are much more difficult to organise. When I was diagnosed with my brain cyst, my MRI images were forwarded via a national electronic system to another NHS Trust, and discussed at a neuro-oncology MDT almost automatically. Contrastingly, when my mother was diagnosed with her tongue cancer (management of which was controversial at best), her ENT surgeon referred her to his oncologist “friend” at another hospital, there was no MDT, and she had to carry her scans across with her to the appointment. I could only rest assured she was receiving best management by flying to Malaysia as an emergency to attend the appointment with her. Some will argue that MDTs are bureaucratic and delay decision-making, I would conversely argue that it discourages renegade practice and promotes accountability amongst doctors.
Similarly, the quality of care received by patients is maintained through a process known as clinical governance. NHS Trusts are regularly assessed internally and externally against a national standardised set of criteria by organisations such as the Care Quality Commission (CQC) and Monitor. These multitudes of checks and balances, highlighting Trusts and departments which do not meet these criteria allow for a more uniform service across the NHS (unfortunately however, over the years the process has become much more of a tick box exercise and the response from the Department of Health has too often been closure of Trusts and departments rather than an increase in funding). Privatisation leads to fragmentation, and a unified method of assessing care quality will be difficult to maintain. In the management of rarer diseases, where each hospital may see less than 10 patients per year, quality of care becomes even more difficult to assess without a national system. For instance, in the 1980s, it was discovered that growth hormone derived from cadavers used to treat growth hormone deficiency in children could rarely cause Creutzfeldt-Jakob disease (the human version of “mad cow disease”). Both conditions are rare and their association therefore even rarer. When clinicians set out to look at the population of children at risk, the UK had a national registry of treated patients, whilst our American colleagues had to trace patients treated by individual clinicians in separate organisations across 50 states.
A nationalised healthcare system therefore comes with far-reaching benefits that are often under appreciated.
These benefits, however can only be fully realised with proper funding and good stewardship from health professionals as well as the public. In my case, some critics have said I should have had my MRI scan earlier, not after 3 months of constant pain, and that I should have had my neurosurgery within the week, not 9 weeks after my diagnosis. In this era of instant results, these comments serve to prove that many are under the illusion of consumerism with regards to healthcare - i.e. the more you pay, the better healthcare you will get. Healthcare however, is not a business, and therefore good quality healthcare does not obey standard economic rules. Few realise that an earlier MRI could have led to unnecessary neurosurgery if the cyst had not been causing my pain (it had after all been there for three decades and my pain was in fact moderately well-controlled on medications). It is crucial that as users of the NHS we realise the finite nature of its resources and do not expect "all and everything now and immediately” from it. There will be some scenarios where private care for those who can afford it is entirely appropriate - elective operations for instance where the nature of the disease does not significantly impact health, or cosmetic procedures.
The media finds it all too easy to blame the NHS for missed diagnoses, delayed management and medical errors.
Good outcomes do not make national frontpage headlines often enough. On 14th September, the government is preparing to debate various issues that have been highlighted in the press and social media recently about 24/7 NHS services and doctors’ contracts, but this is only part of a much bigger picture. The future of the NHS is a reflection of our society as a whole - therefore we need to carefully consider what we expect of it. To what degree is healthcare a right or an economic privilege? Do we trust our doctors and healthcare policymakers to help us make value judgments on our own health? Or would we rather have our hospitals decked out like hotels and our healthcare professionals acting as businessmen and women selling their services to all and sundry who demand it?
It is time we truly appreciated the NHS for what it is - you never know when you may really need it tomorrow.
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