How not to criticize the NHS

The British National Health Service (the NHS) has been in news a lot recently. First it was the Investor's Business Daily in the US, which claimed that:

'People such as scientist Stephen Hawking wouldn’t have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.'

This is a particularly ridiculous claim as Stephen Hawking of course has lived in the UK all of his life! He responded saying:

'I wouldn't be here today if it were not for the NHS … I have received a large amount of high-quality treatment without which I would not have survived.'

The incident has provoked thousands of posts on Twitter by UK citizens detailing how they love the NHS and what it has done for them, and even warranting an open letter of thanks from the Prime Minister. Furthermore, the Guardian has written a helpful article going through other US claims about the NHS and showing which ones have substance and which don't.

It was somewhat surprising after all of this to read an article in The Telegraph on Friday, criticizing the NHS on the grounds of failing to provide some cancer treatments because of their cost. If there is one thing that everyone involved in the debates surrounding health-care should agree on, it is that costs have to be taken into account in deciding when the government will fund a treatment. Obviously the costs are pertinent: if a single person's life could be saved for a treatment costing $1 billion, this is, unfortunately, too expensive to fund. Similarly, the size of the benefits is pertinent to whether a treatment should be funded: if it produces only a tiny benefit (say, extends life for a single day), then unless it is also very cheap, it shouldn't be funded. Sadly, most of these discussions (such as that in the Telegraph) feature almost no details about the costs and benefits of the treatment under consideration, when these are highly relevant to the decision.

Government health programs operate on a finite budget, and if they allocate more money to one thing, there is less to allocate to other things. A health program can maximize the benefits it produces only if it prioritizes based on the ratio of benefits to costs for each option available (these benefits could include more than just health benefits, for example other social benefits). This will seem cold and calculating to some, but doing otherwise involves increasing the amount of death and morbidity due to illness. Every time someone claims that we need to fund a particular expensive drug that would not meet the NHS's guidelines on cost-effectiveness, we have to either explain why it is that the current guidelines systematically fail to assess the benefits a treatment would bring, or ask why it is worth lowering overall health-outcomes in order to fund that drug. 

Maybe in some cases there is a good argument due to considerations of fairness or discrimination, but a decision also clearly depends upon the costs and benefits of the case, and these are very rarely included in the critique. Instead, these critiques often just amount to pointing out that it is unfair that some will die and some will live. It is unfair in a cosmic sense, but it is not necessarily the health system's fault if we can't all live good and happy lives. The real question is whether we are doing the best we can with what is available, and we need information on costs and benefits (including non-health benefits) in order to make these decisions.

[Of course, one additional option that I have passed over, is the possibility of funding a new treatment not by cutting back on other areas, but by giving the NHS more money: either by cutting back on other programs, or by raising taxes. This is indeed an option, but is not really a criticism of the NHS and its policies: of course the NHS wants more money in total, but it is the government which is choosing how much to give it.]

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One Response to How not to criticize the NHS

  • Philip says:

    This is a really good point to make. All health systems, whoever they are funded by are ultimately constrained by the size of their funding. Within that there are questions of efficiency, but in the final analysis it’s about cost-benefit analysis.

    However, where I think that the NHS is weak, and where other health services are better, is that the cost-benefit analysis is done on an aggregate level rather than based on individual preference. That is, if I would like to have expensive cancer medicines, and I would be willing to forgo, for example, dental and eye care, and it all fits within the allowed budget, shouldn’t I be allowed to make that choice individually, rather than it being made by a bureaucrat? Certainly the NHS wants to move in the direction of ‘consumer’ preference, and it should. But it still has a way to go.

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