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Does free health care at the point of delivery trivialise the service?

Introduction

The concept of medicine and by extension health care reveals the unique evolutionary development in humans of a sentient compassion; translating into an impetus to care for, treat and cure others. Whereby natural selection denotes the ‘survival of the fittest’, medicine aspires to a more utilitarian premise of curing sickness and disease for the benefit of wider society. Free delivery of health care amplifies this principle to suggest the right to access health care should be independent of wealth or social status, hence rejecting the application of social Darwinism whereby the affluent, able to afford health care, are perceived as the ‘fittest’ individuals. Although utopian in principle, within the constraints and costs of modern medicine and resulting limitations of free health care, it is fundamental to ascertain it’s consequential influence on a health systems’ efficiency and effectiveness. Extrapolating this to consider a service as a whole, it is necessary to determine the extent to which the principles of a specific system affect the wider medical establishment and whether the implementation of these denotes or alters a patient’s and the wider public’s regard for the service.

To adequately assess the consequences of free health care at the point of delivery it is important to first establish the parameters within which we define the concept of service with regards to health care and in turn the measures which can be used to assess these principles. The World Health Organisation defines health services as “all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health”1 . Similarly for the purposes of this discussion I will consider a country’s health care service as the integrated framework supplying medical care from manufacturers ,including pharmaceutical companies, to patients through the medium of a healthcare system; encompassing primary, secondary and tertiary care.

Discussion

From a patient perspective accessing a health care system implies an expectation of relief, treatment or reassurance regarding symptoms. The Universal Declaration of Human Rights in 1948 first established a mandate for countries to meet this expectation in Article 25;

‘Everyone has a right to a standard of living adequate for the health and well-being of himself and of his family including food, clothing, housing and medical care…’ 2

However contextualising this principal by considering the health care systems of comparably developed countries such as Britain, France and America emphasises the extent of the varying interpretations of this. The contrast between British National Health Service and other ‘Beveridge Model’3 based systems whereby “we cover everybody but we don’t cover everything” 4 and conversely the insurance based broadly private system of America denotes this polarity, with the ‘Bismarck Model’3 of countries such as France and Germany providing a median between the two.

Free healthcare at the point of delivery was a defining principle of the NHS when it was launched in 19485 and hence is singular to Beveridge model systems; encompassing ideals of equality and a rejection of the “hedonism of capitalism”6 .However the requirement of a contribution towards health insurance is continuous across all healthcare systems with a healthcare model and divisions within a model determining whether the individual, employer or state supplies this contribution.

The distinction between the public insurance of Beveridge model and the private insurance of America and Bismarck model countries is that in the latter the insurance contribution is independent of taxation. Though the regulation of the systems in France and Germany aims to insure that coverage is universal and costs are minimal; conversely in America the government maintains a ‘laissez faire’ attitude to the management of the private insurance market. The Affordable Care Act, more recognisably dubbed as ‘Obamacare’, does aim to gradually increase the coverage of health care, subsidising the insurance of individuals who are unable to afford health care through Medicaid and additionally creating statewide websites enabling evaluation of different private insurance packages7 . For comparative purposes I will consider the American health care system prior to the 2010 reform due to the fundamental antithesis of principles between this and Beveridge model systems. In lieu of government control, self regulation in regard of cost and coverage, established the economic incentive of profits as paramount with price inflation, the resultant effect of this prerogative. The greater proportion of GDP accounted for as health expenditure in the US compared to other countries8 affirms this reasoning. Although relatively improved patient outcomes would justify additional spending, analysis of the respective DALE scores of comparably wealthy countries against the percentage of GDP reveals no obvious correlation between the two factors; suggesting instead that inefficiency may be responsible for the discrepancy89. DALE is a qualitative index which adjusts life expectancy to consider the impact of long term and chronic illness10. Hence DALE scores are relevant when trying to quantify the effectiveness of a system as they provide an illustration of the adequacy of preventive measures such as immunisations alongside treatments to cure disease or mediate a patient’s pain.

The relevance of the efficiency and effectiveness of a system in evaluating a service is limited by peripheral influences. Richard Dawkins asserts the importance of this cultural alongside genetic transmission affirming “all life evolves from the differential survival of replicating entities” 11 which encompasses both the inherited and environmental aspects of transmission. However besides these extrinsic influences including the media and cultural memes replicated through imitation12 ; our inherent psychology has a perhaps unconscious effect on the way we discern the fundamentals of a health care service. If we simplify the distinctions between different services to health care that is free at the point of delivery and the converse, the altruism of free health care rejects the necessity of the selfish mechanisms of our genes to compete with others. In contrast in a private insurance health care model this competition is often economic; for example in America with approximately 45 million people lacking health coverage completely or partially throughout 200913 and “as many as 44,789” 14 dying.

The perceived inaccessibility of health care to a proportion of society leads to the enhanced belief in the majority of aspirational social constructs such as the ‘American Dream’ and consumerism. Hence the ability in such a system to access health care; competing successfully against other individuals, implies a basic sense of achievement through a fulfilment of the biological imperative supplied by our genes. In comparison the uniformity of Beveridge model healthcare systems whereby everybody is able to access health care largely inhibits this competition. The intrinsic value successful competition has to the individual is surpassed by the insecurity of the minority without health care access. An exterior perspective, independent of the implication of personal outcomes, enables an unbiased viewpoint. This impartiality accentuates the antithesis between the inequality of insurance-based models of health care systems and a postmodernist principle of equality; including equality in regard to race, gender, social background and hence opportunities such as the ability to access education or healthcare.

Fulfilment of the basic principle of free health care reduces analysis and resulting criticism of the wider basis of a system; instead inducing inspection of the specific mechanisms and means by which this healthcare is delivered. To a lesser extent competition may still arise from this comparative scrutiny of factors such as distribution of health care spending and variations in quality of care across a country such as Britain. Media use of phases such as ‘postcode lottery’ reflect public resentment at a perceived inequality in the distribution of healthcare; similarly to the dissatisfaction of the uncovered minority in private systems. Local and ultimately central government control means the competition is largely independent of an individual’s control. This compounds the perceived sense of helplessness and vulnerability of an individual experiencing an illness or injury. Conversely despite the minority of the population affected, the greater disparity in healthcare coverage in private-insurance based models creates external criticism of the wider concept of private healthcare. The basic premise of public healthcare that is free at the point of delivery is consequently largely safeguarded against critique which is reflected in Britain in political rhetoric regarding the NHS and public antagonism towards suggestions of moving towards a Bismarck model system of public insurance with private service providers. The justification for this opposition is reinforced by many including Allyson Pollock in ‘NHS plc’; analysing the impact of privatisation on our current healthcare model with regard to PFI and other initiatives whereby “a democratically accountable public service was to be replaced by a full health market” 15. The distinction between a “service” and “market” removes healthcare from its intrinsic altruistic values through the implication that a private system would disregard patient care in favour of monetary gain. However the economic feasibility of any healthcare system is fundamental as the inherent nature of healthcare means that if uncontrolled, costs can rise exponentially with the resultant need of organisations such as NICE to ascertain the cost to benefit ratio of specific treatments.

Intrinsic and extrinsic influences are associative; combining to denote and develop our individual attitudes towards a healthcare service. Personal, familial and second hand anecdotal experiences influenced by the media have a predominant influence on our perceptions of a health care service. The relative infancy of healthcare systems is masked by the intertwining complexity of such systems which perhaps is best illustrated by the extensive, often cavernous nature of hospitals themselves.The initial impetus for our healthcare system was a hierarchical imbalance caused by an inequality in access to medicine and absence of experience. Hence in Britain we have changed over the past century from a society where it was relatively common to experience infant and childhood mortality to one whereby diseases associated with later life such as cancer and dementia are at the forefront. The deficit in knowledge and inaccessibility of healthcare to the majority in the late 19ᵗʰ and early 20ᵗʰ century were the casual factors for this disparity; establishing a social prerogative for the introduction of health care. The association of sickness as a direct impedance to breaking the cycle of poverty was affirmed by early social reformers including Charles Booth and Seebohm Rowntree. Moreover the recruitment crisis during the Boer War created an additional impetus to introduce social reform; catalysing Lloyd George’s liberal reforms. This is reflective of the governmental premise of a healthcare system to actuate productivity and economic prosperity through the consequential maintenance of good health. However generally, most health expenditure takes place within the last year of an individual’s life16; encompassing an opposing premise of longevity, reflected in the utilisation of modern health care to treat an increasingly ageing demographic. The change in the basis of a healthcare system denotes a change in wider social attitudes emulated in the popular culture of the times.

Thomas Hardy contextualises his protagonist Tess in his 1891 novel Tess of the d’Urbervilles describing;

“an interval of four years and more between Tess and the next of the family, the two who had filled the gap having died in their infancy” 17

The fictionality of Tess conceals some historical accuracy due to Hardy’s authorial intention to achieve mass appeal; portraying a reality the public could relate to and empathise with. In a modern context this familial situation would be viewed as tragic yet the brevity of the reference indicates the seeming insignificance of such an occurrence; evoking an apathetic removal from humanity by simply stating “the two”. The modern incidence of diseases such as cancer and dementia although comparable in scope are contrastingly perceived as tragic. I believe this contrast is the culmination of the trust we place in healthcare; we expect to survive, assuring ourselves of this expectation with the advancements of modern medicine. Fundamentally this view reveals the wider triviality and inevitable fallibility of healthcare, reflected in Tsung-Mei Cheng’s ironical ‘Universal Laws of Health Care Systems’:

1. No matter how good the health care in a particular country, people will complain about it

2. No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough

3.The last reform always failed 18

Empathetic attitudes to disease further convey the limitations of the selfish mechanisms of our genes, revealing the altruism and utilitarianism of modern cultural transmission.Social values such as charity have transcended their often religious origin to become fundamental in modern society often through the medium of the media.

The portrayal of healthcare in a wider public context directly alters perceptions of a service and can further be used to ascertain public notions regarding health care systems. The inherent negativity of the majority of news stories presented through media can distort and skew attitudes; deviating from reality. Although many broadcasters such as the BBC purport to show an unbiased presentation of facts, the understandable need to fulfill public interest creates a bipolar reality in countries such as Britain whereby coverage of new technological advances, treatments and possible cures are interspersed between negative assessments of the state of our national health care system. The coverage of popular scientific studies compounds antagonism towards the current system as it places a superlative significance on specific often unsubstantiated discoveries; heightening unrealistic expectations of modern medicine and in turn healthcare systems. In contrast, without state oversight of hospitals, the government lacks the accountability for the management of health care system; hence reducing media attention as health care becomes less of a political issue.The transparency and public accountability of Beveridge model system does facilitate media assessment of the system. However public interest limits this analysis to superficiality; focusing on specific areas for improvement without questioning the wider system that filters into this area and is ultimately responsible for delivering the care.

Disparately media is also utilised as part of the wider health service, with advertising campaigns imploring people to stop smoking, lose weight or ensure good personal hygiene essentially concerned with the promotion of health.The limitation of the use of mass media to promote public health messages is inevitable due to the intangible nature of the ‘product’ and the effort required to achieve it.19Moreover health messages coupled with the conflicting messages of news reports reduces the value of such campaigns further; whose appeal is already initially limited to those to whom it is relevant and the proportion within this group willing to exercise the self motivation to change. The limitation of resources in a Beveridge model system increases the necessity of prevention of health problems and hence the frequency of health campaigns. The economic impediment to resources is statistically affirmed as Britain has 2.9 whilst comparatively France has 6.4 hospital beds per 1000 population.20

Conclusion

To some extent triviality in healthcare is an inherent aspect of modern healthcare independent of the specific system. The biological imperative of our genes is augmented by unrealistic expectations founded through the trust placed in modern medicine and influenced by the media. Historically a lack of cohesion and critical analysis has inhibited the advancement of medicine; most notably through the enduring influence for over a millennia of Galen’s erroneous compilation of human anatomy21. To this extent many of the accomplishments of modern medicine are attributable to the formation of the wider medical establishment, systematically developing, testing and trialling to produce effective and safe treatments. However in the recent Reith Lectures Atul Gawande reasoned the continual development and implementation of medicine compounds the fundamental limitations of modern healthcare that the “volume of knowledge and skill has exceeded our individual capabilities” 22. Accordingly the health service trivialises the system; revealing the economic limitations in delivering healthcare and the inherent nature of human fallibility in applying medical knowledge.

The political basis of healthcare that is free at the point of delivery compounds these limitations; effecting an inability to detach ourselves from its association with the historical reform and cultural change that the introduction of the NHS in 1948 facilitated. Conversely the changing demographic of healthcare systems necessitates critical analysis. However the inherent paradox of medicine is that the longevity it enables is the predominant limitation of healthcare systems, reflected in the financial deprivation of the NHS; increasing exponentially into an apparent £30 billion deficit by 2020. This is informally defined as a ‘black hole’ which differentiates it as an apparent apparition from the largely endemic reality. This distinction is further representative of wider social attitudes towards the NHS with public interest deviating from that of the service. A health service aims to enable the inclusion of as many diseases and treatments with the maintenance of cost efficiency and economic feasibility. Comparatively individuals are primarily concerned with there own and familial groups outcomes; disregarding the group selectionist premise of a healthcare service. This objectivity is more distinct in Bismarck and private insurance systems due to the business imperative although in the latter this can lessen the altruistic basis of healthcare; trivialising the service in implementation as opposed to the developmental triviality of free health care at the point of delivery. Similarly to Galen, deprived of the necessity of critical analysis, the erroneous basis of healthcare could prevent development; belittling further additions. Healthcare should be independent of the objectivity of individual selfishness resulting from an economic incentive of profits and the personal partiality of the electorate.

An impetus is imperative to ensure the implementation and maintenance of health coverage. Fundamentally this should have a utilitarian basis encompassing the benevolence of free healthcare at the point of delivery with a lesser economic prerogative to ensure cost efficiency. The Bismarck model currently represents the most appropriate medium between the factors involved. Acknowledging the inherent limitations of the Beveridge model is the necessary basis for reforming attitudes to the concept of health service ‘privatisation’ and so achieving health reform.