Free at the point of delivery was not the only one of Aneurin Bevan’s founding principles for the NHS. More important were his views on how we organise, manage and deliver healthcare – especially how this must ensure equity and fairness such that resources are distributed according to need and not according to want or profitability.

Sadly this is not now the case. Increasingly, deprived areas are receiving less money than more affluent areas – perpetuating what we call the ‘inverse care law’.

The ‘inverse care law’ has been most starkly elucidated in research carried out by Professor Graham Watt, who examined health and social care in what he referred to as “the deep end” practices: the 100 most deprived general practices in Scotland.

What he found was that compared to practices in the most affluent areas, GPs and other staff in the deep-end practices had to contend with shortages of staff, community resources and access to specialist care. This was against a background of high levels of multiple and social complexity in their patients and with patients less able to care for themselves, with lower health literacy, fewer personal supports and less secure accommodation or employment.

Staff in these areas not surprisingly suffered greater stress levels and high levels of sickness. This is a perfect example of the inverse care law and problems where allocation is not determined by local need.

In 1948 there were few effective treatments other than time and ‘tender loving care’. Now we have an armoury of treatments and diagnostic interventions. When these interventions are applied to large populations, then they have the ability to improve the population’s health. However, if not applied fairly then, by implication, the NHS itself widens inequalities in healthcare. The sheer size of the NHS makes rationing a necessary part of any healthcare system – publicly or privately funded.

Only the extraordinarily wealthy can afford all that healthcare has to offer. But for rationing to be effective it must be done fairly. The National Institute for Health and Care Excellence (NICE) is now nearly two decades old. And despite some problems it is still effective in delivering what it set out to do when first established as the National Institute of Clinical Excellence in 1999: to reduce variation in the availability and quality of NHS treatments and care. In other words, to ration fairly and reduce (if not stop) the so-called postcode lottery. This is an important function as it allows, at national level, some equity in distribution of what should be available for patients. While rationing still happens, nevertheless, NICE still has a vital function in determining the bar of what should be available to all patients.

At local level, it is the general practitioner that is pivotal to determining distribution of resource. This is not the GP as the commissioner at clinical commissioning group level, rather the GP as the ‘commissioner’ in the consulting room. General practitioners act as the hub in the health service. Through their interactions between different aspects of it, and in their role of patient advocate, they help to reduce unfairness in the health system and help maintain value for money. There is substantial evidence, from the UK and across the world (including the US), to show that where you have more general practitioners per head of population, health outcomes are better (at individual and population level), at lower cost and with better patient satisfaction. General practitioners’ role as the gatekeeper to NHS resources, helping to determine which patients need on-going care, keeps the NHS safe and effective and in line with Bevan’s principles. Sadly, as the NHS becomes more fragmented, as decisions on resource allocation are determined by market forces and not on health need, and as GPs are fast disappearing due to years of underfunding, the inverse care law will worsen.

Many clinical commissioning groups are now trying to find ways of making less go further. Many in the corridors of political and policy power are beginning to talk about allowing patients to top-up NHS care with treatment paid for privately. This would be a further nail in the coffin of universal health care – and move us to the chaotic system encountered in US. Patient charges will penalise the poor, the sick and old (who after all are the most frequent users of health care). Over time they will lead to a reduction of what would be provided as core part of local (and national) NHS services. Only those more expensive treatments which required top-up payments would be available, as top-up payments would ensure that financially failing Trusts could attract more resources.

The NHS is again in flux. Structural solutions are again being attempted as solutions to addressing the funding and staffing problems we face. Vanguard sites  – which are attempting to integrate care across social, primary, specialist and third sector domains  – are being tested. The answer, to paraphrase a famous song, ‘is blowing in the wind’. We must invest in general practice, ensuring fairer distribution through resource allocation formulae that take account of deprivation. That way we can allow GPs to regain their rightful roles at the centre of healthcare delivery and rationers of care.

This was first published by the Fabian Society

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