Something rotten
Authors: Iona Heath
Journal: BMJ (2007)

There is something rotten in the state and stewardship of the National Health Service and it has to do with the ascendancy of money. I once heard an influential health economist claim that the only valid motivation of human behaviour was the pursuit of money. This was greeted with derision by the nurses in the audience, who thought that their entire choice of career was in itself proof of the falseness of his preposterous but profoundly depressing claim. However, the introduction of payment for performance through the Quality and Outcomes Framework of the current contract for UK general practitioners demonstrates that money does indeed motivate significant changes in behaviour—or, at least, in the recording of behaviour. But if money is thought to be the only motivation, hugely important human aspirations are systematically marginalised and our conception of what it is to be human and a member of society is diminished.

It is fashionable for politicians and journalists to portray doctors as self serving but, if this is genuinely perceived to be a problem, we must ask why the current contract has removed almost all the safeguards that previously limited the more venal ambitions of general practitioners. The limits on the maximum size of individual doctors' lists have been removed with the result that these lists are growing and practices now have fewer partners employing an ever greater number of salaried doctors to see their patients. Not only does this erode personal continuity of care to the detriment of doctors and patients alike but it means that it is substantially more difficult for today's young doctors to become fully participating partners in practices than it was for those of us fortunate enough to belong to earlier generations. Older doctors are depriving younger doctors of the opportunities that they themselves enjoyed. Similarly, the ringfencing of budgets for practice staff has been removed, and again this opens up possibilities for doctors to maximise their profits from practice by reducing staffing levels and minimising terms and conditions—again to the detriment of patients. So why would those charged with the stewardship of the NHS allow such changes? Perhaps because free range for the self interest of individual independent contractors is a price worth paying for opening up UK general practice to the full force of the market, which will allow the infinitely greater self interest of large corporations to generate private profit from the delivery of primary health care on an unprecedented scale. Perversely, evidence of self interest on the individual scale will be used to justify the corporate takeover.

The pursuit of private profit seems also to be driving record levels of private, corporate, and government debt. The Northern Rock banking crisis is closely related to the deceits of the private finance initiative (PFI)—both derive from unsustainable levels of carefully concealed debt. Bizarrely, Derek Wanless, who has advised Gordon Brown on the funding of the NHS, is also a well paid, non-executive director of Northern Rock and chair of its audit and risk committees. Surely this should be worrying the government more than is presently apparent. The Department of Health's own website describes the private finance initiative as providing “a way of funding major capital investments without immediate recourse to the public purse.” In other words, it is a way of postponing but not avoiding public spending and of visiting the resultant debt on future generations. We are told that the UK has a strong economy and yet we apparently cannot afford to finance the health service in the present. Debts resulting from PFI projects last for 30 years, and in September 2006 the Treasury reported that the capital value of all PFI and related projects was over £46bn (€65.8bn; $93.8bn). The public sector net debt is reported as being 36.7% of national income, but this seems likely to be an underestimate as the Office for National Statistics admits that it has not yet found a way of quantifying the financial implications of PFI projects in terms of the national debt.

Student debt and the spiralling price of houses mean that the UK also carries the greatest burden of personal debt in Europe, apparently amounting to £1 trillion. (I find that it helps to put these sorts of sums in context by remembering that there are only just over two and a half billion seconds in a life-course of 80 years.) The health service is meant to be funded from general taxation. Citizens pay taxes and by pooling their risks provide health care that is free at the time of need. It is not meant to be funded by mortgaging the future. There is supposed to be a commitment to sustainability, and yet the immediate postwar generation to which I belong, and to which Gordon Brown also belongs, seems set on squandering the inheritance from which we ourselves benefited—free university education, and hospitals and schools built by genuine and contemporaneous public investment.

In The Burial at Thebes, his translation of the story of Sophocles' Antigone, Seamus Heaney gives King Creon these words: “Money has a long and sinister reach. It slips into the system, changes hands and starts to eat away at the foundations of everything we stand for. Money brings down leaders, warps minds, and generally corrupts people and institutions.” It seems an extraordinarily accurate description of the state of the NHS. Money is everywhere the driver of change but it is warping minds and corrupting both individuals and institutions. There seems no place left for the altruism of public service to flourish and this is taking a huge toll of the morale of those working in the frontline of health care, whose motivation has always gone beyond the simple question of money. The neglect of altruism seems likely to prove both destructive of social solidarity and ultimately extremely costly for individual citizens.

There seems no place left for the altruism of public service to flourish and this is taking a huge toll of the morale of those working in the frontline of health care