The NHS has responsibilities for the health of the whole population. It provides immunization and vaccination for babies, and, at various points in the lives of children, 'booster' doses. GPs and their nurses give detailed advice about contraceptive methods; if necessary patients with special queries are referred to gynaecologists. The GPs organise nationwide large-scale preventive schemes such as 'breast-scanning' to identify early signs of breast cancer. The NHS is also responsible for public health campaigns, such as those against smoking and excessive drinking. (Some campaigns are the responsibility of the government such as those against drinking and driving.) It is currently working with the government to deal with problems of over-eating and obesity. We have doctors and nurses devoted specifically to public health issues since the aim of the NHS is to try, as far as possible, to prevent illness before it arrives.
As we get older more things go wrong with our bodies. About half the beds in the NHS are occupied by people over sixty-five, a striking example of the fact that now many of us are living into our nineties there is a huge and increasing problem of how best to care for older people, and how to pay for this care. Since this is an issue which covers much more than health, I discuss it in the chapter on 'How We Treat Our Grannies'.
Another part of the NHS is the Blood Donors scheme linked to the Blood Transfusion Service. All donations of blood are voluntary, and many people volunteer to give blood on a regular basis. (Paying for blood encourages people who have had dangerous diseases to give blood for money, Voluntary blood is 'clean' and encourages a sense of us all belonging to each other.) Some anomalies: A few years after the National Health Service was founded the government was short of money and decided that patients must pay for prescription medicines and for spectacles for poor eyesight. There was a huge political row; but eventually prescription charges were introduced. So when we are in hospital we get all the necessary medicines (drugs) free but once we are at home we have to pay. However that does not mean that people have to pay huge sums. There is one standard rate for all prescription drugs, however expensive they may be in reality. (In 2009 it is J7.20 per prescription.) And for children, pregnant women, those over sixty and the chronically ill, all medicines are free, so only about a third or less prescriptions are paid for.
We also have to pay significant sums for dental treatment since dentistry has not been satisfactorily incorporated within the NHS. Private dentists are now more common than NHS dentists, demonstrating to all of us the expense of health treatment when the NHS fails to provide it.
The treatment of patients suffering from mental health problems has undergone reforms with troubling consequences. Until the 1980s many patients were locked up in huge 'asylums' where they lived out their lives, sometimes with kindly treatment, sometimes with indifference. Then these big asylums were closed and people with mental health problems were encouraged to live 'in the community'. That was and is fine if they are being treated by medication with someone to check that they take their medicines, and with friendly centres to which they can go when they need to. So the policy works well for some, while for lost souls who have no family, life 'outside' can be more cruel than life in the asylums. The discussions on policy continue with the NHS well aware that with limited money it is difficult to provide all the support these patients need.
Since devolution, policy decisions about the NHS in Scotland and Wales have been devolved to the Scottish Parliament and the Welsh National Assembly. Scotland and Wales have abolished prescription charges and Scotland treats alcoholism rather differently as a matter of policy. No doubt the countries will diverge more as time passes
I am sometimes asked if we also have a private fee-paying health system. Yes, we do, but this is a small part of the country's health care although private health insurance is often offered to certain employees in prosperous businesses. Unlike responses to our educational system, there are no suggestions that you get better health care if you pay. The doctors are the same doctors because some NHS doctors choose to do some private practice in place of some NHS work. The advantages are that you jump queues and get a private room. But there are far fewer queues now than there were when I wrote the first edition of this book. Moreover, for many kinds of long-term illness, for mental illness and for most children's health problems there is no private health treatment. So those people who have enough money to pay for immediate treatment and a private room with a hotel-like atmosphere sometimes choose to pay for private health care. But if anything goes wrong (as it can do), the private clinic may have to transfer them to the NHS - although if they were originally private patients they will continue to pay for their care.
The problems of our Health Service are easy to analyse. The NHS employs more people than any other organisation in Europe. It is huge, and some critics say it is too unwieldy, although the whole point is that it works for everyone, everywhere. So there is bound to be some inefficiency. When it was founded in 1948, ministers believed that it would become steadily cheaper to administer as people became more healthy under its care. In one sense that dream has happened: people are more healthy, we live longer, and many infectious diseases have been eradicated. But people continue to die! And many of them die of diseases which can be treated but require expensive 'high-tech' treatment. Cancer is an obvious example. Secondly, there are popular treatments for common conditions, such as artificial hips for elderly patients with arthritis which more and more people need. And thirdly, we have invented completely new operations such as kidney and liver transplants which are sometimes successful, but always expensive. So the argument is about how much money we should spend on our health and how it should be used.
As compared with many other Western countries, we spend a smaller proportion of our wealth on our National Health Service partly because it is comparatively cheap to administer. But there is still the urgent problem of priorities. Scientific advances and the human desire for good health and long life means that there will never be enough money for the Health Service. We must choose. But how to choose? And who chooses? We must all die sometime, but at what point do you, if you are a doctor, tell a curable patient that he cannot be treated? Or tell the parents of a premature baby it will be kinder to let the child die, since it will probably die anyway (and privately mean that it will also be cheaper not to invest in very expensive treatments for a baby who is going to die)? Or explain to an elderly woman facing years of pain that she will have to wait for a hip replacement. (Fortunately the long waiting lists for such operations have been substantially reduced over the last ten years.) Such questions are particularly acute when new medicines are invented to alleviate or cure difficult conditions.
Most medicines do not and cannot cure patients, but they can alleviate symptoms, improve the body's responses or slow down deterioration. Many drugs with these advantages have been developed over the last two decades; almost all of them are extremely expensive. If the NHS does not have infinite quantities of money, how can doctors decide which drugs to use and which not to use. In other words, how do we ration treatments in a modern health service?