Should the NHS be independent like the judiciary?

The great question which, in all ages, has disturbed mankind, and brought on them the greatest part of their mischiefs … has been, not whether be power in the world, nor whence it came, but who should have it.

–John Locke ¹

The Federalist Papers No. 51 – ‘The Structure of the Government Must Furnish the Proper Checks and Balances Between the Different Departments’ – is not a particularly exciting title. Yet, in 1788, when James Madison began drafting this essay, his aim was not to excite the mass but to inspire the few. Madison skillfully condensed Aristotle’s ideals fixated on a mixed – separated – government with the more refined French constitutional treatise, The Spirit of the Law by Montesquieu. ² Montesquieu’s magnum opus is a direct descendent of John Locke’s ‘Second Treatise of Government’ which in turn subverted Thomas Hobbes pessimistic social contract theory outlined in ‘Leviathan’. Madison’s aim was not to create a hierarchy of political philosophers nor emulate them. It was to siphon political thought – entwining ancient Greece, revolutionary Paris and enlightened Britain – into a constitution entirely American. The crux of this was a separation of powers. An executive branch, legislative branch and judiciary – a tripartite system distributing power to the people. The judiciary, arbitrators of justice, were seen as the least dangerous and hence the most important of the three.

Medicine and law have waning similarities. The doctrines of society and those dictating human biology may seem distinct at first. The first man-made and the second entirely natural, yet society has elevated these two seemingly moral vocations for centuries. Despite a lack of coherent constitution, the United Kingdom does have a legislative branch partially protected from parliamentary influence. Justice, it is deemed, is too important to be swayed by electoral promises and lies, budget cuts and pandering. The institutions protecting human rights and liberty are rightly protected. Yet, the single institution protecting human life is not.

The National Health Service (NHS) is incomprehensibly large, employing millions and treating far more. Often described as a single entity, it is sliced into a multitude of deaneries and trusts. Running on an annual budget hovering around £130 billion, it is arguably the most revered British institution. ³ Yet, despite societal prestige and an almost supernatural ability to democratise healthcare, it is often at the frontline of political warfare. Oscillating between cuts in funding and headline-grabbing injections of cash, the NHS is both the shield and dagger of modern political play. Health secretaries come and go – as do entire cabinets – but half-thought, barely funded policies are left in tatters, for the next minister to discard or resurrect.

In 1997, the day before the national election, Tony Blair famously announced voters had 24 h to save the NHS. ⁴ After a landslide win, New Labour delivered on their promise to increase spending on the health service. ⁵ However, retrospective analyses from the King’s Fund reported the benefits to patients were not proportional to the advertised 7% budget increase. ⁶ Due to increasing drug prices and a salary bump for GPs and consultants, an adjusted increase of 2% was more accurate. Nevertheless, this was an increase from previous government funding, and higher than subsequent administrations. ⁷ The Institute for Fiscal Studies concluded that despite a large increase in public spending on health over the previous 70 years, expedited by labour governments in the 1990s and 2000s, a recent reduction has resulted in the decline of services. ⁸ This is preventable. No intimate knowledge of public health is required to identify the futility of constantly fluctuating budgets.

In 2002, a grandiose proposal to make the NHS paperless was announced – the ‘National Programme for IT in the NHS’ (NPfIT) operating with a budget of £6.2 billion. ⁹ Prefixed on the notion of nationwide centralisation, all patient notes and prescriptions would be stored on software accessible to every hospital. If you broke your leg in Glasgow, and presented to your local GP in Glamorgan, doctors would have access to scans, treatments provided and follow-up recommendations. This leap into the 21st century was dismantled in 2011 without ever fully functioning. Over the course of nine years, it had cost the taxpayer over £10 billion. ¹⁰ The project punctuated both the Blair and Cameron governments. Upon announcing its demise, Dan Poulter – then a health minister – blamed the Labour government for poor conception and naïve execution. In the same speech, he ushered in a new technological revolution, with an amended budget of £1 billion, promising a paperless NHS by 2018. Suffice to say, I still write most patient notes on paper.

The history of politics is studded with broken promises. The human mind, among all else, ceaselessly strives to improve. Words are the building blocks of such striving. With each incoming government, rhetoric is used to whip up a frenzy of human emotion. And the extremes of human emotion, as the romantic poets were well aware, cloud judgement. Our waiting times, cancer screening services, emergency room facilities and quality of medics are too important to be predicated on flights of fancy. Evidence-based budgeting, public health endeavours and increasing important post-hospital care (such as carers for the elderly) are conducive to long-term planning that is not dramatically altered every few years. By instilling time constraints on health policy, we fail to allow ourselves to learn from flawed policy. And history repeats.

Medicine is changing at a rapid pace unbeknownst to the public. In order to keep innovating, diagnosing and treating a more varied, educated, empathic constellation of voices are required. Judges of health – tempered by clinical medicine, nursing, health economics, applied history, anthropology, evidence-based policy and philosophy – are essential. Lifelong advocates with careers that do not ebb and flow with the latest electoral result.

Could it be argued that the NHS is too precious for fleeting political ideas to corrupt?

Could it not be argued that, along with courts of justice, no single institution is as important to protect?