The NHS Constitution states that access to its services should be based on clinical need and not on an individual’s ability to pay and that the NHS should provide a comprehensive service, available to all. For many people in the UK, these are articles of faith: fundamental organising principles that underpin one of the great achievements of postwar British society. They seem, on the face of it, to be unassailable: who could argue? But they beg the questions: what do we mean by need? What is included in a comprehensive service and why?
My dictionary defines need as being in want of something, or to require something ‘of necessity’. In discussing need in the context of organising the NHS we should describe what this ‘something’ is. Do we mean health or healthcare (or something else)?
In 1948 the WHO defined health as not only the absence of disease or infirmity but as a state of complete physical, mental and social well-being. This definition has been subject to criticism for the somewhat vague language (‘well-being’) but also because it excludes people who consider themselves healthy who nevertheless have ‘disease or infirmity’ (for example those with disability). More recent definitions of health describe it more in terms of a resource: one of a number of physiological needs to facilitate a flourishing life.
Health-care is more prosaic. It’s the prevention, management or cure of disease and is therefore defined much more narrowly than health. If healthcare is effective it can result in better health. Other means of achieving better health are sanitation, workplace safety, attention to social, environmental and behavioural factors (eg. smoking campaigns, seatbelt legislation) as well as broad public health initiatives such as vaccination and antenatal care.
Making a distinction between health and healthcare is useful as it allows us to think about healthcare more instrumentally. Healthcare is a means of satisfying a need for health, which in turn allows us to flourish. Other than its practitioners (who rely on it for their income or status), nobody has a need for painful, intrusive, embarrassing and inconvenient healthcare of itself. Thinking about healthcare in this way dilutes the emotional response we have about its provision and funding and allows us the cognitive space to consider whether healthcare interventions are valuable and for whom.
But before we consider whether particular healthcare interventions meet our health needs, we should ask ourselves what our priorities for health are (where ‘we’ and ‘our’ refer to society at large, not doctors, technicians or patients with vested interests in particular conditions). Even if individually we would like to remain in perfect health for ever (there are good philosophical grounds for thinking that immortality is not necessarily to be desired) we recognise that this is impossible. What then is a reasonable health expectation? How does this individual expectation accord with providing a fair distribution of health across society when doing so requires resource. Is this even something we are interested in achieving?
Answering these questions requires us to make some moral choices about what we value individually and collectively. For example should we value better health for everyone at the expense of increased health inequality? Should we value efficiency (more health) over less efficient targeting of those in poorer health? Do we prefer health gains to the young or the old, the ill or the healthy, the rich or the poor, the productive or the unproductive (however you define that)? Is it better to produce small health gains for many or large gains for a few? To what extent should we penalise those who make adverse lifestyle choices (considering that these frequently are likely to be a product of social conditioning). Is equal access to healthcare the same as equitable access? If not, which is preferable?
To explore this, undertake a thought experiment:
Consider two groups of people with a condition meaning 5 year survival is about 70%. One group consists of average 79 year old males in the United Kingdom and the other consists of children diagnosed with a soft tissue sarcoma. Do both these groups have equal need for health? Now imagine there are expensive treatments that can increase the median life expectancy of both groups by 1 year. Ought both treatments to be funded in a comprehensive health service? If we can only afford one, which group should be prioritised? Why?
So need for health, at least in part, is framed by our value judgements about what is fair, right or desirable. It is based on societal preferences rather than any empirical or underlying ‘truth’. Need is defined by our judgements about what is important.
Perhaps that seems a bit nebulous, theoretical and not particularly helpful in organising healthcare. While it’s possible to quantify some value judgements, the resultant metrics are incomplete, crude and only reflect the choices of the people surveyed in their creation (for example the QALY). Maybe we’d get further if we go back to considering healthcare as the primary need. After all, this is the service people access and experience in order to satisfy their subjective need for greater health. If we choose to define need as an entirely subjective experience, need becomes equated with demand. Might demand be a better measure to determine what healthcare society ought to provide?
Neoclassical economic theory deals much more with demand than need. Distribution of a commodity (in this case healthcare) is determined by familiar marketplace concepts under assumptions (amongst others) that individuals are the best judge of what is best for them and that they will act to maximise their welfare. In this view, the distribution of health is determined by market forces and individual decision making within this marketplace.
There are several objections to allowing market forces and demand to be the arbiter of need in healthcare. The most potent of these is that there are multiple inherent conditions in the provision of healthcare which predispose to market failure.
- There is a marked information gradient between the customer (patient) and provider (the doctor or the healthcare institution). The customer is therefore not well placed to make a judgment about what is in their best interest. While it is to be hoped that medical professionals are honest brokers, they are nevertheless subject to unconscious biases, the making of assumptions about what patients think and personal, professional and cultural pressures (such as fee-for-service or intellectual investment in some technologies).
- The demand for healthcare may be heavily dependent on its supply, not on a fundamental underlying need (supplier induced demand). The rolling of block contracts year-on-year is an example of this: future supply is planned on the basis of existing resource and infrastructure rather than on a reassessment of ongoing necessity. It is also evident in the development of new technologies which sometimes seem to be driven by professional and commercial interest rather than a true needs assessment, resulting in treatments apparently in search of a disease. Do we need nanoparticles to reduce restenosis in dialysis fistulae? Or endovascular robots? Or SIRT for advanced hepatocellular carcinoma? Maybe, maybe not. Innovation can be transformative (the iPhone, triple therapy for H. pylori, the COVID vaccines) but it can also create demand without reaping any (or enough) health benefit.
- Health and wealth are correlated. The more wealthy live longer and are more healthy at all stages of their lives. The most healthy are best placed to demand healthcare and the least healthy are the worst placed to demand it, so demand does not reflect lack of health. Making healthcare free can mitigate this differential demand, but does not abolish it entirely, particularly for utilisation of secondary care. This leads inevitably to market inefficiency and widening health inequality.
Even in a functioning market, there is no reason to assume that individual people’s demands for healthcare (and maximisation of their personal health) will result in an overall societal improvement in health or its distribution in a manner we consider important. This remains true even if the healthcare demanded is effective and cost-effective. Demand has no moral or socially determined component. It is purely a function of individual wants and preferences, the drivers of which may or may not be things society values. Individual preferences may be (amongst other adjectives) altruistic, well-meaning and informed or they may be selfish, bigoted, ignorant or cruel.
For these reasons we cannot rely on demand as a valid surrogate for need or as an organising principle for healthcare.
So does this analysis get us anywhere?
Need is a value laden concept. It speaks to a lack of something important, and fulfilling need brings with it ideas of altruism, charity and obligation. But without some clarification, this construction of need and our response to it is not much use in determining priorities for healthcare provision. Is there anything useful we can derive from a discussion of need?
As a first set of simple principles, it seems axiomatic that a healthcare intervention must be effective before it can be needed. There can be no need for ineffective healthcare. Healthcare should also be as efficient as possible in improving health. This means we maximise health gains with available resource. We therefore, as a minimum, should demand healthcare is both effective in improving health and at least surpasses a minimum baseline cost-effectiveness before it can be considered as needed.
Beyond this, organising healthcare according to need depends on a value framework that we should ideally make explicit. In such a framework, lack of health does not necessarily imply need of health (or healthcare), with obvious implications for the concept of comprehensiveness: recall the two groups in the thought experiment. Need is determined not by what a persons health is but by what we are prepared to do about it. It is forward rather than backward looking. It is neither subjective nor objective: rather, it is defined by society’s collective values.
When healthcare resource is limited, even effective and cost effective healthcare may become unaffordable and it may be efficient and equitable for some needs to go unmet. How much we should prioritise health needs at the expense of other priorities such as the education of our children, security, a fair and resourced judicial system, welfare or the protection of the environment is a much wider, though analogous, question. Our health needs exist within a much broader context than that of health alone.
Further reading:
This blogpost was heavily influenced by a collection of essays by Tony Culyer, Emeritus Professor of Economics at the University of York, collated and printed as “The Humble Economist”
doctorhammond.com 