Health Care—A Business or a Service?

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 39 ¦ Number 1 ¦ Autumn 1995 HEALTH CARE—A BUSINESS OR A SERVICE? DOUGLAS BLACK* We see so many problems which persist that there may be a crumb of comfort in noting that there are others which go away. Long years ago, in World War II, there was real concern whether soldiers stranded in the desert, or mariners on rafts in the Atlantic, should slake their thirst by drinking their own urine, or the tantalizing waters of the sea. In the hot Cambridge summer of 1942, we studied in ourselves the effects of experimental water deprivation [I]. We concluded that to drink seawater would impose on the kidneys an osmotic load greater than they could bear; and that a man drinking his own urine "is merely asking his kidneys to repeat work which they have already done, and cannot be expected to do better" [2]. That oblique introduction has this relevance to my theme: that I have the uneasy feeling that I may be asking of my brain something similar to what the soldier in the Sahara might be asking of his kidneys. Anyone with a concern for health care in Britain—and that means actually or potentially every citizen—has been greatly exercised by the radical changes in the National Health Service (NHS) over the past few years, which in my view are transforming it from a service into a business, or rather a series of ill-coordinated businesses; are substituting competition for cooperation; and are making doctors and nurses entrepreneurs concerned with money rather than professionals concerned with health. I have made or been given several opportunities of expressing my reasons for these views, most recently in the first Annual Lecture of the Office of Health Economics [3], from which I quote at some length by permission. *The Old Forge, Duchess Close, Whitchurch-on-Thames, Reading RG8 7EN, England.© 1995 by The University of Chicago. All rights reserved. 0031-5982/95/3901-0931101.00 Perspectives in Biology and Medicine, 39, 1 ¦ Autumn 1995 1 Let me first tackle the most general question, why should the provision of health care not be a business, regulated by some form of market. Although his present-day disciples have gone far beyond him, Adam Smith cannot be charged with blindness to the advantages of a market system. However, in The Wealth ofNations he recognized that in addition to the defence of the realm and the administration ofjustice, the state had a third duty, that of "erecting and maintaining certain public works and certain public institutions which it can never be for the interest of any individual or small number of individuals, to erect and maintain; because the profit could never repay the expense to any individual or small number of individuals, though it may frequently do much more than repay it to a great society" [4]. My general contention is that the principles on which the NHS was founded made it a prime example of a "public institution" of this kind, and that it is the departure from those principles which now endangers the NHS in that role. Of course, the mere recognition that certain public needs can best be met by public provision does not necessarily imply that health care comes among them. In every developed country, there is in health care a mix, in varying proportion, of private and public provision, private provision being further divided between direct payment by individuals as needs arise, and corporate insurance schemes. So all these methods are practicable, but are they equally effective and economical? To answer that question requires a general view of the factors which determine health and disease; some account of the broad characteristics of the different systems; and a consideration of the options for determining priorities in a field in which it is clearly impossible to meet all possible needs and demands. Determinants of Health and Disease The distinction is sometimes made between a "medical model," which stresses acute illness affecting individual patients, commonly in a hospital setting, and a "social model," which emphasizes the psychological and social aspects of health and disease and focuses largely on the care of chronic illness, commonly in the...