SHA: Lessons we can learn from the United Kingdom
Mobile phone with the website of the British National Health Service (NHS) on screen in front of the logo. Photo| shutterstock
What you need to know:
- On July 5, 1948, the NHS officially opened its doors and was open for business. By the time of the launch, the NHS had managed to enroll at least 75 per cent of the population.
Every time I point out that we did not need to reinvent the wheel with the establishment of the Social Health Insurance Fund, especially when we had plenty of lessons to learn from the longest-serving provider of social health, the United Kingdom (UK), I am always reminded that the UK is not our comparator.
Well, at this point, the UK’s National Health Insurance(NHS) is certainly not our contemporary. However, the current state of our economy draws a strong comparison with the post-World War II UK, when the NHS was founded.
Every time I peruse the 2023 blog by Dr Michelle Clement, Researcher in Residence at No.10 Downing Street, and lecturer on government reforms and delivery at the Kings College, London, “The founding of the NHS: 75 years on”, I fail to understand just how difficult it is to learn from other people’s journeys, and pick the lessons.
Michelle artfully paints the picture of how much work went into building the foundation for the current NHS and how much time it took to build consensus around its establishment. Even amid a resource-draining war that took everything from the British people, their loved ones, their homes, their businesses, and their human dignity, the coalition government of the day, led by Winston Churchill, was already thinking about rebuilding after the war.
Beyond supporting the frontline, the government still prioritised setting the stage for economic recovery, ensuring that its people did not succumb to hopelessness. The government, in 1941, appointed a committee under Sir William Beveridge, to review its existing social security provision, giving birth to the famous Beveridge report that highlighted the five key areas of focus that would need to be addressed, if the UK was to rise to its rightful glory: Want, Disease, Ignorance, Squalor and Idleness. Trust the Brits to use their quirky terminologies!
A war-ravaged post-war UK very much compares to the current state of affairs in Kenya, with the crumbling economy midwifed by a decade of poor political choices. The Beveridge report recognised that for the UK to rise again, it needed to leverage heavily on assuring the welfare of its people; a reality that the then coalition government worked to set in motion. About healthcare, there was an urgent need to expand the mandate of the then-existing National Insurance Act (1911).
In 1945, the newly elected Prime Minister, Clement Attlee, took over from Winston Churchill and continued the work they had started as a coalition government without missing a beat. Despite acknowledging the huge challenge ahead of his government with a dismal economy and limited resources to pull off the grand plan, Attlee did not once hesitate. His Mantra was simple, “We live in a state of society where the vast majority live stunted lives – we endeavour to give them a freer life.”
He set up a winning team in his health ministry, Aneurin Bevanand his chancellor of the exchequer, Hugh Dalton. In order for the 1946 National Insurance Bill to see the light of day, Attlee took it to the House of Commons with a deeply altruistic appeal to the members, that despite the hugely significant cost of implementing the bill, condemning the masses to “penury’ in his own words, was not something the UK would submit to the world.
Despite the National Health Service (NHS) Act being signed into law by the Queen in November 1946, there were no rash promises, no ludicrous pronouncements. The real work had just begun. In the very typically conservative British manner, the launch date was set nearly two years later, on July 5, 1948. The actors rolled up their sleeves and went to work.
Almost 2,000 hospitals were taken over by the NHS, in readiness for the roll-out. However, they still had to contend with the doctors, who were not willing to lose out on their autonomy regarding how to treat patients. Instead of fighting the doctors, the Minister chose negotiation, upholding the professionals’ right to self-governance. This laid a solid foundation for self-regulation and the development of care guidelines.
Creating efficiency
On July 5, 1948, the NHS officially opened its doors and was open for business. By the time of the launch, the NHS had managed to enroll at least 75 per cent of the population. The Minister could proudly state that his mission had been successfully achieved.
In the past 77 years, the NHS has undergone massive restructuring, in line with the changing needs of the population. This has resulted in changes in hospital administration, financing, and operations to enhance efficiency. Additionally, a better understanding of the patterns and burden of disease has led to the reorganisation of clinical and public health aspects of healthcare.
It is not possible to have a perfect system in healthcare management due to the rapidly evolving changes in technology, disease patterns, and patient needs. Therefore, any social health insurance model must be resilient enough to handle the versatility without dropping the ball on those who depend on the system.
This is why I stand my ground regarding benchmarking. It takes sweat, blood and tears to build systems that defy time. Careful planning, mapping and true stakeholder involvement, with consensus-building, is the hallmark of a well-founded social health insurance scheme.
The current funding model for healthcare is not working as anticipated. Sustainability has proven to be a challenge, which was largely foreseen but ignored by the implementers of our social health funding models. It is never too late to accept that the decision taken did not work, and there is a need to change it.
Further, it is not just a funding issue. Quality of care is a multi-pronged approach. Regulation of the quality of care is a very small part of achieving quality. Therefore, the whole hullabaloo around the proposed bill needs to take a seat and focus on the bigger picture.
There is a need to introduce clinical care guidelines that prescribe the care algorithms for each and every condition. Yes, this is the foundation of quality of care. It addresses disparities in care and ensures that, irrespective of where a patient seeks care, they are going to get the same exact standard of care.
This is what will drive healthcare institutions to up their game, because, where one is unable to manage a condition as prescribed in the guidelines, they are forced to refer the patient from the outset, and if they desire to manage similar patients in future, they shall upgrade their resources to align.
These guidelines cannot be prescribed by the same regulators. This is the sanctity of the health professional associations. They must be empowered to take up their role and be respected for it. The professionals are the only ones who can set standards in their area of expertise, based on evidence, and review them periodically as evidence evolves.
This gives a clear separation of powers and promotes transparency and equity. Otherwise, for the social health insurance payer, the regulator and the determinant of quality of care to all answer to the same master at the Ministry of Health is a conflict of interest that cannot in any way be in the best interest of the patient!
Dr Bosire is a gynaecologist/ obstetrician
