No Gaps

What is the NHS?

It is a difficult question to answer. Some people say it is free at the point of use, paid by general taxation and others say it is public provision of healthcare, and although both of these are important aspects of the NHS, I think the essence of what is the NHS is something more fundamental: no gaps.

In 1946 the government issued a white paper describing the new NHS (Cmd 6761). The document starts with this:

The Bill provides for the establishment of a comprehensive health service in England and Wales. A further Bill to provide for Scotland will be introduced later.All the service, or any part of it, is to be available to everyone in England and Wales. The Bill imposes no limitation on availability – eg,. limitations on financial means, age, sex, employment or vocation, area of residence or insurance qualification.

The NHS was created to provide a comprehensive, universal health service. Everyone was included, there were no exclusions. No gaps. The healthcare provided was comprehensive and every treatment was covered and made available to everyone. No gaps.

This principle has persisted to today. It is so instilled into the NHS that the public assumes that it happens and cannot imagine any other situation. The NHS puts a lot of effort in making sure that services are accessible by everyone, regardless of gender, race, religion, sexuality or disability. When commissioners plan the services for a population they look very carefully at demographics to tailor a service to the region, but they also plan for the minorities in the population to ensure that the services are accessible to them too. The same is true of providers, hospitals make every effort to ensure that everyone can receive their services.

For example, a patient involvement officer told me about a case he had worked on recently. The local hospital found that a particular service had few people from the Afro-Caribbean community and asked him to find out why this was the case. The officer found that elders in this community distrusted people in white coats and this distrust had been passed down through the community via churches and community groups. The patient involvement officer talked with the elders to find out the reasons for their fears and then liaised with the hospital to make changes to allay these fears. Once the elders were reassured the newly gained trust worked its way through the community and that gap had been closed.

To some people, this was patient choice: patients (though ill informed) chose not to use an NHS service. To people who have an obsession for consumer-led patient choice, the issue should stop there. But the NHS has a policy of no gaps deep in its core and the NHS (the providers and the commissioners) ensured that this population was covered.

The no gaps policy is alien to the private sector. The reason is very clear: it is cheaper to provide a one-size-fits-all service for the majority of people, and it is very expensive to provide a service that is guaranteed to cover everyone. When tendering for a general service, the private sector will deliberately exclude the hard to cover populations. On the other hand, the private sector can, and sometimes is, used to fill the gaps, but they will do so at a cost. 

No gaps in the NHS presents one of areas where the government's policy to have more private provision will fail. The government will allow private providers tendered under the section 75 regulations, or through Any Qualified Provider, to provide patient exclusion criteria. In other words, this government legitimises a policy of gaps in healthcare provision. In these exclusion criteria, private providers will cite their incompetencies: they will list their lack of equipment and lack of expertise to treat patients with multiple co-morbidities or who are difficult cases. Patient choice is meaningless if a patient is turned away from a provider because the provider cannot provide a safe and effective service for that patient. However, the government will claim that there is patient choice, while allowing such providers to turn away patients. It will be NHS providers, with their deep rooted no gaps policy, who will treat those patients, because the NHS never turns a patient away.