Shopping for Health: Medicine and Markets in America

I am very grateful for the invitation to respond to two such wonderful presentations. Nancy and David’s papers speak closely to my own research on the history of patient consumerism in the UK in the second half of the twentieth century, and the development of heroin addiction treatment in Britain over the same period. Both presentations gave me so much to think about, but one of the areas that most interested me surrounds the ways in which the story for the UK is different, but also the same. The UK encountered similar pressures and problems around both patient consumerism and opioid drug use but took a different path in dealing with these issues. In my comments I want to explore two areas of difference, and some of the similarities too. The first concerns the nature of patient consumerism in a collective, state-funded health system (the National Health Service). The second is the apparent absence of an opioid crisis in the UK. These, I think, raise larger questions about the importance of context and how this shapes problems and the ways these are responded to in different places and times.
 
1. What does patient consumerism look in like in a collective, state-funded system?
 
As Nancy pointed out at the beginning of her talk, the notion that patients are consumers was, and continues to be, contentious. This is even more so in the UK. The National Health Service (NHS) was established in 1948 to be comprehensive, universal (available to all) and free at the point of use. As the NHS was funded through general taxation, using the service was a social right that citizens could expect. Consumer ideals played little role in shaping the early NHS, and satisfying individual patient desires was of less importance than meeting collective needs. Things started to change during the early 1960s. Patient groups and consumer organisations began to demand more of a say for patients both in their own treatment, and in the development and running of health services. Using the language of the nascent consumer movement, patient-consumer groups pressed for things such as the right to consent to treatment; collective representation; access to information; and the ability to complain. By the late 1970s and early 1980s, they had achieved some measure of success. Bodies to represent patient-consumers within the NHS were established, and a few basic rights, such as the right to consent and the right to complain, were codified. Patient-consumerism within the NHS at this point was about patients (plural) as much as it was about the individual patient.
 
Things, however, started to change during the late 1980s. Patient-consumerism was taken up by successive governments as a way to ‘reform’ the NHS. Following the introduction of the internal market in the NHS in 1989, there were a series of attempts to make the NHS work more like a market. As a result, there was a greater emphasis on patient choice. The choices given to patients, are, from a US perspective still fairly constrained (you might, for example, be able to choose which hospital to go to for a procedure rather than simply being sent to one by your family doctor) and while aspects of greater patient choice have been welcomed by many, others, including some patient-consumer groups, have pushed back on the choice agenda. This is because greater individual choice often comes at a cost within a collective system. An educated, articulate patient may be able to exercise choice but there are plenty of other patients who are less able to do so, leaving them with potentially worse care and worse outcomes. For some, this undermines the entire ethos of the NHS: equity is being sacrificed in order to satisfy individual demands rather than collective needs. Such debates are not resolved. But it is important to note that underpinning these changes is a different notion of consumerism to that which first appeared in the 1960s and 1970s. This model of patient consumerism revolves around markets and choice, not rights and collective representation. Yet, there are clear limits to the penetration of this mode of consumerism within the NHS. There may be more of a role for private companies and quasi markets, but the service continues to be (mostly) comprehensive and (mostly) universal and funded through taxation. And as any American visitor to a UK General Practitioner will know, there are clear limits to individual choice: even being able to see your doctor in a timely manner is often difficult.
 
So, this might look like a rather different story to the one Nancy tells about patient-consumerism in the US, but there are, I think a number of areas of overlap. Many of the issues that exorcised patients (and to some extent doctors too) were the same: for instance, the ability to access relevant information, and the need for the codification of patients’ rights, were relevant on both sides of the Atlantic. Nonetheless, the different systems produced different pressure points which in turn produced different forms of consumerism. Examining these in more detail will reveal much about what is specific and what is particular to each.
 
2. Why no opioid crisis in the UK?
 
First, it is important to note that it is not entirely accurate to say that there is no opioid crisis in the UK. Prescriptions for opioid drugs have increased in recent years, up from 13.8 million in 2007 to 23.8 million in 2017, as have the number of deaths from overdoses, to around 2,000 in 2016. Nonetheless, the size and scale of the problem in the UK is nothing like that seen in the US, at least not yet. Why is that? The answer to this question is complex and multi-faceted, but here I want to focus on two aspects that relate to David and Nancy’s presentations: firstly, the history of drug policy and drug treatment in the UK; and secondly, the nature of patient-consumerism within the NHS, and especially the limits to individual patient choice.
 
As was the case in the US, Britain began to experience its first significant problems with narcotic drugs in the late 1910s and early 1920s. Cocaine use amongst troops on leave from the Western Front during World War One prompted a drug panic and resulted in the first piece of legislation to restrict the sale of drugs like cocaine and morphine. The Dangerous Drugs Act of 1920 made it a criminal offence to possess such drugs without a prescription. Around the same time, doctors and government officials became concerned about the amount of opioid drugs being prescribed to patients who had become addicted to these. A committee was established to investigate the issue, and in 1926 they published their report. The committee recommended that while every effort should be made to withdraw a patient from drugs, if this was not possible then he or she could be prescribed drugs on an ongoing or maintenance basis.
 
On the face of it, this looks a lot like the system David described of separating out “consumers” who could be managed by doctors and “abusers” who were treated like criminals, but in the UK much more emphasis was placed on medical management than criminal justice, at least in the early days. In large part, this was because most addicts were middle-class, middle-aged, iatrogenically addicted (that is, they became addicted because of medical treatment) and were often doctors themselves. There simply were not many “abusers” to be dealt with. This began to change in the mid-1960s, when a new wave of opioid users began to appear. These new addicts tended to be younger and were more likely to have begun taking heroin recreationally, rather than as treatment for pain. A number of measures were put in place to deal with these new addicts, including the establishment of dedicated treatment centres. Yet, addicts were still largely seen as patients requiring treatment, not criminals needing to be punished. Maintenance prescription of opioid drugs continued, and although more emphasis was placed on getting addicts off drugs, and on non-drug based forms of treatment, it was always part of the “British System” of drug treatment and control.
 
The relative ease of access to MAT (medication assisted treatment) in the UK over a long period is one of the reasons why the opioid crisis has not developed to the same extent as it has in the US. There are other context specific issues too: street heroin is cheaper in the UK than it is in the US; and there has been much less diversion of prescription opioids onto the illicit market. In part, this is because of tighter controls on opioid prescription following the Shipman Inquiry, but it is also due to the different form of patient consumerism and the health system that this operates within in the UK. Whilst it is true that opioid prescriptions for pain have increased in recent years, pharmaceutical companies looking to influence doctors’ prescribing patterns have a harder time than they do in the US. Stronger forms of central control, including regulatory and monitoring systems, make it less likely doctors will overprescribe opioid drugs and more likely that this will be detected should it occur. On the other side of the equation, pharmaceutical companies cannot advertise directly to patients in the EU, and so consumer demand for specific drugs or opioid pain-relief in general is much more muted. Constraints to choice and a less marketized system, may therefore, have helped prevent mass opioid prescription in the UK, and so forestalled an opioid crisis on the scale seen in the US, at least for now.
 
Concluding remarks
 
Taken together, what do these different, but overlapping stories tell us? I think it is clear that health systems and health policies have a big role to play in shaping health problems in the past and their likely solutions in the present. The response to drug addiction in the UK, and its embedment within a different health system has meant the nature of the drug problem in the UK is different to elsewhere. Yet, at the same time, the existence of drug problems in both the UK and the US reminds us that there are larger forces and issues that all countries face, no matter what their health or criminal justice system looks like. As historians, we are well-placed to point out when, and where these similarities and differences occur.
 
 
 

I am very grateful for the invitation to respond to two such wonderful presentations. Nancy and David’s papers speak closely to my own research on the history of patient consumerism in the UK in the second half of the twentieth century, and the development of heroin addiction treatment in Britain over the same period. Both presentations gave me so much to think about, but one of the areas that most interested me surrounds the ways in which the story for the UK is different, but also the same.

I’d like to thank the speakers for two really stimulating talks. With such provocative material, it’s a pleasure to respond. As my fellow commentator, Dr. Alex Mold, points out in her excellent piece, “Shopping for Health” looks, in some ways, very different from the perspective of the United Kingdom, with its universal health provision free at the point of need. The “internal market” notwithstanding, the UK’s National Health Service (or more accurately, its four separate national health services – NHS England, NHS Scotland, Gig Cymru in Wales, and Health and Social Care in Northern Ireland) is rarely perceived or culturally represented as a marketplace. And while the UK has a flourishing medical marketplace for over-the-counter, alternative, complementary and health-related products and services, these are rarely considered in the same light as medically mediated goods and services, whether they are prescription drugs, professional services or expert consultations. Indeed, other than in dentistry, privately purchased medical services, as opposed to services commissioned by the NHS from private and corporate providers, are and are likely to remain a minority concern for most British citizens. In the most recent figures available (for the year 2016), 79.4% of all healthcare spending in the UK was paid for directly from government coffers – and thus from general taxation. To date, UK citizens need not carry identification to access these services, and even with my noticeable US accent, I have never in almost 20 years of living in Britain been asked to prove my right to use these services. Implicitly or explicitly, consciously or unconsciously, in this country, access to medical treatment is regarded as a right for all residents.[1]

This view of healthcare has had profound effects of the British medical marketplace, marginalising many forms of health consumerism that have flourished in the USA. Private medical insurance offers one such example. Even at its peak in 2008, only 12.4 percent of British citizens (some 4.35 million people) carried any private health insurance for use in the UK. Even with concerns about Brexit prompting more companies to offer their employees private cover, the most recent figures available suggest that just over 4 million Britons have any private health insurance. Since over 3 million of those receive that insurance as a workplace perk, it is clear that the consumer appetite for pre-paid access to purely commodified medical care is limited. Individual subscribers – that is, people paying for health insurance themselves – make up only 952,000 of the policies in the latest figures available, though some of these will include cover for dependents.

There are a number of reasons for this low uptake. Private policies cost on average some £650 per year for healthy individuals in their thirties, escalating to some £2300 for individuals in their 70s, who are much more likely to claim.[2] This is seen as an unaffordable luxury for many, particularly since the NHS, for all its flaws and waiting lists, is perceived as reliably excellent at providing both emergency and acute care. In fact, while critical attention to failings in the UK’s national health services has been an abiding feature of the British news media since 1948, and has expanded rapidly in the wake of both cost cutting and with the rise of an ever-larger elderly population with complex needs, so too have cultural representations of a heroic, high-tech, and above all compassionate health service. British contemporary culture abounds in such imagery, perhaps most powerfully via wildly popular reality/documentary programmes including “24 Hours in A&E” (14 series and two special broadcasts so far); “GPs: Behind Closed Doors” (now showing its sixth series); “Ambulance” (in its fourth series); and “Helicopter Heroes” (in its eighth series of covering what are in fact only partially public, NHS-funded air ambulance services). The health service is also portrayed, largely positively, through historical and dramatic programmes ranging from the very popular and now internationally distributed “Call the Midwife” series to the wealth of historical documentaries recently produced to celebrate its 70^th anniversary. It is perhaps worth noting that these historical representations often include unflattering (and not always entirely accurate) comparisons between access to care under the NHS and in pre-NHS Britain, while the proliferation of US medical dramas on UK television ensures that UK audiences are acutely aware of the frightening limitations of wholly marketised, for-profit medicine for all but the most affluent.

Practical as well as cultural factors are important in curbing UK consumer demand for medical services on an insurance or fee-for-service basis. Private hospitals notoriously and controversially rely on NHS-trained medical staff, and beyond London patients are likely to see the same specialists whether in an NHS clinic or its private equivalent. No UK insurers cover emergency or primary care, and few offer cover for two of the non-emergency services most likely to be used by their 30-64 year old customer base: maternity and mental health care. Best current data suggest that truly “comprehensive medical insurance” simply is not available to UK consumers, precisely because it is not needed. Private general practice does exist in Britain – indeed the right both to practice medicine and to purchase medical care beyond the NHS was guaranteed in the 1948 Act that established the NHS in England and Wales (and in the separate Acts for Scotland and Northern Ireland). However, uptake is vanishingly small as compared to the use of NHS primary care services: the most recent data suggests its extent to be some 7 million private GP consultations, less than 3% of the total.

The NHS very publicly struggles, and in almost every region, fails to meet public demand for mental health services, so US readers might expect a different picture of “shopping for health” in this sector. But while the private mental health care sector earns its providers over twice as much as private family practice (approximately £1.1 billion as opposed to £500 million per annum), 87% of its consultations are in fact paid for by the NHS, and only 7% were purchased by individual consumers. In fact, children, adolescents and the (retired) elderly are all but invisible in the in any case unimpressive ranks of the privately insured in the UK, making its provision very profitable, but culturally almost irrelevant. In essence, when people talk about healthcare in the UK, they mean the NHS. And in the NHS, equality of access, if not of outcomes, is both assumed and fiercely cherished.

One site in which this difference becomes very clear relates to local and regional variations in health service provision. This is an increasingly pressing topic for national as well as local policy makers in the current economic and political climate: as austerity drives cuts in health service provision, sharp regional divides – economic, social and political – prompt loud calls for greater local and regional autonomy. Yet one of the most enduring and pervasive critical discourses pertaining to the NHS, at least since its proto-marketisation in the 1980s, addresses the much decried existence of a “postcode lottery” in access to services and treatments.

As one US observer wrote, evaluating the NHS at its 10^th anniversary in 1958:

The logical difficulties of [national health] planning … inevitably lead to psychological tensions which may become quite unbearable in a period of serious scarcity. To decide between the relative weight of an improvement of the mental health versus the tuberculosis service, or between the demands of the Newcastle versus the Manchester region… may try emotional stability as well as the calculating intelligence. (Eckstein, 1958, p. 272).

This has certainly remained the case. Far from offering a solution, the loosening of top-down guidelines and homogeneity initially encouraged by the advent of the NHS internal market and the deployment of “GP fundholding” (a policy from 1991-1998 which granted some general practitioners greater control over their practice’s share of the NHS budget, and allowed them to commission services independent from national health objectives) produced greater strains. Neighboring primary care practices, local areas, and regions of the UK funded different packages of services for their patients, based on expert assessments of need, local health priorities and often-vague notions of “community standards”. This might have been seen as opening a space for local consumers to act on the health service, and to allow demand to drive provision. But instead, when members of the British public found themselves denied a treatment offered to a friend or acquaintance, or described as available by the media, they were infuriated. In a national health system, funded by general taxation, not local or regional hypothecated taxes, local variation was read straightforwardly and consistently as iniquitous – as a “lottery of care” undermining the equality that was perceived as a fundamental feature of Britons’ right to medical care. This model has been subsequently recapitulated – with much the same disputatious effects -- by the current dispensations of “Clinical Commissioning Groups” and regional devolution.

As the levels and range of services available free at the point of delivery in the NHS expanded to include treatments intended to improve as well as to preserve life – for example, fertility treatment, smoking cessation, addiction prevention and treatment, “psychologically necessary” plastic surgery, gender reassignment surgery, gastric band and other weight reduction modalities, even wheelchair provision – and a wide range of expensive new chemotherapeutic and pharmacological interventions, local decision-making became ever more problematic. Alan Milburn, the first Labour Health Secretary for 18 years, argued in 1997 that, instead of opening the door for a more consumer driven and responsive health system, market-driven NHS reforms were perceived as setting “hospital … against hospital, doctor against doctor and patient against patient. … In the two-tier health service, access to care depend[ed] on the lottery of patients' post codes and their GP practices.” (Milburn, Hansards, House of Commons, 25 June 1997). Markets and the variations they produce were and are simply not readily understood or accepted in the area of healthcare. And while Britain’s consumers were more than happy to shop for over-the -counter pills and potions, skin treatments and vitamins (to the tune of £2.6 billion in 2017-18 alone) and an ever-growing array of health-related products – from “slimming aids” to medical devices (accounting for an estimated additional £810 million per year) – they were far less enthusiastic about the concept of choice driving service availability in the NHS.[3] In terms of healthcare, “never enough” in the UK context is balanced by “never unequal,” at least in the public imagination.

I’d like to thank the speakers for two really stimulating talks. With such provocative material, it’s a pleasure to respond. As my fellow commentator, Dr. Alex Mold, points out in her excellent piece, “Shopping for Health” looks, in some ways, very different from the perspective of the United Kingdom, with its universal health provision free at the point of need.