2008 marks the 60th anniversary of the UK National Health Service (NHS), the Universal Declaration of Human Rights, and the World Health Organisation. In this week's edition, Lancet Editor Dr Richard Horton discusses the meaning of the NHS in the 21st Century and how delivery of the right to health can be achieved. The Viewpoint is linked to an Editorial which discusses the forthcoming publication of Ara Darzi's year-long review of the NHS -- in particular, the controversy surrounding the proposal to phase-in so called polyclinics rather than keep smaller general practices. On Feb 5, 2009, The Lancet will be spearheading the debate in this area in the first Health of The Nation Summit. This will be a yearly independent event to discuss the current state of the NHS, identify its weaknesses, and investigate its opportunities.
In the Viewpoint, Dr Horton says that doctors need to revise their vision on the NHS, and help shape the reforms necessary to help strengthen it. He says: "Although doctors appear to know what they are against, they do not seem to be clear about what they are for. Doctors need to behave differently. And how they need to behave might begin with the principle on which the NHS was founded -- the principle of equity." He says the future vision of the NHS should be based on four principles set out in by the UN in General Comment 14 -- from article 12 of the International Covenant of Economic, Social, and Cultural Rights -- availability, accessibility, acceptability, and quality.
In terms of availability, an effective health system must have sufficient services and people to deliver care for its citizens. Dr Horton draws attention to the gulf in this area for mental health, which is neglected many countries, rich, poor and all income-levels in-between. He points out the lack of availability of mental health services for young people. For accessibility, an NHS devoted to equity must be available to all people. The recent case of Ama Sumani, a terminally-ill 39-year old Ghanaian mother of two with multiple myeloma, who was deported from the UK and died shortly thereafter, was described by the Lancet at the time as an atrocious barbarism. Dr Horton says: "The NHS should be available and accessible to all those living at the margins of our communities. Services should not be denied to those living within the UK's shores if they have no other means of achieving the standard of care available in Britain.
In terms of acceptability, the various groups that are part of the NHS must enter dialogue to design policies and change behaviours. Doctors, patient groups, policy makers, and scientists all have their part to play, yet each may resist changes that threaten the status quo or their various interests. And a high-quality health system depends on creating a medical and public-health research culture that is scientific, highly skilled, and sustainable. Despite the strong research base and investment in science, Dr Horton says that the UK is too bureaucratic in the way in organises research, and that too much time is spent on process instead of concentrating on outcomes.
For 60 more years of an NHS committed to equity, three institutional changes are needed. First, a Technical Advisory Group should be established to make recommendations based on the best available clinical and health systems science about the priorities, policies and strategies for the NHS. Second, the NHS needs a General Health Council, where technical advice can be weighed in a more democratic forum -- including patient and civil society groups among others. And finally, the NHS needs to undertake an independent annual assessment of the UK health system's performance, especially from the perspective of a human right to health.
And how can the individual doctor champion this? Dr Horton says the first act of a doctor could be to embrace the right to health as a central tenet of his or her professionalism. Secondly, advocacy and education -- doctors can diffuse the right of the highest attainable standard of health among their colleagues and in the community. And thirdly, they can incorporate issues of availability, accessibility, acceptability, and quality of care, adapted to local circumstances, into their practice.
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The Lancet