In healthcare,you get what you pay for

Has the winter crisis hit yet? The reason I ask is that recently, in an unprecedented alignment of think tanks, the chief executives of the King’s Fund, Nuffield Trust and Health Foundation wrote to The Telegraph newspaper to highlight their concerns about the funding shortfall that made a NHS winter crisis inevitable. ¹ ‘In health care, you get what you pay for,’ warned Chris Ham, Nigel Edwards and Jennifer Dixon. And hardy Britons are getting some of the poorest care of any advanced nation according to the Organisation for Economic Co-operation and Development.

The Organisation for Economic Co-operation and Development needs to be taken seriously. These leaders of think tanks need to be taken seriously, especially when they speak with one voice. Their letter also made a case for investment based on facts. Eighty percent of English Trusts are in the red. The NHS in England is about to post a deficit of £2 billion for this year. These facts are worth repeating because England now spends less on health as a proportion of GDP than other major nations, and the rate of spending growth in terms of GDP is slower than it has ever been since the NHS was created. The numbers speak for themselves, say the think tankers, the state of the NHS and quality of care are in decline. ‘There is no quick fix’ and investment is required now.

These unfortunate developments lead us neatly to one of this month’s research papers. Sanjay Budhdeo and colleagues ² examine the effects of changes in government healthcare spending on health outcomes in all countries of the European Union from 1995 to 2010. The findings are disturbing. A 1% decrease in government healthcare spending is associated with an increase in several mortality indicators, from neonatal mortality to adult mortality. These detrimental effects are not only short-term, as increase in mortality was evident five years after the spending decrease.

A second research paper finds benefit in an ancient treatment for transphincteric fistula-in-ano. Cutting setons are an old treatment, retested by Soliman and colleagues, who make the case that there is ‘nothing new under the sun’. ³ But old doesn’t necessary mean gold. The MRC’s Therapeutic Trials Committee of the early 20th century favoured studies that were physiological rather than clinical, single-centre instead of multicentre, and used controls to measure physiological changes in varying conditions when they might have been used to ensure a fair trial. ⁴ The MRC today operates to different standards.

In healthcare, you get what you pay for. In research, you get what you design.