Can Communities Save Healthcare?

My wife and I recently attended the National Theatre production of Nye, about the life and career of Aneurin "Nye" Bevin. He's the British politician credited with founding the UK National Health Service. Bevin grew up a century ago in Tradegar, a town in southern Wales. From a health perspective it wasn't a great place to live. Most of the jobs were in coal mining, and coal mining was extremely dangerous. Bevin's own father died young of pneumoconiosis caused by inhaled coal dust. But there was one bright spot: The Tradegar Workman's Medical Aid and Sick Relief Fund. Founded in 1890, this community health system ran a hospital and employed doctors, nurses, and dentists, all funded through worker contributions (one penny per worker per week in 1910).

Nye Bevin went on to represent Tredegar in Parliament. After becoming Minister of Health in 1945, he proceeded to, in his own words, "Tradegarize" the United Kingdom. Just like the Tradegar Medical Aid society, the National Health Service was much more than just an insurance program. The NHS nationalised the country's hospitals and directly employed the doctors.

What happened to the Tredegar Medical Aid Society? The irony is that the creation of the NHS rendered it essentially obsolete. It hung on for a few more decades as a sort of supplemental medical plan for Tredegar residents, eventually closing its doors for good in 1994.

One way to tell this story is as a natural progression: Pilot a healthcare system at the local level, work out key operational details there, and then later scale up to a national level where it can really succeed. And I think that version of the story is largely true. But also I think that something important gets lost in the transition from local to national.

Have you ever stopped to wonder why so many food businesses, from coffee shops to high-end restaurants, are locally owned? National chains have economies of scale and do many things well, but they don't do as well in catering to local preferences. People like getting their coffee from local shops. This principle applies even more to businesses that involve personal services and personal relationships. The more important it is to you that a business or service provider cares about you as a person, the more valuable it is for that organisation to be locally owned and operated.

Healthcare and social services obviously fall into this category, and providers have traditionally had strong connections to their communities. This can be a beautiful thing. I loved this recent story about an English town taking collective responsibility for the health and wellness of its most vulnerable residents. Here's a different story about a town in Belgium with a centuries-long history of humane treatment of the seriously mentally ill. (How many places in the world can make that claim?)

I should note at this point that the NHS isn't quite the national monolith that it's sometimes made out to be. GP surgeries (clinics) are run as small local businesses, and NHS hospitals are operated by 215 different regional trusts. But there's enough centralisation to create vulnerability, particularly on the funding side. (Mostly) Tory governments starting with Margaret Thatcher have gradually de-funded the NHS to the point where it's struggling to function. Doctors and nurses are quitting in droves due to low pay and poor working conditions. Hospital bed capacity is so low that patients in ambulances sometimes wait for hours in the hospital parking lot before space is freed up for them to be brought inside. Tying up ambulances in parking lots isn't great for other patients experiencing emergencies, either. 

Communities throughout Britain are upset about all this, but feel powerless to fix it. The problem is that global NHS budgets are set nationally. And too many of the people involved (MPs, donors, and lobbyists) aren't all that affected by the NHS's dysfunction. People like Rishi Sunak, the current Prime Minister, former investment banker, and billionaire's son-in-law. How often do you think Sunak and his family use the NHS? This is the same Sunak who once caught flack for wearing £500 Prada loafers to a construction site.  He and his family have probably never used the public system, because anyone with money in the UK is likely to get most of their healthcare through a separate private system.

In the US, centralisation is playing out a bit differently. There, it's driven by huge healthcare corporations such as United Healthcare and Healthcare Corporation of America (HCA) on the for-profit side, and Kaiser and Ascension and Common Spirit on the nonprofit side. Mergers and acquisitions are universally accompanied by promises of quality and efficiency, yet there's never been good evidence that this actually happens. What consolidation does bring, on the other hand, is higher prices. And in some places, like rural North Carolina, severe cutbacks in staffing and services.

Of course, local community ownership with local funding isn't a perfect solution either. The most glaring problem is that it punishes low-income regions. Pre-NHS (as pointed out in the Nye production), working class areas of Manchester and Birmingham had one GP for every 50,000 or so people, whereas wealthy areas like Chelsea in London had closer to one GP for every 50 people. It reminds me of when we lived in New Hampshire (USA) in the 1990s, and schools were funded entirely through local property taxes. Our daughter's first grade class in Hanover (a wealthy community around Dartmouth College), at the phenomenal Bernice A. Ray School, had two teachers for fewer than 20 children, an amazing facility, and lots of extracurricular programs. Schools in working class towns a few miles away, on the other hand, were really struggling to provide the basics. (New Hampshire's supreme court has since forced changes to the funding model to provide more equity.) 

So maybe the optimal solution would involve local control of healthcare delivery, together with a funding model that supports local control, but with enough national-level redistribution to ensure equity. Easy? Of course not. But I believe this is one of the most important political issues affecting healthcare today.