Cancer, central planning, and the NHS (National Health Service)

I think most of the readers of the blog are outside the UK, and would probably be bewildered at how the BBC, almost every day, has one of its main headlines about A&E (Accident and Emergency) waiting times. “Targets not met (again)”. You would scarcely think it would make the headlines (again). Many other headlines are about other aspects of health and the resources it requires: over the last few days we have had how mortality rates are higher than usual for the time of year, and how half of us Brits will have a diagnosis of cancer in our lifetime. (So I’m not even in a minority!   It is a consequence of people living longer and not dying of other things).

Many friends and colleagues from outside the UK have asked about what second opinions I have sought, and suggested leading cancer clinics I might go to for one. (All this, as well as the many suggestions for alternative – non-mainstream-Western – treatments, but that is not my topic today)

The first time this happened it came as a surprise. My case had already been discussed in a cancer-team meeting between a number of specialists – oncologists, surgeons, radiologists, palliative care – and they had worked out that the team I should be under was the oncology one.

My cancer bible is “Anti cancer” by David Servan-Schreiber, a Frenchman who practices in the US. (I can’t cope with multiple sources of advice as they are so likely to contradict each other, giving my more grief than relief, so I’ve found one book I like and stick to it.) He says, speaking of his experience with his own cancer,

As is often the case with cancer, the surgeon I consulted told me an operation would be best, the radiologist said radiology would be a good approach, and the oncologists advised me to consider chemotherapy. (p 117)

In his case, he needed to approach the specialists independently, and make his own judgment about what to do once he had gathered the opinions. Talking to other friends, from Bulgaria to the US to Taiwan, this has been the usual case: you need to work out enough about your own condition to work out which specialist to see, and will get a treatment accordingly.

For me, in the care of the NHS, this had all been taken care of by the team looking at my case, and working out at their meeting whose care I should be under.

I’m not a generalist, by nature. I am full of admiration for the jack-of-all-trades, who can turn their hand to anything, but for me, I’ll call in the electrician for the electrics, the plumber for the plumbing, the decorator for the decorating. If you have a lexical computing problem, call me in! (I’ve always found, to my surprise and delight, the more interesting the work, the more people pay me for it. Such are the delights of being very specialised.) I’m a specialist and I’m inclined to trust other specialists in their areas of expertise.   I know what it takes to become an expert: a Masters, plus (in my case) a PhD, plus a decade and more of accumulating experience. I don’t pretend I can become expert enough in other people’s areas of expertise to challenge their opinion. Provided that I think they are intelligent and acting in good faith, and answer any questions I have about what they propose, I will accept their greater understanding. I sometimes feel this is an unfashionable thing to admit.

So it suits me very well that the experts make the decision, in their meeting, and I am not expected to choose between what the oncologist, surgeon and radiologist have to offer.

I think this connects with the headlines about A&E waiting times. The UK, unlike other countries, has a central-planning approach when it comes to health. This is the source of good things and bad. Markets are good at allocating resources and centralised systems have trouble with it: problems with waiting times at A&E are a manifestation of the difficulties that centralised systems have with allocating resources (amplified by it being under political control, so, in the run-up to the UK election, A&E waiting times are a political football; it even made the headlines when Ed Milliband, Labour Party leader, is rumoured to have said he wanted to weaponize the NHS, with the Tories expressing shock and horror that he should use such a military metaphor.) But the good thing about centralised systems if that the parts can be made to integrate with each other. When well designed, they are better at planning for, and achieving, optimal outcomes. Where there is competition for limited resources, markets are valuable, but where we want everything to work well, as for the nation’s health, top-down planning, by an organisation which has all the cards in its hands, and works collaboratively rather than competitively, has a lot to be said for it.

I’d like to connect this blog piece to wider observations about large organisations and small ones, and limitations of markets, inspired by a book I read recently, “23 things they don’t tell you about capitalism” by Ha-Joon Chang. But I need to work out what I think a bit more first. For the time being, thank you, the National Health Service, for working out the best treatment for me!