In the U.K., the National Health Service (NHS) Constitution states that access to its services should be based on clinical need and not on an individual's ability to pay and that the NHS should provide a comprehensive service, available to all. For many people in the U.K., these are articles of faith -- fundamental organizing principles that underpin one of the great achievements of postwar British society. They seem, on the face of it, to be unassailable. Who could argue?
My dictionary defines need as being in want of something, or to require something "of necessity." In discussing need in the context of organizing the NHS, we should describe what this "something" is. Do we mean health or healthcare (or something else)?
In 1948, the World Health Organization (WHO) defined health as not only the absence of disease or infirmity but also a state of complete physical, mental, and social well-being. This definition has been subject to criticism for the somewhat vague language ("well-being") and because it excludes people who consider themselves healthy who nevertheless have "disease or infirmity" (e.g., those with disability). More recent definitions of health describe it more in terms of a resource -- one of a number of physiological needs to facilitate a flourishing life.
Dynamic hierarchy of needs of Abraham Maslow referring to Krech, D./Crutchfield, R. S./Ballachey, E. L. (1962), Individual in society, Tokyo etc. 1962, S. 77. Image courtesy of Philipp Guttmann. Licensed under CC BY 4.0
Healthcare is more prosaic. It's the prevention, management, or cure of disease and is therefore defined much more narrowly than health. If healthcare is effective, it can result in better health. Other means of achieving better health are sanitation, workplace safety, attention to social, environmental, and behavioral factors (e.g., smoking campaigns, seatbelt legislation), and broad public health initiatives such as vaccination and antenatal care.
Making a distinction between health and healthcare is useful, as it allows us to think about healthcare more instrumentally. Healthcare is a means of satisfying a need for health, which in turn allows us to flourish. Other than its practitioners (who rely on it for their income or status), nobody has a need for painful, intrusive, embarrassing, and inconvenient healthcare. Thinking about healthcare in this way dilutes the emotional response we have about its provision and funding and allows us the cognitive space to consider whether healthcare interventions are valuable and for whom.
Priorities and expectations
Before we consider whether particular healthcare interventions meet our health needs, we should ask ourselves what our priorities for health are (where "we" and "our" refer to society at large, not doctors, technicians, or patients with vested interests in particular conditions). Even if, individually, we would like to remain in perfect health forever -- there are good philosophical grounds for thinking that immortality is not necessarily to be desired -- we recognize that this is impossible.
What then is a reasonable health expectation? How does this individual expectation accord with providing a fair distribution of health across society when doing so requires resources? Is this even something we are interested in achieving?
Answering these questions requires us to make some moral choices about what we value individually and collectively. For example, should we value better health for everyone at the expense of increased health inequality? Should we value efficiency (more health) over less efficient targeting of those in poorer health? Do we prefer health gains to the young or the old, the ill or the healthy, the rich or the poor, the productive or the unproductive (however you define that)? Is it better to produce small health gains for many or large gains for a few? To what extent should we penalize those who make adverse lifestyle choices (considering that these frequently are likely to be a product of social conditioning)? Is equal access to healthcare the same as equitable access? If not, which is preferable?
An alternative approach is to define need as an entirely subjective experience: individuals are best placed to know what is best for them and what they need. In general, Western capitalist society is more comfortable with this idea than with the collectivist ideas of the previous paragraph. If we define need subjectively, need becomes equated with demand. Might demand be a better measure to determine what healthcare society ought to provide?
Role of market forces
Neoclassical economic theory deals much more with demand than need. Distribution of a commodity -- in this case healthcare -- is determined by familiar market forces and individual decision-making within this market.
There are several objections to allowing market forces and demand to be the arbiter of need in healthcare. The most potent of these is that there are multiple inherent conditions in the provision of healthcare that predispose to market failure.
There is a marked information gradient between the customer (patient) and provider (the doctor or the healthcare institution). The customer is therefore not well placed to make a judgment about what is in their best interest. While it is to be hoped that medical professionals are honest brokers, they are nevertheless subject to unconscious biases, the making of assumptions about what patients think, and personal, professional, and cultural pressures such as fee-for-service or intellectual investment in some technologies.
The demand for healthcare may be heavily dependent on its supply, not on a fundamental underlying need (supplier-induced demand). The rolling of block contracts year-on-year is an example of this: Future supply is planned on the basis of existing resource and infrastructure rather than on a reassessment of ongoing necessity.
This is also evident in the development of new technologies, which sometimes seem to be driven by professional and commercial interest rather than a true needs assessment, resulting in treatments apparently in search of a disease. Do we need nanoparticles to reduce restenosis in dialysis fistulae? Or endovascular robots? Or selective internal radiation therapy for advanced hepatocellular carcinoma? Maybe, maybe not. Innovation can be transformative -- the iPhone, triple therapy for H. pylori, COVID-19 vaccines -- but it can also create demand without reaping any (or enough) health benefit.
Health and wealth are correlated. The more wealthy live longer and are more healthy at all stages of their lives. The healthiest are best placed to demand healthcare and the least healthy are the worst placed to demand it, so demand does not reflect lack of health. Making healthcare free can mitigate this differential demand, but it does not abolish it entirely, particularly for utilization of secondary care. This leads inevitably to market inefficiency and widening health inequality.
Even in a functioning market, there is no reason to assume that individual people's demands for healthcare (and maximization of their personal health) will result in an overall societal improvement in health or its distribution in a manner we consider important.
This remains true even if the healthcare demanded is effective and cost-effective. Demand has no moral or socially determined component. It is purely a function of individual wants and preferences, the drivers of which may or may not be things society values. Individual preferences may be -- among other adjectives -- altruistic, well-meaning, and informed or they may be selfish, bigoted, ignorant, and cruel.
For these reasons, we cannot rely on demand as a valid surrogate for need or as an organizing principle for healthcare.
Conclusions to draw
So does this analysis get us anywhere?
Need is a value-laden concept. It speaks to a lack of something important, and fulfilling need brings with it ideas of altruism, charity, and obligation. But without some clarification, this construction of need and our response to it is not much use in determining priorities for healthcare provision.
Is there anything useful we can derive from a discussion of need?
As a first set of simple principles, it seems axiomatic that a healthcare intervention must be effective before it can be needed. There can be no need for ineffective healthcare. Healthcare should also be as efficient as possible in improving health. This means we maximize health gains with available resources. We therefore, as a minimum, should demand that healthcare be both effective in improving health and at least surpass a minimum baseline cost-effectiveness before it can be considered as needed.
Beyond this, organizing healthcare according to need depends on a value framework that we should ideally make explicit. In such a framework, lack of health does not necessarily imply need of health (or healthcare), with obvious implications for the concept of comprehensiveness. Need is determined not by what a person's health is but by what we are prepared to do about it. It is forward rather than backward looking. It is neither subjective nor objective. Rather, it is defined by society's collective values.
When healthcare resource is limited, even effective and cost-effective healthcare may become unaffordable, and it may be efficient and equitable for some needs to go unmet. How much we should prioritize health needs at the expense of other priorities such as the education of our children, security, a fair and well-resourced judicial system, welfare, or the protection of the environment is a much wider, though analogous, question. Our health needs exist within a much broader context than that of health alone.
Acknowledgment: This column was heavily influenced by a collection of essays by Tony Culyer, emeritus professor of economics at the University of York, U.K., collated and printed in 2012 as The Humble Economist.
Dr. Chris Hammond is a consultant vascular radiologist and clinical lead for interventional radiology at Leeds Teaching Hospitals NHS Trust, Leeds, U.K.
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