Health Care Management Science 5, 239���242, 2002 ��� 2002 Kluwer Academic Publishers. Manufactured in The Netherlands. Managing for Health: Why Health Care? SIR ALEXANDER MACARA ���Elgon���, 10 Cheyne Road, Stoke Bishop, Bristol BS9 2DH, UK Abstract. Health and health care are increasingly big business. The challenge is to apply our knowledge and skills to meet people���s needs, if not their demands as efficiently, effectively and beneficially as possible. ���Value for money��� is the slogan. For those who deliver the goods as required, the converse, ���money for value��� should equally apply, and not only in a market driven system. This paper offers a very personal view of these issues in the light of recent UK policy developments. 1. The epidemiological background It is vital first to address the environmental factors that affect health and health care in any society. First, in the UK, as throughout other developed areas of the world, demographic developments demonstrate the unin- tended consequences of birth control. ���Man who knows no good unmix���d and pure, Oft finds a poison where he seeks a cure��� said the poet Crabbe in The Library. Anxious to con- ceive only children whom we can nurture and to save them from preventable premature death, we face in consequence a remorselessly ageing population in which centenarians are commonplace and the ratio of the productive to the dependent population is declining, with serious economic and social im- plications. Second, the wondrous products of science and technology, mostly unforeseen and unforeseeable, proceed at an ever more bewildering pace, exposing our unpreparedness and ambiva- lence about developments which are revolutionizing the diag- nosis and treatment of disease and throwing up new dilem- mas of control and use which illustrate the aptness of the very word ���dilemma���, meaning two equally valid assump- tions. The genetic modification of animals and crops the unravelling of the human genome the unlocking of nature���s pharmacopoeia the micro chip and the internet ��� all these and many more innovations portend both unprecedented benefits and incalculable hazards, depending upon our fallible human judgement and political will. Third, however fast we deploy our more numerous and potent weapons against disease, demand for their use con- sistently outstrips our capacity to satisfy it, with public ex- pectations of an instant ambulance, a perfect delivery, an uncomplicated operation, incited by irresponsibly idealistic patients��� charters and tabloid telejournalism. And as poten- tial patients, as well as impatient patients, become generally more knowledgeable (if not better informed) the inequalities between the ���haves��� and the ���have nots��� increase. Fourth, we may be encouraged by the triumphs of preven- tion: immunization and vaccination, family planning and ev- idence of the striking value of investing in health education [11]. In 1950 when Doll and Hill first proved the link be- tween smoking and disease, the UK had one of the highest rates of lung cancer in the world, but since 1965 the num- ber of deaths from that cause has fallen to one half of what it would have been but for the dramatic reduction in the num- ber of people who smoke. Moreover, the saving in health care costs is incalculable. Any temptation to complacency is, how- ever, removed by the realization that there remain 10 million smokers in the UK with an increasing proportion of young women smokers, of whom one half ��� five million people in all ��� will be killed by tobacco if they do not stop. Among men who continue to smoke today, 16% will die from lung cancer before the age of 75, but for those who stop before they are 30 the figure is under 2%. Prevention clearly pro- vides the best value for money, both in saving life and health and in containing health care costs. Fifth, the sinister factor is, as ever, untamed nature which continues to strike back with new variant diseases, anti-biotic resistance, side effects of treatment, melting icecaps, ruptured ozone layers and so on. The battle continues. 2. The political background So much for the epidemiological and epistemological back- ground. What of the political environment? Let us con- sider the health scene in the UK. In direct lineage to the WHO���s Health For All policy, updated in Europe in 1999 [12], and of the preceding Conservative administration���s com- mitment to the ���Health of the Nation��� in 1992 [6] we now have ���Our Healthier Nation��� [5], the Labour administration���s public health White Paper, issued in July 1999 after extensive consultation. Simultaneously, the European Union is updat- ing its health policy to include a drive for health care reform [8]. More recently, the UK Government has issued its NHS Plan [7], unveiled in July 2000 intensive work by multidisci- plinary, multisectoral ���modernizationaction teams���. To quote from the Department of Health Press release: ���The NHS Plan . . . will create an NHS in which the pa- tient is the most important person. In the future, care and treatment will be re-designed around their needs, at their convenience.��� [4]

240 A. MACARA Note the admission that care and treatment have not pre- viously been designed around patients��� needs. One may, however, be forgiven for questioning ���at their convenience���, which raises the issue as to whether convenience is always compatible with effectiveness. The main features of the NHS Plan may be summarized as follows: ��� major investment in staff and facilities, quantitatively and qualitatively ��� enhanced mechanisms for modernization, prioritization arid monitoring of services ��� new, stronger links between health and social services ��� ���greater choice��� and ���new protection��� for patients, no- tably ���ensuring a healthy start in life��� and ���dignity, se- curity and independence in old age��� ��� a ���concordat��� between the NHS and the private health care sector ��� reducing health inequalities and improving health, notably by specific programmes of prevention against smoking and drug abuse, by the promotion of good nutrition, and by increased resources for deprived areas. Implementation will be staged and monitored. There is a realistic recognition that there can be no quick fix, and a com- mendable emphasis on partnership and leadership. Equivalent planned reforms can of course be found in most developed na- tions. 3. Caring for health Overall, this tour d���horizon reveals a healthy recognition of the fact that health care systems can function relevantly only within the context of a care for health which depends upon every area of organized society, notably the quality of the en- vironment including housing, sanitation education nutrition physical activity, at work and in leisure public safety social support and services for the deprived. Bevan���s aim of ���free- dom from fear��� comes to mind fear of Beveridge five gi- ants of disease, unemployment, ignorance, want and squalor. Put positively, the need is for what Alderslade [1] describes as ���sustainable development of societies���. However, freewill enters the equation, and the culture and ���lifestyle��� of individ- uals, families and communities are ultimately crucial. Hence the need to address the perversity of human nature which em- braces knowingly self-destructive behaviour such as smoking, and drinking alcohol and eating to excess. This implies a need for public policy which makes the healthy choice the attrac- tive choice and which recognizes that even the most benefi- cent state cannot satisfy the deep yearning in every soul for emotional and spiritual fulfilment. Within the context of caring for health, a health care sys- tem can scarcely do other than embrace the same philosophy as the NHS Plan. I believe that it pays in every sense, to pro- mote health and to prevent the preventable at every stage in health and disease. Indeed, within this philosophy, disease management is seen as an agent, or vehicle, of prevention ��� preventing death, development of more serious disease or dis- ability, dependency and despair. However, experience shows that there is little popular demand to attach a priority to pre- vention. What people demand is responsiveness to urgent per- ceived need, especially in an emergency. The responsiveness of a service is the criterion by which it is judged in the pub- lic eye. Witness the furore in the UK over waiting lists and waiting times. People readily acknowledge that clinical pri- ority should prevail over any other consideration, including personal convenience. A sense of fair play ��� what we profes- sionals call equity ��� remains strongly embedded in the British character. 4. Health care: the role of the state What then is the proper role of the state in the provision of health care in contemporary society? In the lst century BC, Marcus Tullius Cicero proclaimed in his De Legibus ���salus populi supremu est lex��� ��� the health of the people is the high- est law that is the ethical imperative. Almost two millen- nia later, Benjamin Disraeli in his novel Sybil asserted, ���The health of the people is the foundation upon which all our pros- perity and powers of state depend��� that is the economic im- perative. Together Cicero and Disraeli argue that health is both a public duty and a vital investment for society. But we have made a distinction between health, to whose attainment all public policy should contribute, and health care. Is the provision of health care likewise both a public obligation and an investment? In a democracy people are free to choose. Hence a plurality of systems, public and private, must pre- vail. Should the state then confine itself to providing a floor below which no citizen can fall, or core services ��� however defined���for all, whilst leaving individuals, and possibly em- ployers, to add on whatever they can afford to choose for themselves? In practice, those in a position to choose for themselves will always do so, whether in a democracy or in an autocracy. There is a question as to whether the state should use taxpayers��� money to subsidize, and thereby encourage, plurality of choice. This already happens involuntarily in the UK where the private health care sector makes no recompense to the taxpayer for the cost of training staff whom it employs. Moreover, the provision of supplementary or better services for those able to pay extra for them ��� a solution proposed by advocates of a ���free market��� in health care ��� is to guarantee a two-tier or even a multi-tiered system, which runs counter to widely held beliefs in solidarity and equity, although it is the accepted norm in some countries. Given the value system in the UK, the imperative in terms both of ethics and of economics is to ensure the provision of services proportionate to need, not demand, and inde- pendently of the individual���s ability to pay. The problem is that those with the strongest voice ��� the so-called mid- dle classes ��� often demand and consume more than the less fortunate whose relative need is greater. This social dispar- ity is compounded by geographical inequalities in the avail- ability of services, which still reflect historical discrepancies