Where do I myself stand?

• I support universal access to therapies of demonstrated benefit. It’s difficult to tease apart the inequities of access to healthcare from other social inequities, so it’s difficult to know for sure whether unequal access to healthcare alone is bad for the population overall, but the World Health Organization’s (and others’) statistics suggest that in countries where there is wide socioeconomic disparity, everyone’s health suffers, rich and poor.
• Cost to the user is a barrier to access. It is not the only barrier, and it is not necessarily the determining barrier, but it is the barrier that receives most attention. I think there should be some cost to the user, so that they value health care as they value their CDs, costume jewellery and concert tickets – which can cost the same as a prescription and are paid for without complaint. There is a strong element of take for granted for a free system. That said, there will be people who must have the cost covered, and the process of getting the cost covered should not in itself be a barrier. Chronic ill-health is impoverishing, and, conversely, poverty is bad for your health. And the cost must be capped. Need for health care is not shared equally, and a minority of people will be very needy for most of their lives, most of us will be very needy for small parts of our lives, and another minority will die suddenly and – from the point of view of the health care system at least – cheaply.
• I said proven interventions, and I am of the opinion that a universal access health care system cannot afford to pay for what has not been shown to work. Which is a statement laden with traps for the pronouncer, because our knowledge of what works changes weekly: witness the recent flip-flops over recommendations about hormone replacement therapy and mammography, and does anyone know whether I’m supposed to be eating cholesterol or not this week? The present “gold standard” for evidence, this decade at least, is the double-blind randomized controlled trial, but there are immense challenges in running such trials well, so as to get good answers on meaningful questions, and they answer the questions for people-in-aggregate rather than individuals. With emerging information from the human genome project and molecular pathology it’s becoming apparent that people respond differently to treatment, and diseases that we thought were uniform entities actually have very different subclasses. Then there is the question of how to feed evolving scientific knowledge into a beaurocracy, so that not only do you have to keep track of what works this week, but what is paid for this week … um.