Essentials of health economics: Part IV--Challenges for the future.

The aim of this series of articles was to introduce doctors to the essentials of health economics and to assess the contribution of economic analysis to solving health service problems. Nevertheless , the Health Service is neither totally "economic" in its operation nor is economics as a discipline completely "healthy" in its development. Both could show signs of improvement. In this sixth and final part of the series we, therefore, present a personal view of the current state both of the NHS and of health economics and (in the final article) outline some challenges for the future. Sources of inefficiency in the NHS Anyone who both watches and plays sport will know that it is often easier to stand on the sidelines criticising the players than to do better oneself. In mounting our critique, therefore, our comments may seem misplaced to those NHS clinicians and managers in the "team" attempting to grapple with seemingly intractable problems on a day-today basis. (Indeed this dilemma has attracted previous comment from economists.' 2) Health economists are, however, excluded from the team, as there are very few positions for them within the NHS at present, so perhaps we can view a situation better when apart from it. It is to be hoped, therefore, that we do not display the arrogance of which Engleman' accuses economists, an arrogance which may be born partly of the frustration of having to watch the team's struggles from the side of the pitch. (For this reason one of us has become a member of a health authority.) To put our criticisms into perspective, there is much about the NHS that we (and most of our British health economist colleagues) admire. For example, we see no compelling economic reason to change the system of financing health care in the United Kingdom. While bearing in mind the point made earlier in the series that the choice of system is predominantly determined by ideology, there is no evidence that any other financing system would increase efficiency. Indeed, the evidence is that such a move might make it even harder to ensure more cost-effective provision in line with social priorities. Furthermore , Culyer et all pointed out that there was a "crude evolutionary argument that the countries now having ... (tax-director of health economics research unit and senior lecturer in health economics financed, publicly directed) ... health care systems did previously have. .. …