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THE NATION'S HEALTH Introduction The NHS has been described as the ‘flagship’ of the Welfare State; less charitably as the bottomless pit of the ‘dependency culture’. With what today must seem staggering naivety, in 1948 the Minister of Health was claiming that the cost of the NHS would ‘naturally’ decrease as it went about improving public health. In fact it is now the largest employer in Europe and the fourth largest in the entire world. And we’re still hearing of overspent NHS budgets and demands for additional funding to cope with expanding workloads. Meanwhile the politicians keep imposing new performance targets and prodding health authorities to improve their management of the ever-increasing resources at their disposal. In response, almost all NHS staff close ranks in resisting any significant reform of existing policies and practices, claiming that ‘bureaucracy’ and ‘underfunding’ are the only matters needing attention….now an established parrot-cry in every hospital soap opera on TV. And with around 72p in every pound of NHS expenditure going on salaries and wages, any serious reforms will impact on employees most of all. Faced with such facts, and given the general public’s seemingly inexhaustible indulgence of the so-called ‘caring professions’, very few politicians are likely to do other than promise extra funding and superficial changes to the status quo. In short, there are no votes to be had for radical NHS reforms. Yet radical they must certainly be, since we cannot expect the NHS to cure its own diseases and it is daily more apparent that the service is - to use a current expression - ‘not fit for purpose’. And this despite dazzling examples of medical technology and the devotion to duty of most NHS front-line staff. While the ordinary punter asserts ‘It’s wonderful what they can do nowadays’, enormous increases in NHS resources have made no discernible impact on the incidence and outcome of most common diseases in the population. So much is easily demonstrated by a simple graph showing the increase in the medical payroll over the last 50 years compared with the mortality index for almost any common disease. So we are not actually getting value for money. While there are certainly outstanding exceptions, the actual quality of care provided is also in question in many instances. As the drugs bill continues to expand, unwanted and often dangerous side-effects now fill many volumes in medical works of reference and have become the unhappy experience of countless patients. The continued reckless use of ‘broad spectrum’ antibiotics has resulted in the emergence of drug-resistant pathogens such as MRSA, now a serious problem in hospitals. Cancer remains the most dreaded diagnosis, yet the hundreds of millions collected by high street tin-rattlers and research grants over the last fifty years have had negligible impact on the survival prospects of those affected. Indeed, some authorities have claimed that, for example, women who refuse surgery, radiation and chemotherapy for breast cancer survive a lot longer than those who don’t. Moreover, the campaign for routine screening to detect early signs of breast cancer doesn’t actually influence the eventual outcome in terms of survival for the cases detected. About one in three people still succumb to cancer within a year of the diagnosis. More generally, pathologists claim that up to 40 per cent of death certificates give an inaccurate diagnosis; while there are reports that about one in ten patients admitted to hospital are suffering from ’iatrogenic’ (doctor-caused) conditions. As an example of fossilised professionalism, consider the fact that all medical students undergo the same five-year basic training regardless of the fact that very large numbers will end up in specialist careers which make most of their undergraduate training irrelevant and superfluous. Do dermatologists, psychiatrists and ophthalmologists really need to pass exams in general surgery, obstetrics and orthopaedics? (A medical technician in Russia performs more cataract operations in a day than a consultant eye-specialist in the NHS will do in a month). And research into general practice workloads has concluded that about two thirds of the patients seen could be adequately diagnosed and treated by nurse-practitioners, given of course the medical back-up when needed. For all the loose talk about people living longer nowadays, the 60 year old man has a life-expectancy only three and a half years longer than his 17th century forbears. And the fact that more people survive into old age has very little to do with advances in medical science. The decline in epidemic diseases is mostly attributable to improvements in public hygiene, diet and education. Similarly, most common ailments like arthritis, rheumatism, asthma, bronchitis, migraine, high blood pressure, digestive and circulatory disorders are due to dietary, life-style and environmental factors. But doctors are almost wholly concerned with treatment, not health maintenance; and their recourse to high-tech modes of diagnosis and treatment often has more to do with PR than clinical necessity. The profession’s claim that ‘everything possible is being done’ for their patients may be all too accurate; but the issue is not what is possible but what is strictly necessary. You may well be startled to hear that the term ‘evidence-based medicine’ is becoming fashionable among doctors; so what other kind have they been practising all these years? It needs to be said that the foregoing comments on the current state of the NHS do not lessen our admiration and respect for the commitment and competence of most of its staff. Most of us have every reason to be profoundly grateful for their help in times of need. Even so, an organisation as large and complex as the NHS, and mostly governed by a profession insisting on its members’ ‘independent contractor’ status in this publicly-funded service, is afflicted by serious problems which the most conscientious employees can do little to resolve ; they have to make the best of a bad job much of the time. This is not the place for a detailed prescription of the reforms needed to transform a national treatment industry into a genuine national health service. Suffice it to say here that no significant progress in that direction is likely without a radical reform of the medical profession which
Above all, however, there has to be a massive shift of emphasis and resources from hospital treatment to public health programmes. We must hope the time will come when the success of the NHS is demonstrable from the declining incidence and improved outcome of common diseases; not by treating more patients and more expensively. F Kimbal Johnson March 2007
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