Four years ago, when I was chair of the health treatment watchdog NICE, I developed cancer of the head and neck. My career had taken me from the grassroots of the NHS — I spent 36 years as a rural GP — to the service’s commanding heights.
Cancer brought me right to the heart of the health service as an anxious patient. I found myself needing urgent and aggressive treatment.
This meant undergoing two operations, followed by 30 sessions of radiotherapy and five of chemotherapy.
At the end of my first radiotherapy bout, I thanked my good fortune for living in a country where I don’t have to meet the hugely expensive cost of my treatment.
Cancer was worrying enough without the added fear of bankruptcy. That’s the kind of healthcare we need to preserve.
In recent years my work involved advising senior ministers in countries around the world, all facing the same extraordinary challenge of affording healthcare. I asked them all the same question: ‘Do you really know what your healthcare system is trying to achieve?’
Beyond this current crisis, there lies a greater one. For despite the advances we are making in our ability to diagnose and treat illness, the demand on health services continues to rise inexorably
What is healthcare? What is it for? And if we have a goal in mind, are we going the right way about trying to achieve it?
The NHS has suffered a double whammy in recent years. The pursuit of austerity after the global financial crisis of 2008 vastly reduced its capacity.
Waiting lists rose to 4.6 million and staffing became seriously inadequate. The pressures were massive and unsustainable. Then Covid-19 tested the NHS to its absolute limits.
Beyond this current crisis, there lies a greater one. For despite the advances we are making in our ability to diagnose and treat illness, the demand on health services continues to rise inexorably.
There is a mismatch between supply and demand. Resources can never be infinite, but the demand for healthcare in Britain appears inexhaustible. This imbalance is a source of immense tension and is only getting worse.
If we can accept that there will never be enough money to cover every possible eventuality, how should we make difficult choices about who to treat and how?
This question repeatedly struck me while I spent six years as chair of NICE, from 2013 to 2019. The institute looks at new technologies and treatments, to determine if they are cost-effective and should be used by the NHS.
Waiting lists rose to 4.6 million and staffing became seriously inadequate. The pressures were massive and unsustainable. Then Covid-19 tested the NHS to its absolute limits
Unless we take some tough decisions, it is inevitable that at some point there simply won’t be enough money to pay for all the healthcare we want or feel we need.
In 2013, the distinguished British health economist Professor John Appleby wrote: ‘If healthcare spending were to grow at the rate seen over the decade since 1999-2000, then by the mid-2070s the NHS would be consuming close to 100 per cent of GDP. Clearly this is not fiscally sustainable.’
I believe we need to make fundamental widespread changes.
I’m not talking about yet more structural change to the NHS — the very last thing that we need.
Instead, the problem is far deeper and more profound than that. And we need to start making these changes now.
Don’t medicalise everyday life
In 2019, a leading U.S. clinical psychologist described loneliness as ‘social isolation syndrome’, and there are suggestions that drugs might be developed to address the problem. Yes, medication is being proposed to treat loneliness.
I do not wish to minimise the heartache that loneliness causes. But is it wise, logical or beneficial to expand the remit of healthcare when our health systems face ever-escalating costs?
Today, many aspects of human existence are at risk of being medicalised. During the pandemic, it became clear that being obese and unfit raised the risk of severe illness with Covid-19. In response, Boris Johnson announced that GPs would prescribe cycling.
The underlying idea — cycling is good for you — is excellent. However, the idea that doctors should prescribe cycling is symptomatic of an unsustainable approach to healthcare: the gradual medicalisation of everyday life.
While the population has, in general, never been healthier, we seem to consider ourselves to be more at risk of falling ill than ever — and, paradoxically, we are more anxious about our health than at any time in history.
Originally, health systems were introduced to ensure a country had a sufficiently healthy workforce, or a sufficiently fit population to defend itself in case of war.
Resources can never be infinite, but the demand for healthcare in Britain appears inexhaustible. This imbalance is a source of immense tension and is only getting worse. If we can accept that there will never be enough money to cover every possible eventuality, how should we make difficult choices about who to treat and how?
However, as the possibilities offered by medicine and pharmaceuticals have expanded beyond all recognition, the activities on which money can be spent have become disconnected from these aspirations, so that lifestyle issues such as loneliness and sedentariness have become categorised as ‘medical problems’.
In a health service struggling to meet ever-growing medical needs, we should as a priority tackle this overmedicalisation, along with the unnecessary medical tests, diagnoses and therapies that can lead to waste — not just of money but of time and expertise.
Instead, we should shift our focus towards more non-medical solutions. The benefits can be not only greater but dramatically cheaper.
Take the example of the small Somerset town of Frome. In 2013, Dr Helen Kingston, a local GP concerned about the number of patients who were unhappy with the medicalisation of their lives, launched a project called Compassionate Frome.
The GPs at Frome Medical Practice recognised that the impact of social connectedness — belonging to a group — can have as much of an effect on people’s wellbeing as giving up smoking, reducing excessive drinking, reducing obesity and other preventative interventions.
They became aware of the role played by primary and community services in identifying those people who are in need of support at moments of crisis.
The Compassionate Frome project combined a programme of community development with routine medical care. The results were remarkable: when isolated people with health problems were supported by community groups and volunteers, the number of emergency admissions to hospital decreased spectacularly.
The number of admissions per 1,000 population in Frome fell from 25 to 21, at a time when for wider Somerset they rose from 28 to 36.
The cost of unplanned hospital admissions in Frome fell from £5.7 million in 2013 to £4.5 million in 2016, a decrease of 20.8 per cent.Kindness, compassion and community get better results than focusing only on the medical model. In an ideal future, these services and this support will be readily available to citizens directly without people necessarily feeling a need to see a doctor or nurse.
The all-too-common expectation that every problem can be treated medically must fade away.
Prevent rather than only treat
If a GP offers advice and treatment that prevents a heart attack, nothing appears to happen. The individual might lose weight, allowing their blood pressure to fall. Maybe they will change their diet or start taking medication.
We almost never meet someone who is aware that prevention has helped them, because the whole point is that it stops something from happening.
When it comes to prevention, if you’re looking for a dramatic outcome, you’re out of luck.
But if someone has a heart attack and is saved by an ambulance crew with sirens blaring, followed by care by a skilful hospital doctor with impressive technical support, there is a dramatic story.
It may be hard for politicians to see that something not happening is better than a dramatic success, but I am certain that you would prefer not to have a heart attack than to be resuscitated after one.
Despite this, prevention rarely becomes a priority for spending.
If a GP offers advice and treatment that prevents a heart attack, nothing appears to happen. The individual might lose weight, allowing their blood pressure to fall. Maybe they will change their diet or start taking medication. We almost never meet someone who is aware that prevention has helped them, because the whole point is that it stops something from happening
Between 2004 and 2018, numbers of hospital medical staff in the UK grew by more than a third, from 87,000 to 119,000. Costly hospital consultants rose by two thirds.
Over the same period, the number of GPs fell. However, research shows that hospital mortality rates are more closely related to the number of family doctors in an area than to the number of hospital doctors.
A major study in the BMJ by Imperial College London in 1999 showed that in order to reduce hospital deaths by 5,000 per year, the NHS would need either 9,000 more hospital doctors or 2,300 more GPs.
And there can be little doubt that keeping patients away from hospital — except when essential — is generally good for them and reduces the ever-increasing pressure on our healthcare systems.
A 2017 review of the cost-effectiveness of public health measures showed that for every £1 invested in public health, £14 will subsequently be returned to the wider health and social care economy.
A GP assigned to each patient
Evidence increasingly shows that continuity of care with a general practitioner really matters. However, many recent healthcare policies have reduced this continuity, with many patients seldom seeing the same GP twice.
In January, researchers in Norway reported in the British Journal of General Practice that patients who stay registered with the same GP over many years have fewer out-of-hours appointments and acute hospital admissions, and a reduced risk of death.
These benefits increase the longer the relationship continues. People who had kept the same GP for more than 15 years had a 25 per cent lower chance of dying than those with a GP relationship lasting a year or less. It should be noted that Norwegian GPs care for half the number of patients as their UK equivalents. If drugs produced benefits of this scale, massive investment would be found to provide them.
Instead, British governments prioritise rapid access over continuity. After all, problems seeing your GP cause headlines. Continuity problems tend to be invisible, although many older people mourn the passing of the phrase ‘my doctor’. We need to create a workforce that can offer continuity of care whenever appropriate.
Benefits can work both ways. Having an ongoing relationship with patients is far more satisfying for clinicians; it boosts morale and reduces the likelihood that doctors and nurses will leave healthcare or retire early.
In 2020, a paper in the journal Health Policy warned that some doctors fail to give patients the proven best treatments and instead provide substandard care thanks to irrational biases.
One reason is that doctors prefer to stick with what they have always done, rather than update their practice in the light of new knowledge.
This is partly due to ‘failure embarrassment effect’, the paper said. Doctors feel disinclined to admit that a treatment they have been offering for years is of low or no benefit. Similarly, the ‘status quo effect’ leads them to prefer what is known and comfortable.
Many doctors argue that their treatment choices are to some extent determined by their patients’ expectations rather than by what is necessary. Indeed, when doctors are patients themselves, the treatments they choose are frequently different from those they typically offer to patients.
In a study in the journal Archives of Internal Medicine in 2013, doctors were asked to assume they were the patient with bowel cancer, or were asked about advice they gave others.
When the physicians answered for themselves, 38 per cent chose a treatment with a higher risk of death but fewer side-effects; yet only a quarter said they would recommend that treatment to theirpatients.
We have an intriguing scenario where doctors seem to second-guess what their patients want, often without good evidence.
‘Risk aversion’ is another powerful bias. In a complex and challenging medico-legal world, clinicians often feel it is better to be criticised for doing something than for not doing something, which leads them to practise what is described as ‘defensive medicine’ that can lead to costly but pointless treatments.
Two further examples of biases strike me as particularly relevant. ‘Availability heuristics’ is a bias by which something is used because it is there rather than because of any distinct clinical need — the idea of ‘scan because you can’.
I have always taught (and tried to practise) the importance of only carrying out an investigation if you have an idea what you might do with the result. If all you do is file it away, why carry out the investigation in the first place?
The final bias is the ‘boys and toys effect’. Technology may be fun and interesting, but its use can cost money that robs other patients of the chance to receive vital treatment.
Support DIY care
If healthcare systems are to flourish, there must be a far greater emphasis on patients using self-care rather than relying on medical staff and hospitals.
For example, a patient with type 1 diabetes spends around 0.02 per cent of their year in contact with the NHS, which probably equates to four 30-minute consultations. That leaves 99.98 per cent of their time having to deal themselves with the reality of living with diabetes, according to a report in the BMJ in 2021.
So far the NHS has been poor at supporting many aspects of self-care. Many long-term conditions such as type 1 diabetes are followed up through hospital outpatient visits. These cost time and money but offer minimal benefit.
Conducting this traditional follow-up digitally would save time and cut costs, as well as helping to empower patients.
And there is public support for a shift in emphasis to self-care. In 2017, a King’s Fund study entitled ‘What Does the Public Think of the NHS?’ showed that 65 per cent of the population believed keeping healthy was primarily down to the individual, with 7 per cent feeling that it was an NHS responsibility.
There is no doubt that if any healthcare system is to thrive, patients and the public need to take responsibility for their own health, but this cannot be done by edict. It needs education and support, which requires investment.
Stop squandering cash
Health services have to be paid for but we need to control escalating costs.
An analysis of 39 cancer drugs approved by the European Medicines Agency between 2009 and 2013 shows that more than half had no supporting evidence of better survival or improved quality of life when they went on the market.
After an average of some six years on the market, only six of these 39 drugs were shown to improve survival or quality of life.
At the time of this study in 2017, it was estimated that the average cancer drug cost more than £80,000 per year of treatment — despite the dubious benefits.
In England, an official report on waste in non-specialist acute hospitals in the NHS in 2016 showed about £5 billion of unnecessary variation in spending, with bad purchasing a serious culprit. As an example, the average price paid for a hip prosthesis varied between £788 and £1,590, with the hospitals that bought the most tending not to pay the lowest price.
Tackling waste also means tackling duplication, which wastes time for patients and clinicians, as well as wasting resources.
On a simple level, the absurd situation whereby a patient sometimes needs one appointment for a consultation, another for a blood test, another for an X-ray and another to get the results takes up a remarkable amount of time and resources.
A Spanish study published in The American Journal of Managed Care in 2019 showed that by, instead, focusing outpatient treatments efficiently around patients’ single visits, productivity increased by 34 per cent, satisfaction improved and complaints fell.
Modern medical science pours ever more money into the aggressive treatment of the seriously ill, as exemplified by the idea of ‘one more course’ of chemotherapy in people who are close to death. Is this what society truly wants? If we are trying to beat death, it’s a game we will inevitably lose.
In 2011, a remarkable paper entitled ‘How American Medicine Is Destroying Itself’ warned: ‘Our main achievements today consist of devising ways to marginally extend the lives of the very sick . . . ours is now a medicine that may doom most of us to an old age that will end badly: with our declining bodies falling apart as they always have, but devilishly — and expensively — stretching out the suffering and decay.’
For a long time, it seemed that medical advances were potentially unlimited — that we could take on and defeat one condition after another. Developments such as genomics and stem-cell technology promised to result in us all living long and healthy lives, followed by rapid deterioration and death at an advanced age.
That aspiration seems as far away as ever. Every small medical advance has a massive economic and human cost, and ill health seems to have infinite reinforcements. We are all going to die. While it is wonderful that medical science can spend unimaginable sums researching and treating disease, we seem to have forgotten than death is not the worst thing that can happen to the elderly.
Disability, isolation, frailty, poverty and fear can make their last months — if not years — something dreadful, yet we spend nowhere near as much time or money trying to address these issues.
The natural process of dying has been overmedicalised. Old age is a phase of life rather than a disease. It isn’t there to be defeated or endured. It is there for living — not just for merely existing.
As we get older, the medicalisation of our every waking activity feels like a curious priority. We can’t beat the Grim Reaper. Scrambling for new things that might possibly prolong our life is no way to live. There’s much more to life — and ageing — than that.