Richard Smith: Is the NHS being the top issue in the election a sign of a degenerate society?

richard_smith_2014Some polls suggest that the NHS is the number one issue for voters in Britain’s coming general election. That’s one reason that the Labour Party has put it at the centre of its campaign, the other being “when in doubt retreat to where you are comfortable.” But would a healthy society put the NHS as its top concern, or is this a sign of degeneracy?

Before being dismissed as a Tory apologist, I must make clear that I have never voted Tory and have no intention of doing so. Although something of a Bollinger Bolshevik, I’ve lived all my life in safe Labour seats and have usually voted Labour. Sometimes I vote Green to signal that I think the environment, especially climate disruption, the most important issue. I was once a member of the Labour Party before I joined the Young Communist League. And I was a member of the Labour Party’s Independent Commission on Whole Person Care.

The National Health Service is a classic example of doublethink. Just as the Ministry of Defence is really a Ministry of War so the National Health Service is really the National Disease Service. I was about to write that most people know this, but do they? A vote for health is a fine thing, but a vote for treating disease is less compelling. If you vote for housing or education you get houses and education (of a sort), but vote for health and you don’t get health—you get a lot of extremely expensive tinkering with disease, much of it not very effective.

When the NHS began in 1948 it made lots of sense. People suffered from infectious diseases that could be diagnosed, treated, and cured. Spending on the NHS meant that some people who would have died or been severely disabled could be returned to full health. There’s not much of that now. This is the age of chronic disease, where doctors are patching up not curing, and some people (even, I suggest, many) are kept alive when it might be better for everybody, including themselves, if they were dead.

We knew even in 1948, although it’s become much clearer since, that how long people live and how healthy they are has little to do with misnamed health services. Investing in health services actually achieves the opposite, a large number of diseased people kept alive. So the main benefit of the NHS in 1948, and still now to some extent, is that it stops people being impoverished and bankrupted by developing a condition like leukaemia that is extremely expensive to treat. Nobody would want to deny curative treatment to a child with leukaemia, but most of NHS expenditure is not on such cases. Rather it’s treating people with late stage chronic diseases at considerable expense and with indifferent results. We could avoid impoverishment without spending 9% of our GDP on disease treatment.

Another problem with carrying on with the same old model is that with the old model the doctors cured you. Getting you well was their business. If you had meningitis there was little you, the patient, could do: the doctors would take over and fix you. In hours you’d be recovering. In contrast, if you have diabetes how well you do depends primarily on you, and if you and your doctors don’t recognise it then it’s bad for everybody.

I’ve been sceptical about the benefits of medicine ever since I was a student in the Royal Infirmary in Edinburgh in 1973 and came to feel that much of what went on was for the benefit of the doctors not the patients. Then I was convinced by Ivan Illich’s argument that “the major threat to health in the world today is modern medicine.” Illich had a broad view of health: it is primarily the capacity to cope with the pain, sickness, suffering, and death that are an important part of being human. Much of that capacity lies not with individuals but with their communities, traditions, and beliefs. Illich argued that modern medicine with its false promises of stopping pain, curing pain, eradicating suffering, and delaying (and perhaps eventually defeating) death destroyed those traditions.

Interestingly, Atul Gawande, our modern surgeon guru, has reached the same conclusion. “In the past few decades,” he writes, “medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.”

There is a growing feeling among doctors that medicine has over-reached itself, taken a wrong path. The reason that health systems in developed countries demand more and more cash is not primarily because of the aging of the population or even patient expectations it’s because medicine can do more and more. Unfortunately much of that “more and more” is extremely expensive and offers marginal benefits. The highly expensive drug that fends off death from cancer in some patients for weeks is one example, but there are also heroic operations, admitting to intensive care patients who have little chance of returning to a meaningful life, and much more.

The number of doctors has increased dramatically since the start of the NHS, and most of those doctors are specialists. For example, I’ve visited the NHS in Dumfries and Galloway over the decades, and when I first went in the 80s people could remember when there were two physicians and a general practitioner who did surgery on the side. Now, as elsewhere in the NHS, there are dozens of specialist physicians and surgeons. All are busy, and all are appreciated. But are they adding lots of value from society’s point of view? I fear not. Carers who visit the elderly at home and community nurses probably add much more value (partly, of course, because they are much cheaper: value is benefit divided by cost.)

As the American writer, Lewis Lapham, wittily puts it: “to regard the mere fact of longevity as the supreme good—without asking why or to what end—strikes me as foolish, a misappropriation of time, thought, sentiment, electricity, and frequent flyer miles. Of the $2.4 trillion assigned last year to the care and feeding of our health care apparatus, a substantial fraction paid the expenses of citizens in the last, often wretched, years of their lives. Who benefits from the inventory of suffering gathered in the Florida storage facilities?”

A society that puts treating disease as its top priority is, I fear, a degenerate society. It is a society that puts disease, and particularly the delaying of death, before knowledge, joy, togetherness, children, learning, love, exploration, the environment, and—for want of better words—moral development and spirituality. “A society’s image of death,” writes Illich, “reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.”

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interest: RS was a member of the Labour Party’s Independent Commission on Whole person Care.

  • Michael Schachter

    I totally agree. It is a sad and rather hopeless society that puts health as its most important issue. It is of course vital and without health your options are to say the least limited, but surely it is a prerequisite for actually enjoying life, not just worrying where your next appointment is coming from.

  • Personally I find it heartening that the health service is at the top of the agenda, because it indicates to me that people want more from their health service in the very way that you describe. The remit of health care is extending, as is our definition of health. People are increasingly seeing the importance of the ‘care’ bit in ‘health care’. This is surely the case if so many people are counting the NHS as important despite an absence of ill-health and curable disease.

    I am by no means a representative case, but I am healthy and satisfied with the NHS and yet would put it at – or close to – the top of my election priorities. My main reasons for this are that i) I very much care about the “marginal benefits” you describe, ii) I believe the NHS needs to go through some important changes and iii) I see threats to universal healthcare here and abroad.