Richard Smith: Move money from the NHS to social care

Richard SmithWhen governments spend money on “health” they get lots of sickness but very little health. Increasing expenditure on healthcare—now 17% of GDP in the United States and 9% of GDP here—leads to more and more people clinging onto life in a seriously impaired state. Better, I believe, to recognise that death is a friend and that our money can be better spent.

Politicians and even medical schools have failed to notice that the nature of health care has changed fundamentally. If you ask a woman in the street to describe what doctors do she’ll probably answer: “Diagnose patients’ problems and cure them.” The chief medical officer a few years ago defined the work of doctors as “diagnosis, diagnosis, diagnosis.” But less and less of medicine is about diagnosis and almost none of it is about curing.

The main activity of health care these days is looking after frail, elderly people with not one disease but many. We don’t have good figures for Britain, but data from America shows that people with more than five conditions account for two thirds of Medicare costs. Visit any hospital or GP surgery, and it’s frail elderly people that you’ll see. The days of “Emergency ward 10” and “Dr Kildare” (showing my age here) are long gone.

The patients may have changed but unfortunately the health system hasn’t. Many of the frail elderly people are not looked after well. Their concerns don’t tend to be their diabetes or high blood pressure but rather are social: Can I live on my own? Will I be able to make it to my granddaughter’s wedding? Who’ll look after my cat if I go into hospital? But their social concerns are often forgotten by the army of specialists each devoted to one part of their body—heart, lungs, blood, gut, kidneys. The costs ratchet up as they are passed from specialist to specialist, but the patients are no happier.

Like most of the world we have health systems that are driven by the four d’s: diseases, diseases, drugs, and death. But it’s time to move from a 20th to 21st century system, argues Lord Crisp, once chief executive of the NHS, in his excellent new book “Turning the World Upside Down.” The health system that has been successful in combating the infectious disease is becoming part of the problem rather than part of the solution. We should concern ourselves with health not disease, recognise that doctors are very expensive and can be replaced by cheaper, more holistic practitioners, use more non-drug treatments, and learn not to keep fighting death but to welcome it as a friend.

What Crisp calls “the triad of the professions, commerce, and technology” are driving us towards unaffordable and unsuitable health systems. The United States may well be the first empire to be brought down not by disease but by health care. The triad is “strongly incentivised to do more, treat more patients, and increase overall costs.” The vested interests are huge.

We currently spend over £100 billion on health care and around $8 billion on social care. The ratio is wrong. Increasingly people need caring not curing, and the care should be person not disease centred. For most people social concerns trump health concerns. Politicians instead of squabbling over how we should pay for long term care for the elderly should be bold and recognise the need for a shift from medical to social care.