Richard Smith: Is the NHS three times better than in 1979?

Richard SmithReading the accounts in the BMJ of how various doctors and mangers would make savings in the NHS, I thought back to a series based on the same idea that I edited when I first arrived at the BMJ in 1979. Then I thought that in 1979 the cost of the NHS was about £35 billion in today’s prices whereas now it’s well over £100 billion. What have we got for that near tripling in spend in less than a professional life time? Has it been worth it?

 My suspicion is that any doctor practising in 1979 will immediately answer “no” to that last question. Things weren’t so bad. Indeed, for many doctors they were much better. Patients were grateful. There was much less bureaucratic hassle. This was long before Bristol and Shipman, and doctors were still seen as part of the solution rather than part of the problem. There was camaraderie, black humour, lots of alcohol, and plenty of casual sex in that pre-AIDS era. It’s all well captured in the Houseman’s Tale by Colin Douglas, who now writes the prime minister’s speeches.

 Oddly I think that most patients would also answer “no.” You could see your GP almost anytime, and he (they were mostly he’s then) would smile, reassure you, and send you home with a bottle. He would also come and see you at night. You might have had to wait for operations, but once you got into hospital it was rather jolly. Lots of patients were not very sick and so had time to chat and bring each other tea. The nurses were attentive and tucked you up in bed at night. You didn’t perhaps live as long, but death was more familiar, less scary.

 This must, of course, be an old man thinking back to a golden age that probably wasn’t golden at all. But what have we got for that tripling in spend?

 Certainly we have a lot more people. In 1979 there were about 40 000 doctors and dentists in the whole NHS (it was one NHS in those days) but now there are 122 000 doctors (not dentists) in the English NHS alone. Nurses have increased less dramatically—from 300 000 in the whole NHS in 1979 to 400 000 in the English NHS now. In particular we have many more specialists. Cardiologists were exotic creatures when I was a junior doctor; now they’re a dime a dozen, all busy putting catheters in all day long.

 There aren’t more buildings and beds. Indeed, there are many fewer. The huge mental hospitals have been turned into luxury flats, and some of the sleepy community hospitals have become GP surgeries, although a remarkable number have managed to survive—kept alive by (probably misplaced) local affection. But the hospitals we do have are bristling with machines that didn’t exist in 1979. The first CT scanners appeared in the 70s and nobody where I worked knew how to read the resulting scans. In many cities in Britain you were lucky to be dialysed if you were diabetic or over 60.

So we have lots of people, specialists, machines, tests, activity, and interventions, and we know that inflation in medical costs far outstrips general inflation. But does the extra spend produce value? This is perhaps an unanswerable question, but one answer must be “Of course it does, otherwise countries would not be willing to pay so much—and every country that can afford it has seen the same kind of increase in spend.”

 But that answer doesn’t satisfy me. The same argument that says that you can’t have a proper market in health care because people don’t have good information on the value of what they are paying for seems to me to apply at a national level. I fret that people think they are paying to ease suffering and fend off death, but I fear that they are paying for a more existential kind of suffering and for a prolonged period of unhealthy life. Life expectancy may have increased since 1979, but I’m skeptical that much of that increase comes from health care. My bias is that public health improvements are increasing healthy life span and health care unhealthy life span.

Of course there is no going back. If we were to go back to a 1979  spend the massive national debt would be cleared in a few years—but for having to pay redundancy and unemployment benefit to 80 000 doctors and 100 000 nurses. But the thought of sacking so many health professionals is clearly ludicrous.

 But it’s amusing to read what an unnamed paediatrician said to me in an unsigned article in 1979: “Doctors have tended to work in the past as if the NHS had access to a bottomless pit of resources. This attitude cannot continue any longer: we must recognise that resources are finite and we must take decisions about how those resources can best be used.” (1) Or, he might have said, we can spend three times as much on the NHS. People would have thought him crazy.

1 Special correspondent. If I was forced to cut…Consultant Paediatrician. BMJ 1979; ii: 1570-1.