Nicholas S Hopkinson reviews “The state of medicine”

nick_hopkinson“I am furious, sad, and scared for the NHS” —Margaret McCartney’s opening words in the introduction to her latest, timely book, The State of Medicine (Pinter and Martin 2016). Understandable sentiments, as the NHS heads for £20 billion/year underfunding by 2020 and politicians can launch thinly veiled xenophobic attacks on our colleagues born overseas.

McCartney’s writing has been characterised by a consistent critique of the distorting effect and waste that follows from misconceived interventions in healthcare; the harms these can cause to the lives of those who need care and to those who provide it. The Patient Paradox (Pinter and Martin 2012) challenged the growth of screening and consumerism; how time and resources are being shifted away from people who are unwell and disadvantaged, towards those who are healthy and who themselves risk being treated for conditions that may never affect them. Living with Dying (Pinter and Martin 2014) focussed on the balance of risks and harms of interventions at the end of life and the need to prioritise human kindness over remote technology.

McCartney now scales these concerns up to the level of the NHS as a whole. Battered by destructive reorganisations, it is the carer of last resort as social support and public health are cut to the bone. Staff vocation is threatened by marketization as money drives out other sources of value and the ethos of professionalism is eroded by oppressive systems of appraisal that demotivate and undermine.

Democracy requires public reasoning, and rational or reasonable policy requires the best use of evidence. Instead, time and again evidence is distorted or ignored to advance non-evidence based, or indeed in-the-face of the evidence, policy. The undermining of NICE by the Cancer Drugs Fund, the bypassing of the National Screening Committee in order to be “doing something about dementia,” the continued political deceit about the so-called “weekend effect.” Benefits are exaggerated, harms—opportunity costs, perverse outcomes, wasted resources—are ignored.

Should politics be taken out of the NHS? McCartney certainly demonstrates how harmful the political trend in recent decades towards marketization has been—“buying healthcare is not like buying fruit.” But the provision of universal healthcare, funded by pooling the risk at a population level through taxation, based on need not ability to pay, is a political achievement and profoundly ideological. It is politically threatened and must be politically defended. Withdrawal from politics is capitulation.

Each chapter is preceded by short contributions from people with experience and insight. These underline why this is an important book and a resource, setting out clearly what we have lost and why and what is at stake if we do not fight to preserve and restore a decent, rational system of health and social care.

Nicholas Hopkinson @COPDdoc, reader in respiratory medicine, Imperial College, London.

Competing interests: None declared.