The recent John Pilger film / documentary produced by ITV “The dirty war on the NHS” was released on terrestrial TV Tuesday evening. It has been available in cinema before this, but possibly suppressed before the election. The film begins with anecdotes, and derides the privatisation. It fails to compare UK with any other system than the USA, which we in the professions all know is inferior. It fails to give comparative population numbers, and it does not mention really cheap and effective systems such as Cuba. In EU there are at least 4 other systems that have consistently scored better on survival and life expectancy, but the producer seems fixated on the USA (Is there a worse system?). He says that the politicians are equally fixated! God save us all. From the political footballs that are the 4 health services….
In the final analysis the duty of a government is to populations ahead of individuals. That’s why defence and internal security come above health in Maslow’s hierarchy of needs. That’s why immunisation programs are more important than surgery for cancer. In the UK health lottery, poorer people are missing out because the waiting lists mean richer people buy faster (private) care. There is a problem: fear. The original single health service, which devolution has replaced with 4 health services, was In Place of Fear. A Free Health Service 1952 Chapter 5 In Place of Fear People fear cancer more than they fear infectious diseases (measles), demographic lifestyle diseases (Obesity, Diabetes) less than they fear cancer…. Education is the answer, and not just about health, but also about health systems and the rationing choices that have to be made.
Nigel Hawkes reports in the BMJ on “The 2010s: a decade of disappointment in UK healthcare”, BMJ 2019;367:l6895
Despite health system reforms, improvements in life expectancy and neonatal mortality have stalled. Nigel Hawkes reflects on the past 10 years
A decade that began with a Conservative health secretary promising to transform the NHS in England through market discipline, legally enforced, ended with an election manifesto from his party embracing the polar opposite. Competition is dead; long live cooperation.
This meant that, even before the general election votes were counted, a 30 year experiment in the English NHS was over. “Choice and competition,” a mantra pursued as energetically by the Labour governments of Tony Blair as by the Conservatives, was dead.
How the NHS is organised generally makes less difference than its planners hope, though competition and choice seemed to have some successes, including shorter waiting times. But this was before the 2008 financial crisis cast its long shadow over the succeeding decade.
Since then, progress has faltered, not only in the UK but across Europe. Decades of improvement in life expectancy have plateaued, even gone into reverse.1 Neonatal health has paused in its steady improvement.2 Doctors are demoralised, GP surgeries and hospitals are under siege, and public satisfaction with the NHS, which rose sharply between 2000 and 2010, has fallen back as quickly as it rose.3 The 2010s have proved to be a decade of disappointment.
Many blame austerity. In England, health department spending rose by an average 1.5% a year over the decade, much slower than the long term average growth of 3.7% a year.4 Productivity improvements failed to fill the gap. The pips began to squeak.
Austerity had an effect, certainly, but not only in the UK. Eurostat data on life expectancy, for example, do not show the UK as a conspicuous outlier,1 with an increase in life expectancy at birth (sexes combined) between 2010 and 2017 of 0.7 years, greater than in France, Germany, and Italy but less than in Spain, Switzerland, and Sweden. For life expectancy at 65, the UK fared worse than all these countries except Germany over the same period. Not a good performance, but other countries also struggled.
The decline in UK infant mortality tailed off after 2010, a trend also seen in other countries.2 In 2010 the UK had 4.3 infant deaths per 1000 live births, while France had 3.6. By 2016 the gap had narrowed: the UK down to 3.9, France up to 3.7. Similar countries saw little progress or, in some cases, declines.
The common challenge, at home and abroad, is affordability. How can any healthcare system continue to pay for care whose costs rise inexorably year by year, unaffected by the state of the rest of the economy? This question has dominated domestic politics in the US during the Obama and Trump administrations, with no sign of consensus emerging. In France, often seen as an exemplar of good medical provision, the state has recently been forced to take over €10bn in public hospital debt after months of protests and strikes by healthcare workers.
Can digital health cut costs and improve outcomes? Certainly many think so, even though experience during the 2010s was mixed. Websites and phone services such as NHS 111 (launched in 2013) have not reduced demand. Health apps appeal to the young and fit, not the old and multimorbid people who fill the wards. The same applies to “digital first” online services such as GP at Hand, 94% of whose patients are under 45. Electronic health records have made slow progress, and the promise of a paperless NHS by 2020 is already in the wastepaper basket.
Sluggish drug pipelines
The 2010s were not a great decade for new drugs, either. Pharma pipelines were sluggish, though they picked up later in the decade. About half of newly licensed drugs were biologicals, which are around 20 times as expensive as traditional drugs and account for almost all the increase in the drugs bill. A splendid exception to this gloomy picture was new treatments for hepatitis C, which NHS England, swallowing hard, finally agreed to pay for.
Credit, too, should go to Public Health England for championing electronic cigarettes, which has given tobacco cessation a boost at no cost to the public purse.56 Critics of vaping, vociferous at the start of the decade, have largely fallen silent, in the UK at least.
If somebody could come up with a similar technological fix for obesity they would be the hero of the 2020s, as exhortation has failed. The decade began with 26% of men and women classified as obese in the Health Survey for England. In 2018 (the latest data available) the figure for men remained the same, while that for women had risen to 29%.7
To end on a brighter note, sometimes things can change for reasons that aren’t immediately obvious. The teenage conception rate in England and Wales, long the cause of hand wringing, halved in the 2010s from 34.3 per 1000 women in 2010 to 17.9 in 2017.8 All credit to those who brought this about: mostly young people making sensible decisions.
Market discipline not adequately implemented with the difficult arithmetic of personnel and costs, faltering steps are not confined to UK healthcare but easily extend to the continent. A huge influx of refugees creates changed equations of healthcare costs. Westwards, insurance has risen in costs and coverage affected. In developing countries, the percentage expenditure on health has the scope of being enhanced for better output.
In short, in the last decade, almost at a global level, disenchantment with health services has grown. Outbreaks continue to threaten and lifestyle disorders dominate. Influence of AI may take over, but at what pace may be a guess difficult to make.
Dr Murar E Yeolekar, Mumbai.
US Hospital to advise London on safety….. and what a terrible record their country has when treating populations
Meningitis B – Can Wales afford it? Government’s treat populations and not individuals.