Only that careworn cliché "a steep learning curve" was anything like adequate to describe what hit me when I became health spokesman for my party in Parliament. Up to that point, just like almost everyone in Britain, I had revelled in the progress made in clinical practice, marvelled at medical innovation, and expressed acute frustration at the apparent inability of the NHS to deliver a comprehensive service to every citizen.
To my horror, what I discovered was that almost all the beliefs I had imbibed over many decades were fallacious and that it would be electoral suicide for any politician to tell the unvarnished truth about the NHS and the policies required to improve the nation's health. Now that once again the government is pouring still more millions into the NHS, primarily to make a good impression on the electorate, it is a good moment to confess all and to try and stake out the high ground.
First, the remarkable extension of life expectancy - which was as low as 26 years in 1851 in a large city, and then progressed from 48 to 75 for men and from 49 to 80 for women during the past century - came about through public health measures, such as clean water, sewage disposal, clean air and, to some extent, from immunisation and vaccination. Latterly the continuing increases are a consequence of increased income and education. Life expectancy has never improved as a result of clinical practice. To continue to extend life expectancy requires further emphasis on public health, including nutrition, rather than on developing clinical practice.
Second, statistics that appear to indicate progress in clinical practice have considerable limitations. For instance, lowering the rate of perinatal mortality, ie babies dying in the first days of life, is perceived to indicate the increasing success of the NHS. However, there is clearly a rate below which one would be using sophisticated technology to keep babies alive that have a very low potential of worthwhile existence. In other words, technology is now capable of counteracting nature to an extent that is arguably unjustified. Where should the NHS draw the line? It is a nightmare dilemma.
Third, virtually all screening services for the detection of cancer are not justified by the results. The evidence is that the finance required to run the millions of screenings would have more effect if spent directly on the cancers being screened for. In addition false indications are known to cause ill health to some of those involved.
Fourth, the media focus on amazing hi-tech and glamorous innovative procedures, particularly in regard to children, skews provision to the few to such an extent that services to the many are detrimentally affected. These technical advances are hugely expensive and can only be paid for by budget reductions elsewhere.
Fifth, it would be better for patients' health, as well as enabling substantial financial savings, for there to be a limited list for prescribing medicines. Unless they could make a specific case for a drug not on the list, doctors would only be able to prescribe from a designated list of items. When Health Minister Kenneth Clarke introduced a partial limited list, a constituent wrote to me and complained that a drug he had been on for five years was not now available. I checked it in the British National Formulary and it was listed "for short-term use only". I told the constituent that I was not a clinician but I thought he ought to take it up with his GP!
Even if the government, any government, poured the whole Gross National Project into the NHS it would not resolve its funding problems. Health provision is well able to eat up every penny it gets and it would simply lift the level of provision to a new height, whereupon the clamour for more resources would recommence. At the heart of the dilemma is the separation of the power to spend from the power to tax. The hospital or the individual clinician can order the treatment but cannot raise the cash to pay for it. It depends entirely on funding from the government. In this respect it is different from local government which, at least in theory, can determine its priorities and then levy the council tax to pay for its budget - and then defend it to the electorate.
Each of the five points set out above illustrates the politicians' dilemma over legitimacy. It is legitimate for the individual to demand treatment but it is legitimate for the government to refuse it. The individual's needs are often immediate and critical but the government knows that the resources allocated to those individual needs detracts from its key task of improving the country's general health.
Political cowardice has always ensured that access to medical provision has been rationed by the waiting list rather than by logic and every government bangs on about reducing that waiting list. Simple logic suggests that if consultants' waiting lists get shorter GPs refer more patients, and that the more efficient and effective a consultant is in dealing with his or her list the more patients will arrive. That same cowardice has also ensured that, arguably, more resources than are justified have gone into glamorous specialties, such as paediatrics, than into psychiatry or geriatric work.</ p>
There is an urgent need to promote a serious debate on what the NHS is and what it can achieve. That debate is not helped by sloganising and shroud waving. If people are treated as sentient beings, capable of understanding relatively complex arguments, they might well surprise the politicians.
22 July 2004
