In its current form the NHS is not a “Health” service but a “Disease Service” – we use almost all or our resources for treating the ill, not maintaining the health of the population. The current arrangements are unsustainable and we need to change the model. A huge challenge but a necessity. I offer below my thoughts as to why we are in the present position and two major suggestions for the way forward.
What has gone wrong?
I believe that the major causes of our present unsatisfactory situation are due to two factors – a failure to recognise the amazing success of medical research over the past 50 years, and a failure to provide the manpower to deliver the health benefits resulting from that research. My justification for having an opinion on this is the fact that I have been a doctor for the past 55 years, and a professor of medicine for 46 of those. I was the first consultant medical oncologist to be appointed in Scotland and led the development of that speciality for many years. I am still active in research and believe that Cancer is a good model for considering the future of all forms of illness. One in two of us will experience cancer in our lifetimes so it will always be of importance to medical planning, but my comments are equally relevant to most other areas of health.
Medical research has literally transformed the potential outlook for people with cancer over the past decades. When I began my consultant career we had about 12 medicines for treating a limited number of cancers. Now we have > 250 medicines, can help almost everyone, and with the recent development of immunotherapy are actually curing some of these diseases, something that I could never have envisaged in years gone by.
Equally important have been the major advances in surgery and radiotherapy. In Edinburgh we were leaders in the concept of “multidisciplinary” care – patients being discussed at the planning stage by surgeons, physicians radiotherapists, clinical psychologists, nurses etc. All of this is time consuming and requires adequate funding.
The second and related reason for our current problems is the failure to plan for the manpower required to deliver these developments. We have fewer specialist cancer doctors per 100,000 people than almost any other country in the developed world, and one of the consequences of this is “burnout”, with the consequence that some specialists seek early retirement, thus reducing the planned workforce even further.
What Should we do?
In thinking about solutions I believe that we should aim high in our ambition and seek solutions that if not “ideal” are at least a significant improvement on the present.
PREVENTION. Many of the causes of illness are preventable. Mental health is a huge problem that I will not comment on here in order to stick to the example of cancer, but we know many of the preventable causes of cancer and other major diseases. Nutrition/poor diet, obesity, tobacco, alcohol and drugs all contribute to ill health. We need to educate young people to better understand this but I fully recognise the challenge this presents and of course it overlaps with major societal issues such as poverty, social deprivation etc. But we should not ignore the value of prevention. People working in primary care clearly have a role in promoting the concept of prevention.
SCREENING. We need to improve the uptake pf screening to detect early signs of cancer. We do well with breast and colon screening and there are controversies about the value of screening for prostate and lung cancers. In the near future developments in genetic screening are going to offer the chance of identifying many more people who are at risk of developing cancer and these will need selective and more intense screening than the population at large. Hence more resources needed but the rewards will be significant later on.
TREATMENT. We need to dramatically improve the efficient use of hospital facilities and clinics. These should be focussed on the active management of patients not the “caretaking” problem of bed blocking because there is nowhere for patients to convalesce.
We should also improve communication between hospital and GPs so that the latter can help more with aftercare . Electronic record sharing is an important step towards this.
So how can we achieve this?
Health care planning is at present done by politicians. The inevitable consequence of this is that they have to be short-term minded and appeal to particular sections of the public who elected them. This has to change. I suggest that the responsibility for managing health care budgets and planning future developments should be undertaken by a new independent organisation. I suggest the formation of a Medical Commission comprised of 15-20 people representing a broad spectrum of appropriate expertise – medical, political (of all parties), economists, lawyers etc. who would serve for 5 years renewable once in order to allow long term planning – 10 years at least. Whatever monies are available this should surely give a greater allowance for making the very difficult decisions about priorities. But surely better than leaving it to politicians alone? And I would fund this differently.
Compulsory health insurance
I have been heavily involved with fellow oncologist in Europe throughout my career, and served as President of the European Society of Medical Oncology and the Federation of European Cancer Societies. For a decade I was Editor in Chief of the European Journal of cancer and responsible for founding the Cancer Drug development Forum, an association that seeks to speed up the process of introducing new medicines for patients. Most of the European countries provide health care through a mixture of state funded and private funding and I believe that the time has come for us to consider such a dramatic move. The much spoken of term “free at the point of delivery” is nonsense since we pay for the NHS through income tax. The latter is means tested and the European models incorporate just such systems. We could have a setup where the state provides such things as Accident and Emergency services and obstetrics and possibly geriatrics. All the other services could be provided by a limited number of approved Private Health Companies to which the public would have to sign up. Exceptions would apply to those on low incomes or unemployed. Differential rates would be applied for people with chronic conditions – diabetes, hypertension etc. There are some excellent examples to review.
So, I hope that these ideas may be of interest and warrant discussion at least in part. I am convinced that the current setup is unsustainable and future research is only going to compound the problem. Serious change is needed.
Professor John Smyth FRCPE, FRCP,FRCSE,FRCR,FRSE is Emeritus Professor of medical Oncology