Thursday, September 17, 2009

National Health Service - The Times 14th Sept 2009

They didn't publish it so I will!

In your leading article "National Health Service? - Health policy has done less to counteract health inequalities than was always hoped" on the 14th September 2009 the writer briefly examined the original aims of and subsequent developments in the NHS and public health policy. I would take issue with some of the basic tenets offered in the discussion.

First, I detect some confusion of the boundaries between Public Health Medicine, Health Policy and the NHS. Indeed, the blurring of these boundaries is to blame for the administrative and financial mesh throttling the NHS. Public Health Medicine is the prerogative of busy-body, do-gooder, meddling, paternalistic nannies and is of no proven benefit. This has led to the government using NHS resources to service its various poorly supported efforts to tell the public how to live their lives. These “initiatives” are often informed by bigoted lobbyists such as ASH (Action on Smoking and Health), who are also succoured with public money, and by the pharmaceutical industry, whose only interest is to sell drugs. Health Policy is the random thoughts of the ignorant, garnered to win votes, proven beyond doubt to have failed. The author seems to treat the terms NHS and Health Policy as synonymous. Far from this I would suggest that Health Policy has been the main downfall of the NHS. The service continues to be the jewel in the crown despite policy repeatedly being the poor relative. The service is a tangible physical entity whereas the policy is wishy-washy propaganda. I have worked exclusively in the NHS as both a general practitioner and a hospital doctor for 29 years. As a constituent part of the service I have witnessed serial offences of health policy crime committed by sequential and recidivist governments. The heart of each crime is the position that the NHS occupies as a political football.

Second, in dissecting the title "National Health Service", the author neglects to allow for changes in the meaning of words over the time period involved and for the perversion of the term "health". Equally scant regard is given to the modern usage of the word "service" with its associated categorical inventions of "client", "user" and "service provider". Bevan's idealistic aims may have been optimistic but were informed by the state of medical knowledge of the time and entirely pure. Whatever the current meaning of the words in its title and whatever people think it should do, the NHS is and has always been a deliverer of advice and management for illness and disease - nothing more and nothing less. This service has been run by the highest quality medical professionals and been highly integrated with academic medicine. The gradual and systemic erosion of these two facts has, in my opinion gravely contributed to its downfall.

Third, the author alludes to the excesses of human consumption or behaviour being in someway contributory to the state of the NHS. Why then are we living so long? Is it not an irony that the aim of Public Health Medicine has shot the NHS in the foot? Simply old people get ill more. Furthermore and without rare intellect can you not see that cancer, heart disease and stroke are diseases of the elderly? Seriously, the NHS will thrive if fat, drunken, lazy smokers die quickly. Incidentally, this would solve the pension’s crisis and maintain tax revenue superbly - especially in the case of smokers. Drinkers you're next! Health economics produces fallacial statistics daily, merely in an attempt to disguise propaganda or erroneously provide back up for unsupportable health policy. The best example of this is that supporting the denormalisation of smokers. Paradoxically, however, with scrutiny, it is obvious that the complete financial picture surrounding tobacco shows the NHS to be in debt to smokers and to tobacco to the sum of several billion pounds sterling.

Furthermore, the metaphorical battle that has been and still is fought is not against human excess, but rather against the relentless advance and therefore cost of medical science. The other melee is going on, on the touchline, against rampaging public expectation. Demand is simply outstripping supply. This latter tussle is fuelled by irresponsible media hype over "health" matters and scandalous big pharma. A very good example being the phenomenally costly peddling and supply of nicotine replacement therapy, proven beyond doubt now to be of little or no value.

Fourth, as is always the case, no mention or consideration of the cost or status of mental illness is pursued. I feel sure that the pressure on the NHS is made all the greater by the neuroses occurring in the vulnerable public due to “health mongering” and scare tactics. By health mongering I refer to the propensity to infer that in some way I will be in danger if I do not exercise 30 minutes a day and eat five portions of fruit and vegetables, or avoid the sun for fear of cancer and soak in the sun for fear of vitamin D deficiency. I could go on. By scare tactics I specifically refer to the WHO inspired campaign to make people believe they are in some kind of peril from smokers being in their vicinity! Now, I can add the current TV advertisement campaign of pathetic children attempting to tug the hard heart strings of their smoking parents. Whatever next?

Lastly, death is never "premature", but always inevitable. Poverty is associated with lower life expectancy. Poverty has decreased so life expectancy has increased. This is not in anyway related to the NHS, Public Health Medicine or Health Policy. It is due to the improvement in the infrastructure of civilisation. Simply look at third world countries and compare infant or perinatal mortality or life expectancy.

It would seem wise and fair for me now to outline some constructive suggestions. The National Health Service needs radical, root and branch reform not piecemeal initiatives. An independent body should examine the whole organisation and subject it to stringent system analysis. Simply put it should be decided what its outcomes should be and what system is needed to complete these outcomes. It should then be disbanded and started again.

It should be independent from government but funded partly by public money. All other funding options should be considered. It should be intimately linked with academic medicine. It should be separated absolutely from public health medicine and public health “campaigns”. NHS money should only fund illness advice and management. Its biggest areas of deficit currently are communication globally, administration, management and its complex funding.

A metaphorical or analogous image which may serve to illustrate my opinion of the situation is that of a marionette puppet, some of whose strings have become entangled with several other puppets’ strings, some have been broken and knotted together and some have been left dangling. The NHS needs to be cut down and restrung. The other marionettes are Public Health Medicine, Health Policy, countless QWANGOS and committees, silly lobbyists and some charities.