Side Effects (eBook)

Foreword

I’ve spent my life working in healthcare. For many years, I was involved in both devising and implementing many aspects of local and national health policy, and I’ve also experienced it first-hand, as a patient. From every perspective, there is clearly a mismatch between supply and demand. While resources can never be infinite, the demand for healthcare in Britain appears to be inexhaustible. This imbalance is a source of immense tension, and the situation is only getting worse. In this book, I will first assess this extraordinary challenge and then attempt to suggest how we might tackle it.

In the past few years, the NHS has faced a double whammy; first the government’s pursuit of austerity reduced its capacity and then the immense challenge of Covid-19 tested it to its limits. Even before this, it faced massive and unsustainable pressure. While increased funding is critically important, it cannot be the only solution to every problem.

The coronavirus pandemic has, to an unprecedented degree, devastatingly exposed the challenge that is facing us. For a while, it trumped everything else, and not just in Britain. All around the world, governments recognized the supreme importance of health and healthcare, as well as the key role that the state has to play in protecting its citizens.

In ancient Rome, the statesman Cicero wrote that ‘the health of the people is the supreme law’. Two thousand years later, as the UK stood on the brink of crisis in March 2020, the Chancellor of the Exchequer Rishi Sunak said, ‘Whatever extra resources our NHS needs to cope with Covid-19, it will get. Whatever it needs, whatever it costs, we stand behind our NHS.’ In countries around the world, politicians displayed the same sentiment. Funds somehow appeared, and no expense was spared. Repeated comparisons were made to the challenges of wartime. In March 2020, the prime minister Boris Johnson declared that his government would act ‘like any other wartime governments’ to support the British economy and take ‘steps that are unprecedented since World War II’.1 Other world leaders used similar descriptions. The US president Donald Trump referred to himself as a ‘wartime president’ and Andrew Cuomo, governor of New York, reportedly said that ‘ventilators are to this war what bombs were to World War II’.2

The battle with disease – with a single disease that spread easily and posed a particular threat to the eldest and most vulnerable – was in full swing. Humankind had to fight this virus with whatever weapons it could muster, which initially meant prioritizing healthcare over the needs of the economy and all the other various priorities that usually jostle for attention. It was extraordinary, but it was necessary. However, things were far from typical. Funds are not infinite, and they never can be. In more normal times, when we are not facing a global pandemic, we still find ourselves having to make life-and-death choices. After all, healthcare can be massively expensive. Every year, the cost of care escalates, and the money has to be found to pay for it. Even prior to the pandemic, in 2017, the UK spent £197 billion on healthcare, equating to £2,989 per person.3 Research scientists continue to develop new drugs and therapies; the potential benefits that they offer to humankind are phenomenal, but the accompanying prices almost inevitably go up and up.

Even before Covid-19, the proportion of national wealth that was spent on healthcare was increasing every year, and every prediction of future trends showed that this challenge was only going to worsen. Although this issue is facing every country on earth, we seem remarkably reluctant to discuss it. Society might in the short term have debates about whether a particular amount of spending is sufficient, but we rarely consider the longer-term perspective. Burying our heads in the sand and ignoring a deepening problem can never be a sensible long-term policy, however tempting it might be.

However, the increasing cost of care isn’t our only challenge. Of the diseases that posed the greatest threat to the average family just a few decades ago, many have now been eradicated. Life expectancy has also increased since then, yet people are as anxious about their health as ever, and there has been no let-up in demand for the medical profession, particularly for reassurance. A hundred and fifty years ago, a typical day’s work for a British general practitioner would have consisted of a constant stream of patients with pneumonia (which was frequently fatal), diphtheria, cholera and acute rheumatism, in addition to the flood of minor problems that all family doctors would still recognize today.4 Today’s GPs might look at that workload from a previous age and notice that almost all these illnesses have either been wiped out or are now eminently treatable. They might find themselves wondering what would be left for them to do, but as some challenges have been eliminated, new problems have arisen to take their place. Family doctors today are busier than they have ever been – and this is discounting the impact of the Covid pandemic. So, what is going on? Can we foresee a world where healthcare facilities sit unused while a healthy and happy population has no need for care? Or will the predictions that envisage perpetually rising expectations and demand prove to be accurate? If they do, is this a sustainable model? And what is driving it?

This dilemma is the subject of this book. If we can accept that there will never be enough money to cover every possible eventuality – and it’s hard to imagine that there ever could be – how should society make choices? What is the real value of healthcare, and what is the endgame? Disease and infirmity will never disappear completely, so we need to ask ourselves whether we are using the available funds in the best possible way. When can it be justifiable to spend more money on healthcare, if that means taking money away from other areas of our lives, which might include education or even security? This was another challenge that was thrown into sharp focus by Covid. When populations were locked down, although they were relatively safe from direct impact by the virus, the restrictions had a damaging impact on happiness, education, physical health, mental health and wellbeing. Governments found themselves having to balance the dangers of the virus with the dangers of lockdown. If a country’s economy suffers, a major impact on its population’s health will follow. And conversely, if the health of the nation suffers, there will be a major negative impact on the economy. So how can we decide where our priorities should lie?

The problem is a global one, and in the long term, simply increasing healthcare spending is unlikely to be the sole solution. That said, the challenges facing the National Health Service in the UK have been exacerbated by a decade or more of underfunding; I should emphasize that I will most definitely not argue in this book that British healthcare currently has enough money. Years of austerity following the global financial crisis of 2008 have had a major impact. Waiting lists had risen to 4.6 million even before Covid attacked, and staffing levels were clearly becoming seriously inadequate.5 As the wide-ranging LSE–Lancet Commission on the future of the NHS made very clear, the Covid-19 pandemic has reinforced the economic case for investing in health, which is crucial for both fiscal sustainability and societal wellbeing.6 The commission estimated that in order to implement its funding recommendations, total expenditure on the NHS would need to increase by around £102 billion in real terms, which will represent around 3.1 per cent of the UK’s gross domestic product in 2030–31.

In September 2021, Boris Johnson announced a new funding settlement for health and social care in England, which included an additional £6.6 billion for NHS England in 2022−23 and £3.6 billion in 2023−24 – on top of the plans made before the pandemic – as a result of ongoing pressures from Covid-19. Few people working in healthcare felt that this would be sufficient. Even the Institute for Fiscal Studies stated that while the extra funding would help for about two years, it was unlikely to be sufficient in the medium term.7

These are eye-watering sums, and there is no doubt that the NHS is facing an uphill struggle if it is to catch up once the pandemic is over. But it is equally clear that in the longer term, a more fundamental reconsideration of how we perceive healthcare is required. Indeed, while the population has, in general, never been healthier, we seem to consider ourselves to be more at risk of falling ill than ever – and we are more anxious about our health than at any time in our history. Despite all the advances we are making in our ability to diagnose and treat illness, the demand on healthcare services continues to rise inexorably.

The key question I will return to throughout this book is a simple one. What is it that we are really trying to achieve through our healthcare system? And if we have a goal in mind, are we going the right way about trying to achieve it?

Today, many aspects of human existence are at risk of being medicalized – another side effect of the hard-won successes of modern medicine. But is this really healthy? Is it logical? And is it beneficial? In the future, it may be that we look back on current events and realize that the pandemic opened our eyes to this challenge. With the vast level of government...