How can we fix the bones of our broken healthcare system?
Professor Sir David Haslam has chosen a title — Side Effects — that undersells his excellent new book. It would be tempting to write off the work, based on its title, as yet more bandwagon post-Covid hindsight, and pass along the bookshelf.
Don’t! Here be substance. Haslam credibly tackles a thoroughgoing analysis of what has gone wrong with Britain’s NHS, identifying cost challenges that could bring it down.
In later chapters, he ventures into the swampy ground of how the system might be fixed. It is a must-read for anyone involved in health care policy. With reform of our creaking NHS a priority Haslam’s authoritative contribution to the debate is welcome.
The GP knows a thing or two, based on front-line experience. Yes, I know that’s unfashionable when you can be Prime Minister of Finland these days if you have a degree in Karaoke, mean well and are stupid enough to have an accessible Twitter account.
The author has been president of the Royal College of GPs, the British Medical Association and was until 2019 Chairperson of The National Institute for Health and Care Excellence (NICE), the government’s dragon at the NHS gates, spotting budget-busting novel therapies threatening to wolf down spending, with potentially little impact on health conditions.
These days he’s a bit of a rare bird. A medical man who takes care of his patients and plays a role in shaping the structure that serves them. Quangocrats have mushroomed since the Blair era. Clinicians have been transformed from professional leaders to shift workers.
His writing style is concise, undramatic, and accessible. Jargon-free. The book has an excellent index and useful footnotes.
Chapter 2, “How did we get here?” frames the dilemma that scientific progress and an increased ability to supply effective interventions not only ramps up costs but require the abandonment of previously cherished practices.
Take heart disease. In the 1950s a cardiac arrest required three weeks of hospital bed rest. Now, it’s immediate intervention, up and out in a couple of days and off to the gym for a fortnight. Unsolvable challenges for previous generations have become routine treatments for ours.
This ability to respond, adopt new diagnostic inventions like MRI scanners and shovel increasing quantities of newly invented lifesaving drugs down the throats of a grateful population comes at a price. Haslam points out “Healthcare is a business”, but unlike other businesses, it has no direct access to the capital required to fund growth.
The essential weakness of the NHS economic model in the UK is that is dependent on third-party funding — the taxpayer — so is slow to respond to changing patient and clinical demands. It would have been useful to learn more about Haslam’s views on the shortcomings of the economic healthcare model.
I happen to share Haslam’s view that primary care, “the least dramatic area of healthcare is also one of the most potent”. It is the gateway to care — and, being closest to patient populations, the most powerful driver of change in care pathways.
It is a pity the book does not recount the gutting of primary care that has gone on quietly since the late 1990s. I would have liked to hear Haslam’s judgement on the startling statistic that around 90 per cent of GPs are now part-time. If that is not a hollowing out of our NHS, I don’t know what is.
I must ask the Avatar on my local GP practice website what he/she/it thinks of that.
Another Side Effects chapter, “Overtreatment and Overdiagnosis” deals with the painful screening dilemma in the context of breast cancer. Because we can screen for something doesn’t mean that we should. Mammograms can lead to an early diagnosis of “something” but are often followed by surgical interventions that are positively harmful. Haslam acknowledges that is often not a popular fact for campaigning pressure groups, gathered around the campfire of their cause, to acknowledge.
NICE was established precisely to analyse what new therapies work, do not work, and might be cost-effective. NICE has left a permanent stripe on my back. I was the Minister for Health who set the process of its founding underway after having to take an agonising decision on the introduction of beta interferons for the treatment of multiple sclerosis in 1996.
Cost of treatment per patient was, roughly, £15,000 per annum. No one could tell me what practical impact the drugs might have on a patient.
It would make a “difference”, but, I asked, would it allow sufferers, for instance, to make a cup of tea? Answer came there none. Pressure groups were banging noisily on my door. Jim Naughtie was chastising me on the Today programme for being a “meanie”.
A proper body, capable of calm, informed analysis was required. Not a Minister on the news round hunt looking for a simple answer. The Blair government, to its credit, continued with the plans. Which meant that here today, gone tomorrow Ministers are no longer asked to make these judgements of Solomon, seared by the heat of some torrid PR pressure group campaign.
Haslam not only “gets it” re NICE, the body he chaired for six years, but in later chapters on ageing, future care patterns and the need to blend social care spending with healthcare budgets, makes powerful arguments for extending the approach to these areas that still tempt politicians to make headline-grabbing statements.
They are still at it. Only last week Liz Truss was banging on about removing £13billion from the NHS budget and devoting it to social care. She needs to read Side Effects. And, if I were lucky enough to be her incoming Secretary of State for Health, not only would I have read his book. I would find Haslam another job.