Why does demand for healthcare always outstrip supply? Could it be that we don’t have a clear idea about what health is or what healthcare is for? David Haslam looks beyond debates about funding and health systems to examine this seemingly insatiable need. In doing so, he offers examples from his work as a GP, his leadership roles at the National Institute for Health and Care Excellence (Nice), and his personal experience of cancer treatment.
There are now more than 6.6 million people on NHS waiting lists in England, fewer than two-thirds of patients receive prompt cancer treatment and most waiting-time targets have not been met for several years. The Commons health and social care committee has reported that the NHS is missing 12,000 hospital doctors and 50,000 nurses and midwives, predicting that 1 million more jobs will be required to meet demand for health and social care over the next decade. The acute crisis undoubtedly results from more than a decade of austerity, exacerbated by the pandemic. But this is not just a local problem. A World Health Organization (WHO) report found health spending growing faster than the economy in almost every country.
Why? “My father didn’t have time to develop cancer,” Haslam writes. “He died of a heart attack before he reached the age that I am now. Indeed, had I died at the same age as him, I would not have developed the cancer that I have recently undergone extensive and expensive treatment for.” Mortality from coronary heart disease has plummeted in the last 50 years due to reduced smoking, improved diet and more effective treatment. Life expectancy has increased. This success brings with it spiralling health and care costs as people age, many of them with multiple long-term conditions.
The intensification of medicine also raises costs. Haslam quotes paediatrician Cyril Chantler who said: “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.” Technological advances, including those in the field of genomics, have transformed our understanding of disease mechanisms leading to new diagnostics and treatments. The resulting drugs can be effective but also expensive, in extreme cases costing millions for each person. On the other hand, some initially promising cancer drugs haven’t led to extended or improved life for patients. Haslam acknowledges that everyone wants the best possible treatment for a loved one, but also asks: “How can we decide whether it is preferable to spend healthcare funding on a single person with a rare, serious and hugely expensive condition, or 1,000 people with common and cheap but painful conditions?”
The expansion of healthcare to “treat” aspects of life that many would argue are social rather than medical issues is the third factor underpinning rising costs. Haslam expresses alarm at calls for a drug to address loneliness, and scoffs at Boris Johnson’s suggestion that GPs prescribe cycling. But the boundaries are not always clear. Even the WHO defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. The edges are particularly blurred when thinking about risk and early signs that people might become unwell. New conditions such as “pre-diabetes” emerge, thresholds for treatment are lowered, generating demand for further monitoring and intervention. For some, this will prevent deteriorating health. Others will not benefit, and some will suffer from side-effects or anxiety as a result of being diagnosed.
The book gathers these strands together to paint a compelling picture of how healthcare has lost its way. Having made his diagnosis, Haslam outlines a prescription, albeit recognising that “no single solution will address all these issues”. This is refreshing, since so many commentators suggest simplistic fixes. He acknowledges the need for more funding, questions the role of the private sector, and defends the principle of universal access, but admits that this won’t be enough. He suggests that we – the public – need to think about what we want from healthcare and debate its boundaries.
He also makes the case for doctors and other healthcare professionals to revisit our responsibilities. He is optimistic that we can deliver better care if we shift the emphasis away from super-specialist treatment in hospitals towards a more holistic approach, including an end to the cruel demarcation between health and social care. The welfare of the patient is our first concern but, in the words of the General Medical Council, we should also “use resources efficiently for the benefit of patients and the public”. And that means recognising and challenging the dominance of forces determined to expand profitable biomedical markets while allowing essential care to be neglected.
• Helen Ward is professor of public health at Imperial College, London. Side Effects: How Our Healthcare Lost Its Way and How We Fix It by David Haslam is published by Atlantic (£20). To support the Guardian and the Observer, order your copy at guardianbookshop.com. Delivery charges may apply.
