The fall and rise of the NHS

The sustainability of the NHS is an urgent question. It was an urgent question before this year’s general election, it remained an urgent during the campaign and is still one today. It’s an urgent question that can’t seem to find a quick answer. A recent meeting at the RSM addressed this very issue head on, and eminent physicist Stephen Hawking was clear in his view that ‘the crisis in the NHS has been caused by political decisions’.¹

While many of the solutions rest in the hands of politicians too, much also depends on clinicians. Whatever the failings of the service we operate in, all of us can further the cause of sustainability in our day-to-day practice. Overtreatment and overdiagnosis are particular issues that affect many specialties and don’t speak well for the motives of clinicians or for how patients’ interests are considered.

Take cardiology, for example, a specialty that accounts for about 10% of all inpatient episodes and costs the NHS several billions of pounds each year. Warriner et al. explain that while less is often more, research focus is on more drugs, more tests and more devices.² The global market for interventional cardiac devices was worth $20 billion in 2016 and grows at a rate of 10% annually. Of course, the blame for this unnecessary growth lies more broadly with the medico-industrial complex, but doctors are certainly culpable too.

Specialists in cardiology and each other specialty must take responsibility, argue Warriner et al., for doing less. This is a brave stand, in a piece that challenges head on the failings in their own specialty. Often, specialists use space in journals for special pleading for their specialty, for a higher priority, more staff and more pay. Not these authors, though.

Their case is supported by another commentary from the world of oncology and dermatology, which highlights how drug manufacturers across Europe might be avoiding submitting cost-effectiveness analyses by agreeing confidential discounts for new immunotherapies.³ Indeed, it might be best to focus on behavioural and lifestyle interventions, such as cognitive behavioural therapy for people with a history of suicide events.⁴ Some of these challenges might be complicated by the uber-complexities of healthcare and difficulties in developing effective leadership of population healthcare.^5,6

In the end, the NHS might learn most from the rise of western empires from nothingness.⁷ The six factors that delivered this triumph are the scientific revolution, modern medicine, consumerism, capitalistic competition, the right to property and an unbridled work ethic, says Salil Patel, and with some adjustment, these might be applied to halt the fall of the NHS and begin its rise.