Wednesday, March 17, 2010

What's wrong and what's right about the NHS

A report yesterday suggested that £2 billion was wasted every year by the NHS in treating trivial illness. Most symptoms seen by a GP are self-limiting. If you have a cold or even flu, if you have backache or diarrhea, if you have indigestion, if you're feeling unhappy, if you have cuts or grazes, if you have twisted your ankle, fallen off your bike, or blacked your eye, the doctor has little to contribute to getting you better. Go to the pharmacist and get some ibuprofen or paracetamol. Take magnesium hydroxide if you are constipated, loperamide for diarrhea and proprietary lozenges for a sore throat. You don't need to bother your doctor. It is only when your symptoms persist that he might think of something more serious.

The NHS has lots of benefits, but by it's very nature it has some major drawbacks. If something seems free then it is not valued. When it started people used to line up to get their 'free' hot-water bottles! There is much to be said for a nominal charge to see the doctor to discourage nonsense visits.

The way it is designed the NHS provides what is unnecessary and what is questionable, but fails to provide what can be provided in no other way.

Here is a list of things that I think should be removed from what the NHS provides:

1] IVF. Some people are infertile because of chemotherapy and there is perhaps an argument that the NHS made them infertile and therefore it ought to provide a remedy. But most infertility is caused by pelvic inflammatory disease, often a consequence of an adventurous sex-life before matrimony (by either partner).
2] Termination of pregnancy. There are perhaps 10 occasions a year when continuation of the pregnancy would kill the mother. Most terminations are for inconvenience. I am against them, but if the law allows them I don't see why I have to pay for them. An abortion is not expensive; it probably costs less than the alcohol that made it necessary.
3] Trivial ill health remedies. I know many people who haven't seen a doctor for decades. They get colds and tummy upsets just like everybody else, but symptom control is available over the counter in most instances.
4] Homeopathy. It is astonishing that this mumbo-jumbo is still provided free on the NHS.
5] Mammography screening. For sure breast cancer mortality has come down since mammography began, but it has come down most in women too young to be screened. There are too many false positives and too many unnecessary mastectomies (see my article on cancer screening).

Here are some things that are questionable.

1] Provision of care for self-inflicted illnesses. Although it is seldom enforced, treatment for injuries sustained in a motor car accident should be charged to the motor insurance company. When patients develop lung cancer or chronic obstructive pulmonary disease from smoking cigarettes, perhaps the tobacco companies should be charged, and when they come into the ER having been 'glassed' (smashed in the face with a beer glass) while out on the town, perhaps the purveyor or manufacturer of the alcoholic beverage should pay. Or perhaps a levy towards an insurance policy should be included in the price. Perhaps MacDonalds or Burger King should pay a similar levy towards the cost of managing diabetes.
2] Other forms of screening for illness. PSA testing is not provided on the NHS because the test is not good enough. Far too many false positives. But GPs are paid huge amounts of money to screen for hypertension, diabetes, obesity, cervical cancer, phenylketonuria and goodness knows what. There is obviously a good reason to make an early diagnosis if this will lead to your not having to pick up the bill for expensive treatment when the disease becomes serious, but is there evidence that screening saves money or adds to a patient's wellbeing?
3] Promotion of breast feeding - and all the other 'nanny-state' things associated with pregnancy. On one occasion I had to chase a health visitor away from the house when she brought an attitude that the baby belongs to the state and not to its parents. Where is the evidence base for all these interventions?
4] Setting performance targets for hospitals and GPs. Inevitably any target will be 'gamed'. Trust the professional and hammer him when he errs. Protect whistle blowers and listen to patients.
5] Making post-code prescribing an anathema. If the worst were as good as the best we would save billions. But it's a moving target. Improve the worst and the best would be yet better. Without competition there is no choice and government intervention always means leveling down not leveling up.

Here are some things that should be done but aren't.
1] Pay for all licensed drugs. Expensive cancer drugs are only suitable for small numbers of people. They may stand out as expensive items on a balance sheet, but so few patients need them that they don't affect the the global budget. Indeed NICE probably costs more than it saves (there are hidden costs since the members of committees and those appearing before it do not charge for their time).
2] Treat Alzheimer's disease as an illness instead of the patient's or his family's own responsibility.
3] Pay doctors more to enter unpopular specialties or less attractive areas. Why can Manchester attract footballers but not doctors?
4] Get serious about policing treatments without scientific merit. There is no evidence that using PPIs to treat heartburn is better than antacids or H2 antagonists. Yet £2 billion was spent on this indication one year in the recent past.
5] Don't let pharmaceutical companies run clinical trials. They cheat. If they want to sell their drugs in a particular market, subject their product to trials designed by people who know not people who want to sell.


Burke said...

I prefer a free country. My health care is my business; your health care is your business; and, his/her heath care is his/her business.

Every alternative is just some exploiting others with force.

Anonymous said...

I absolutely agree about not allowing pharmaceutical companies to run their own clinical trials. It's a tricky world we live in.

~chris said...

Bravo!! Terry.

Anonymous said...

Interesting thoughts. I agree about abortion. Too bad the US is about to have federal funding for abortion on demand.

One problem you point out with socialized medicine is that politicians can force the system to cover things like homeopathy, viagra, IVF, psychic surgery and the like. You may not like it but it is there, and it will stay there.

True believers have the force of obsession on their side.