So May is in, Hunt stays, Brexit means Brexit. It’s all change in a crazy week of politics. But what hasn’t changed is the NHS is still about to collapse. May will likely be the last Prime Minister to oversee its demise.
It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.
In this part we will simply explain why the cost of modern healthcare rises every year just to stand still, which is fundamental to understanding the funding needs of the NHS.
This is difficult, but I think best explained if you simplify the entire health system as treating a single person, let’s call her Beverley.
Beverley is born in 1948- her birth is at home, with no healthcare professional, midwife or monitoring. Several of Beverley’s siblings are also born this way- unfortunately two die before they are one. Sadly an uncle has a heart attack at 52 and passes away.
Beverley grows up, and fortunately remains healthy. She marries, Bob, and she has her kids in 1968. She has every one in a hospital, with a midwife. One requires surgery. Beverley’s own mother has a stroke and dies at 63. Bob decides to stop smoking.
Beverley gets older. Her first grandchild is born in 1988, in hospital with electronic monitoring and emergency caesarean. Beverley’s second grandchild is born at 25 weeks, and spends three months in the new intensive care baby unit. Stressed grandparent Bob has a heart attack- he is rushed into hospital and has an emergency procedure to open the blood vessels in his heart. He is at home in time to hold his new granddaughter for the first time.
Beverley and Bob stride on, both retiring at 65. On their 50th wedding anniversary Beverley feels odd, can’t find the words to toast, and can’t raise her left arm. Her daughter dials 999- Beverley has a stroke, just like her mother. Fortunately she gets to hospital and 30 minutes later she has had a brain scan and a clot buster is being infused into her arm. She makes a full recovery, and goes back home a day later.
The junior doctor looking after Beverley spots a shadow on the routine chest X-ray she has. She is diagnosed with lung cancer.
Bob is going spare. They meet the specialist, the cancer is treatable and they start right away, six rounds of radiotherapy then weekly chemotherapy. It’s hard, and Beverley goes into hospital twice with complications.
Halfway through Bob has lots of abdominal pain and throws up some blood. Rushed to hospital he has an emergency camera test into his stomach – he’s developed a stress ulcer, which they clip and repair. He’s in hospital for a few days. Gratefully Bob and Beverley return home.
Beverley goes into remission, but is very frail now and is falling a lot at home. Now in their 80s, Bob gets chest pain trying to look after them both, and Bob needs three more stents put in to open blocked heart vessels. Bob and Beverley ask for some social services support at home- a carer comes once a day.
Overnight one night, Bob passes away in his sleep. Beverley is distraught, but at the funeral she asks her daughter; “Where’s Bob?”. Concerned, her daughter takes her to the GP. It’s clear Beverley now has dementia. She is moved first to a sheltered flat, then a residential home, then a nursing home.
She dies in hospital of a severe pneumonia at 83.
This isn’t a sad story- this is modern life and modern healthcare.
Why did i tell you this story? To show you how healthcare has changed. Let’s look at some facts.
In 1948 the average female life expectancy was 71. In 2016 it’s 81.5.
Beverley’s mum died at 63, while Beverley lived into her 80s. People are living longer.
Why? Better healthcare, better immunisations and prevention, better nutrition.
But also diseases that were previously fatal are now treatable. Mortality for conditions such as coronary artery disease have halved in fifty years- Beverley’s uncle died of a heart attack, but Bob survived two. Stroke survival and stomach bleeds are now readily survivable where fifty years ago they were not.
But these treatments are very expensive- the technology to open blood clots through vessels is super high tech and costs £3000 a go, advanced chemotherapy and radiotherapy treatment costs can run to hundreds of thousands per person, and intensive baby care costs £12,000 a week.
In short- we can do more every year, so we do. And those that we save live on as survivors- but this comes at a cost.
The cost of healthcare per year for an 85 year old is around 4x that of an under 65. The proportion of the population over 65 will rise to 25% by 2040. And alongside that the population is growing, by around 30% since the start of the NHS- so there are 30% more Beverley’s and Bobs than we started with.
So more people, who need more treatment, are treated with more medicines and survive more to need more treatment in the future. And let’s not forget they will need more social care.
This is why the NHS needs 3-4% more funding every year.
That seems like a lot- it’s a tremendous challenge. But we aren’t rising to it as our neighbours are. Of the G7 countries we currently spend the 2nd least on healthcare, well behind the US, Canada, Germany and France.
With the current healthcare budget under the Tories, we will be spending just 6.7% GDP by 2020- lower than Lithuiania and Hungary.
Despite that the NHS is still consistently ranked as one of the best healthcare systems in the world. In 2012 the US commonwealth fund found it the most efficient, safe and accessible system out of all countries ranked, and also spent nearly the least.
Whew.
So now you now that the NHS needs a rising budget to meet rising demand, like every other modern country. Yet we aren’t funding it anywhere near that level, and we aren’t meeting that demand.
In short, the NHS is about to collapse.
Find out how in;
The NHS is collapsing. Part 2: if the NHS were a patient, I’d be pulling the emergency alarm.
Juniordoctorblog.com
Read the other parts in this series: The NHS is Collapsing.
Part 1: A Life in a Day of the NHS
Part 2: If the NHS were a patient, I’d be pulling the emergency alarm
juniordoctorblog.com 
This junior doctor blog should be widely read and people should sit up and take notice.
I thought Stuart’s explanation was targeted to the average patient . Having worked in the NHS for 30 years, I know patients want help not how much it costs!!
I believe the explanation will make people sit back and think not complain as much
Nice blog but could do with a bit more data / economics. Drivers of health care cost growth are a bit more complex than laid out. If we’re going to get NHS funding right (not just the total amount but allocation between competing demands), we need to be able to be more precise, more scientific about the problems and solutions. We need to be more informed expert and less gentleman amateur.
NHS policy goes wrong because people approach it all anecdote and generalisations – as if it’s something you can intuit or figure out with a part time study.
We wouldn’t practice medicine like that so why should we run a health system like that?
Do you care to expand. And remember we need to address this to the public?
Sure.
If we think of your blog as an attempt to inform the public so that they can make informed decisions about NHS funding, then the blog needs to provide high quality, trustworthy and relevant information in a manner that people can use.
A better use of evidence from policy research, economics and management sciences would strengthen your blog.
For example, you state that the NHS needs 3-4% more funding each year. This seems to be a central point of your piece. The NHS is on the verge of collapse without a large injection (3-4% of GDP) of cash. But where does that figure come from? How do readers know that they should trust this figure? Why 3-4% and not 4-6%? And why is %GDP the right measure?
If we were discussing treatment options with patients we would expect to use the results of high quality clinical trials to demonstrate the expected risks and benefits of any treatment. We use clinical risk calculators to inform discussions of statin prescribing, we rely on large epidemiological studies to justify advice on smoking cessation, we can quote NNTs for the use of aspirin in secondary prevention of MIs. If patients ask us to justify the basis of recommendations or conclusions, we can point to scientific research and empirical analysis.
We should be using the same quality of evidence and insight to inform discussions about system-wide issues like the financing, organisation and delivery of the NHS. These are big issues that affect millions of lives, so why would we hold ourselves to a lower evidential standard when discussing them?
As for communicating this to the public, the information is no less complex than what you’ve already communicated. And you’ve done that well.
Unfortunately it’s very difficult to gain that level of evidence in relation to healthcare systems for fairly obvious reasons of scale, funding and ethics. Running a major placebo-controlled RCT for a new drug is extremely expensive, running it for an entire healthcare system would be a) prohibitively expensive, b) technically impossible (how are you going to randomise people to receive either care under the US system, versus the French system, versus the UK system?) c) probably extremely ethically questionable and d) have an enormous number of confounding variables.
In terms of levels of evidence, on this scale the available evidence is likely to be expert consensus (which is used in this post and the next) and case studies, cross-sectional studies and ecological studies using international comparisons.
I disagree. The belief that we can’t run large scale RCTs for health service delivery or policy interventions condemns us to a dark ages of health policy with decisions based on political conviction, gut instinct and cognitive biases. Remember, people once made the same arguments against running large RCTs of therapeutics that cost hundreds of millions of pounds. It would cost too much so we should rely on scientific theory developed in preclinical studies and expert intuition of clinicians. It turns out that when the evidence will be applied to decisions that cost a lot of money (e.g. hi-tech healthcare), the return on investment in trials can be huge.
Firstly on scale: big RCTs have been run successfully in healthcare lots of times in many countries (including the UK). The RAND Health Insurance Experiment for example was a large scale RCT of the effect of different levels of cost-sharing on healthcare utilisation and outcomes. It ran for 8 years and cost around £300 million in today’s money. Its funders felt that the money spent answering fundamental questions of healthcare economics were worth the investment.
Secondly, cost. In the next decade we will spend over £1 trillion on the NHS. When you’re throwing that much money around, the costs of running a big RCT don’t seem as big. Especially if that kind of evidence can help us avoid making costly and stupid policy errors (e.g. disenfranchising the entire clinical workforce through pursuit of pay restraint policies that do more economic harm than good). The rate of return on investment in health services research comes in at about 40p annual return for every £1 spent IN PERPETUITY. This figure is higher for good RCTs especially in high cost areas.
As far as ethical problems go, I don’t see this as showstoppers. What’s more ethical: a massive, unevidenced, top-down redisorganisation of the NHS or a program of large scale incremental RCTs where we test out system changes before implementing them wholescale? Remember, that in the face of equipoise, not conducting research to resolve uncertainty that may do harm is more unethical than a well-designed study.
We need to stop arguing that developing a proper evidence base in health policy is too hard or not possible. There are absolutely challenges to being more empirical and less ideological in healthcare but they are principally issues of culture and attitude. The medical profession has been through a number of revolutions that have sought to bring science to the centre of what we do, from the invention of the RCT by James Lind (probably) through to the rise of evidence-based medicine since the 1980s. We should be leading the call for a less anecdotal, more data-driven and scientifically sound approach to health policy. And the first step in that is not repeating the tired old idea that it’s too hard to do good quality empirical studies with strong causal identification strategies in the NHS.
The problem I think is that too often people who are passionate about healthcare policy aren’t aware of the extensive evidence base and research opportunities available to improve the design of health systems. As a result they are left resorting to arguments around NHS policy that rely on rhetorical rather than evidential techniques. This is precisely the arena where political actors are much more well-practiced, resulting in them having disproportionate influence on a now distorted debate.
If we are serious about saving the NHS, about depoliticising the health policy agenda, about getting a system that is sustainable and effective for patients, we need to elevate discussion to the level of empirical evidence whenever we can. To try and fight this battle on the terms of politicians and newspaper editors won’t work in the longterm. We have to make empirical evidence the platform for our message. And to do this, we have to stop perpetuating the myth that you can’t do big RCTs in healthcare policy.
This is a great post. People who are outside our echo chamber need something that they can relate to to be able to understand how much they and they people they love need NHS and this story does just that. To be able to get issues on the agenda, we need people to care first, by reaching on an emotional level. Policy makers always seem to like and use anecdotes and stories to help illustrate a point (which is normally built on evidence…).
I agree that the nitty gritty details of statistics and financial modelling are important. However, I don’t think this post wasn’t about that.
[…] The NHS is collapsing. Part 1: A Life in a Day of the NHS […]
[…] The NHS is collapsing. Part 1: A Life in a Day of the NHS […]
[…] I was going to write a blog about this suspicious article in the BBC, claiming consultants are overpaid, right as consultants went back to contract negotiations of their own. I was going to point out the average overtime payment is just each consultant doing 6 hours a week more, compared with their basic salary. I was going to point out aberrant arrangements like the one in the article were locally agreed, to save struggling hospitals from huge government fines for waiting lists, despite their underfunding and understaffing. I was going to point out that huge numbers of consultant posts are unfilled, nearly 40% in medicine alone, and that unspent salary cost far outweighs the cost of any ‘overtime’ consultants earn for covering those same gaps. I was going to point out yet again how the government is spinning and dog-whistling and smearing while the NHS goes under. But I’m not going to. I tried to write a blog full of facts and hope and fight, but I find facts are useless, my hope is gone, and the fight has left. I wrote before how exhausted we are of all of this, but it’s only got worse and it’s about to get catastrophic. […]