Pearls and Irritations

The glories of modern medicine are abundant: diseases once considered incurable are now within therapeutic range. Recently a new mechanical heart, developed by an Australian and weighing a mere half kilo or so, was successfully installed in a patient in the US. While its long-term effectiveness awaits proof, it has been hailed as a turning point in the management of chronic heart failure. The pharmacopoeia of miracle drugs keeps growing. No technical limits on our ability to prolong and improve life are yet apparent.

Yet all is not well. The cost of these advances can be astronomical. Who should pay? And while we await therapeutic breakthroughs, we are seeing a rise in the prevalence of serious long-term diseases of the heart, lungs, muscles and brains, calling for care in the management of flare-ups and long-term support. We find ourselves poorly equipped to meet these challenges – as though we were an army trained for quick encounters on the battlefield but now finding ourselves caught in the attrition of grinding guerilla warfare.

The British NHS was conceived at the time the UK was emerging from the trauma of world war and was a central plank in recognising and delivering more services to those on whom the weight and sacrifice of war had fallen. It has survived, almost as religion, certainly as an icon in the British identity. After all, it featured in the opening ceremony of the London Olympics in 2012 with beds and nurses floating to earth from bountiful skies over Great Ormond Street.

The costs of the NHS have grown faster than the willingness of government to pay – it is said that the health secretary objected to the costs of the Olympic skit. As a result, promises of new hospitals have foundered as have attempts to patch up existing ones. The backlog in hospital maintenance was £5 billion in 2012 and £11.5 billion in 2022/23.

In 2020, authorities considered several options for delivering the 48 hospitals, promised by Boris Johnson. The NHS needed between £3.7 billion and £16 billion of capital funding for the first four years of the hospital program. In fact, Treasury initially allocated only £3.7 billion for the four years to 2024/25.

And that’s just hospital buildings. Similarly desperate stories are told about workforce where the need for doctors and nurses is great and burnout, resignation and disillusionment are rife. Every aspect of the NHS is under strain. Despite all the handwringing about inefficiency, the need for additional funding – now – we can hope is apparent to Sir Kier Starmer and his new government.

Say what you like about the models of care in the NHS, the simple reality is that it needs more money to do its everyday work. The NHS initially had insufficient preventive equipment for hospital staff during COVID. Supplies had been run down for budgetary reasons. Staff died.

Much dreaming has occurred around the promise of prevention. Surely all the high cost treatment could be avoided if we had effective programs of prevention. But effective prevention cannot occur in the presence of incompetent care.

The late David Morley, a highly-principled paediatrician who worked in Nigeria in the 1950s and in many other countries with remarkable results, improving child survival, was a strong advocate for community-based prevention. He had a distaste for hospitals, seeing them as wasteful palaces.

Nevertheless, he said that if you are to have credibility in advocating to parents to boil the water to prevent childhood gastro, you need first to demonstrate that you can treat a child with this problem. It doesn’t work to propose preventive programs without total care credibility. So, to get preventive changes in the food supply with a view to reducing the burden of obesity and diabetes, you need visible programs of effective care for people with diabetes.

It is not hard to see why money goes preferentially to hospital-based services and not to prevention. Emergency and complex care for disorders such as heart disease and cancer require attention – now. Acute care takes precedence over funding for heart disease or cancer prevention that will bear fruit – out of sight – in decades to come.

Proposals to fund prevention independently of health care usually come to nothing. Money in their kitties is fair game when ambulances are ramped outside emergency departments. In NSW 25% of the state budget is spent on health services, principally hospitals, the highest proportion to date. Politicians ask, reasonably, how much further is this growing to grow? With workforce costs (principally) and technological advances (to a lesser extent), steadily rising what can we expect? Identical questions are asked in all countries.

It is tempting in the face of such a challenge to give up thinking strategically and settle for incremental attempts to deal with the most obvious problems. There is nothing inherently wrong with this approach – management by muddling through has a fair reputation and strategic planning can be a beguiling but fail-prone approach. Band-aids have their place.

But with regard to prevention the reality is that effective preventive programs call for action outside the health portfolio.

Sir Michael Marmot, one of Australia’s finest exports to the UK and a valiant crusader-epidemiologist, speaks of health and illness in social context repeatedly and persuasively. He argues that changes are needed in all of society to improve health. These have worked to a fair extent in relation to smoking – education, legislation, taxation and advertising – all play a part, and all are outside the health portfolio. Community action around diet and exercise, fostered by local enthusiasm, can change things. For example, the recent advocacy campaign for shedding a couple of kilograms may have results in reducing diabetes and it depends on support well beyond the healthcare system.

The agenda for prevention is long. Consider for a moment what is on it. Heart disease and stroke are near the top and we know that community-based preventive programs already account for half of all lives saved in recent years. Tobacco control is near the top of the list and that requires action outside the health portfolio.

Gains in reducing the road toll owe much to advocacy from surgeons, improved roads, safer vehicle design, laws against alcohol, speed cameras and more – again, most outside the health portfolio. (As well, improved trauma services now use the golden hour after an accident to better effect.) Winning community support for immunisation depends on education and advocacy, certainly health-informed but addressing social attitudes beyond the hospital or surgery walls. And then there is mental health – the determinants of which include biology, but social and family environment offer opportunities for preventive action.

As Norman Swan reminds us, a huge amount remains to be done with regard to national nutrition, and courageous parliamentary leadership is needed. Parliamentarian and clinician, Mike Freelander, observed on his recent travels around Australia examining diabetes, how limited the supply of fresh food is in faraway community stores and even supermarkets: he saw remotely-settled First Nations children drinking nothing but sugar-laden pop from large bottles. Commerce and profit rule, OK?

Wholesale change is needed in our western societies whose economies at present favour ever more inequality and individual wealth at the cost of impoverishment of social segments – and worse health among those least able to cope.

Sir Keir needs to find the cash to get the NHS back on its feet, including for staffing, infrastructure, innovation, maintenance, and managerial change. If he can be persuaded about the long-term value of prevention, then he needs to recast it as a further argument for bringing the British community back to an appreciation of the humane values that led to NHS in the first place. It is only when these values spring back to life with fresh energy that people will value health and seek to improve it.

John Menadue remembers clearly an encounter he had years ago with a respected First Nations woman in South Australia in which she said to him, “Mr Menadue thank you for what you are trying to do in health but when I speak to young men in my mob, they say to me, ‘Auntie with our prospects in life what is the point of being healthy?‘”

It was the great Indian economist and philosopher, Amartya Sen, (91 in November, Nobel Prize in 1998) who did so much for economic uplift in India, wrote that famine is always politically constructed, never due to a shortage of food.

“Our task,” he said, “is to create the conditions for people to have the freedom to lead lives they have reason to value.”

Listen up, dear colleagues: Sen’s aspiration and a positive answer for Auntie’s reply can only be achieved through the combined efforts of every political portfolio and every citizen. And the values must be right to power the reforms.

Health and illness are socially determined. It is at that level that change must occur and for which we must win community support for greater equity and sustainability – as we know full well from our search for a solution for that other great challenge of our time, global warming.

So let’s hear it for health. And best of British luck to Sir Keir!

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