Can Medicine Be Cured Read online

  There is a consensus among politicians and society at large that health spending will have to keep rising, year after year, above inflation. Powell pointed out that this was nonsensical and unsustainable. Nowadays, however, not even the most free-marketeer Tory would dare agree. This consensus is now unquestioned, although deep down the British public, and their public representatives, despite all their loud protestations of loyalty to the NHS, know that the current model cannot continue. Health care will consume an ever-greater portion of public funds, leaving less and less for housing, transport, education and (God help us) the arts. The NHS was founded, in part, because of the simple insight, after the Second World War, that if Britain could mobilize an emergency medical service during wartime, then the same organization and social co-operation could just as easily be brought to the establishment of a peacetime health service. The consummate don and committee-man Noel Annan observed in Our Age: ‘During the war people had observed the decencies of equal treatment… As in war, no queue-jumping. Accept your rations.’ The moral foundation of the NHS was the 1942 report by William Beveridge, which identified the five ‘Giant Evils’ of squalor, ignorance, want, idleness and disease. Clement Attlee and Aneurin Bevan envisaged the Welfare State as a two-way social contract between government and people. Addressing the Fabian Society in 1950, Bevan warned that the National Health Service came with new responsibilities, and would demand that its users behave with responsibility, prudence and a sense of the greater good. Britain would not be a ‘mature civilization’, he said, ‘until we have produced a citizenry which is capable not only of selections but of rejections; which says not only who goes at the head of the queue, but who goes right at the bottom of the queue.’ His ‘mature civilization’ has not materialized, and the citizenry has ignored its moral obligation. Now, government and people collude in a mutual deception: that spending on health can and should continue to rise indefinitely, and that this service, while continuing to be free to all users, should offer the same choice and customer service as a private enterprise. This deception is now being painfully exposed.

  Powell believed that a nationalized health service, free at the point of consumption, subject to infinite demand, was inherently flawed, but acknowledged that there was no political or public appetite for any alternative. He argued that these flaws were not blemishes which could be ‘reformed away’. ‘The Service’, wrote the economist John Jewkes in a review of Powell’s book in 1966, ‘was based upon national self-deception, the belief that everybody can be provided with unlimited supplies of the highest quality of medical care.’ The public and politicians continue to subscribe to this consumerist fallacy, although both, deep down, know it is a lie. The internal market, introduced by Margaret Thatcher, was based on two assumptions: the first – that the NHS was a monolithic bureaucracy – was true; the second – that health care would benefit from competition – was false. Far from reducing red tape, the internal market led to increases in administration costs; around 10 per cent of the NHS’s annual budget is now spent on running this internal market. Labour was initially opposed to the internal market, but when Tony Blair came into power, New Labour expanded it. Many new hospitals were built as private finance initiative (PFI) schemes, the bill for which is projected to exceed the original capital cost seven-fold. The money wasted on PFI schemes would have paid the entire NHS budget for two years. The investment bankers, construction firms, commercial lawyers and management consultants have been the main beneficiaries. Hospitals were encouraged to become ‘foundation trusts’, which are paid by activity, rather than by annual fixed budget; administration and transaction costs are significantly higher. The ‘revolving door’ between government and the private sector ensured that this model has prospered – the British people have been the victims of a vast politico-commercial swindle. They are both sentimentally attached to the NHS and fed up with it. They know that something has to change, but there is no political or public appetite for this difficult conversation. Richard Smith explained the stark choices which a ‘mature civilization’ would have to make:

  ‘The best health-care system in the world’, which politicians in every country promise, will not be one that provides everything for everybody but rather one that determines what that society wants to spend on health care and then provides explicitly limited, evidence-based services in a humane and open way without asking the impossible of its staff.

  What is the best model for health care? The Nobel Laureate economist Kenneth Arrow argued that the normal rules of a market do not apply to health care. In his paper ‘Uncertainty and the Welfare Economics of Medical Care’, published in the American Economic Review in 1963, Arrow wrote: ‘The special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and the efficacy of treatment.’ His fellow economist and Nobel Laureate Paul Krugman expressed it better:

  There are two distinctive aspects of health care. One is that you don’t know when or whether you’ll need care – but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor’s office; and very, very few people can afford to pay major medical costs out of pocket. This tells you right away that health care can’t be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either – they’re not in business for their health, or yours.

  … The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping. (‘I hear they’ve got a real deal on stents over at St Mary’s!’) That’s why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners… Between these two factors, health care just doesn’t work as a standard market story.

  Who should provide health care – the market or the state? The answer, predictably, lies somewhere in the middle. Many European countries manage demand by their use of sometimes complex systems of co-payments. The French model of health care funded by income-based social insurance is rated by the WHO as the best health-care system in the world. The post-war establishment of this system was inspired by the same Beveridge Report which laid the foundations for the NHS, but provision is both public and private. The German system has a complex mix of public and private insurance. The late German-American health economist Uwe Reinhardt argued that the German model was ideal ‘because it blends a private health-care delivery system with universal coverage and social solidarity’. (Reinhardt helped devise a new health system for Taiwan; this system now covers the entire population and costs 6.6 per cent of the nation’s GDP – about a third of what the US spends.) Both the French and German systems spend more than the NHS but less than the US, and both are superior, in terms of patient satisfaction and measures such as cancer survival, to the UK and the US. The French and German systems have their flaws: the French population is hugely over-medicated, while health care in Germany is highly consumerist and constitutes about a quarter of the entire economy.

  I last attended the United European Gastroenterology annual meeting in 2014 in Vienna. The conference attracted 13,000 gastroenterologists and was held in a vast neo-brutalist concrete building in the city’s northern suburbs. Many – like me – were there to fulfil certain professional educational requirements, in this case, the metric known as ‘external’ hours. The Royal College of Physicians of Ireland will only recredential me if I spend a few days every year in neo-brutalist conference centres. Conferences like these are of real interest only to the small group of academic and medico-political players; the rest of us are registration-fee fodder, there to make up the numbers and collect our educational points. The scientific sessions are dull affairs, but these gatherings are sometimes interesting from an anthropological point of view.
Medicine being an enthusiastic early adopter of new technology, I found that all questions addressed to speakers at the end of a talk or lecture had to be submitted via smartphone, which excluded me from any such dialogue. One of the main (‘plenary’) sessions was called: ‘Healthcare in Europe 2040: Scenarios and Implications for Digestive and Liver Diseases’, where three possible future scenarios were presented. I was interested to see that the project had been carried out in conjunction with a management consultancy firm called NormannPartners UK (‘Strategy Consulting for a Networked World’), who market themselves as modern soothsayers and diviners of the future. I wondered what portion of my registration fee was given to this firm and what fate had placed me in the dust of clinical medicine, instead of the marble halls of NormannPartners.

  NormannPartners came up with three scenarios or ages that might play out by 2040: ice, silicon and gold. During the Ice Age, Europe becomes impoverished due to depletion of natural resources, climate change and economic crisis. The European Union collapses, as does public health care. The rich are well looked after by a private health-care system, and the poor are left to fend for themselves. In the Silicon Age, there is growth of both the population (from non-EU immigration) and technology, with widespread use of social media and ‘E-medicine’, and with doctors working increasingly as advisors. In the Golden Age, there is a United Europe, with universal access to health care, and a single homogenized health-care system across the continent. The snazzy booklet has a timeline chart for each possible scenario. I have looked again very carefully, but it seems NormannPartners UK (who are London-based) did not anticipate Brexit, which rather questions their credentials as predictors of the future. Ireland, where I live and work, already has an Ice Age Health Service; I won’t have to wait until 2040. In Britain, the Brexiteer politicians promised their electorate that withdrawal from the EU would free up an extra £350 million every week for the NHS. They now concede that this was untrue. More importantly, Britain has lost its best chance of health reform by leaving the EU. There will be no Golden Age – except for strategy consultants.

  Aneurin Bevan established the NHS without the assistance of strategy consultants – although Lord Moran (president of the Royal College of Physicians and Churchill’s private physician) smoothed the way for him with the medical profession. Bevan was born in Tredegar in South Wales; he started work as a miner at the local colliery at the age of thirteen. The Medical Aid Society set up by the miners’ unions in South Wales inspired Bevan to extend free health care to the entire nation. Launching the NHS, Bevan said: ‘All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to “Tredegarise” you.’ The novelist A. J. Cronin worked as a GP in Tredegar in the 1920s (‘Aberlaw’ in The Citadel); he was less enamoured than Bevan of the Miners’ Medical Aid Society: ‘There is certainly value in the scheme… but it also has its own defects, of which the chief one, in Tredegar, was this – with complete carte blanche in the way of medical attention, the people were not sparing by day or night, in “fetching the doctor”.’

  The consumerist ethos is at the heart of the new model of the doctor–patient relationship. According to Dr Catherine Calderwood, the chief medical officer for Scotland, ‘the future model of care is one with an empowered patient in a shared decision-making partnership with the clinician’. She argues that the paternalistic era of ‘Doctor knows best’ is over, and that the doctor–patient relationship must change. Her suggestions include ‘more engaging multimedia formats’, audio recordings of consultations, and the use of ‘navigators’, advocates who explore with patients what is important to them in terms of quality of life, life expectancy and side effects. ‘Catering for this new type of relationship with our empowered “Google generation”’, she says, ‘is one of our biggest challenges.’ Dr Calderwood’s professional background is in obstetrics, where most of her patients are in their twenties and thirties. One of her civil servants might have gently pointed out to her that those most in need of health care – the elderly – do not regard themselves as part of the ‘Google generation’, and are not particularly interested in ‘engaging, multimedia formats’.

  Contemporary commentators such as Catherine Calderwood use the word ‘paternalism’ in an exclusively pejorative way. But some older doctors, such as Bernard Lown (b. 1921), author of The Lost Art of Healing (1996), believe that a certain kind of paternalism gives hope and reassurance to sick people. Lown watched his mentor Samuel Levine conclude every consultation by placing his hand on the patient’s shoulder, telling them – regardless of their problem or prognosis – ‘you’ll be fine’. The gesture and words were so powerful that Lown used them throughout his forty-five-year career.

  Consumerism has created patients who confuse needs and wants, and who often want the wrong things; it has created doctors who view medicine not as a profession, but as a service industry. Aneurin Bevan challenged the British people to take on the moral responsibilities that came with the NHS. These responsibilities included utility – the maximizing of benefit for the majority of the population – and equity: ‘My Methodist parents used to say, “Have the courage my son, to say ‘No’.” Well, it takes a good deal of courage, but we shall have to say “No” more and more, because only by saying “No” more and more to many things can you say “Yes” to the most valuable things.’ But neither politicians nor people were equal to this challenge; the Thatcherite consensus prevailed over Bevan’s grand vision of a ‘mature civilization’.

  10

  Quantified, Digitized and for Sale

  The American rich can now access a new type of hyper-consumerist health care, a model they present to the rest of the world as how medicine really should be. The biotechnology entrepreneur Craig Venter is in the vanguard of this movement. He is most famous for the bitterly contested race his company, Celera, fought against the publicly funded consortium headed by Francis Collins to be the first to map the human genome. Venter was later sacked by Celera, and now heads a venture called Human Longevity, Inc.™ (HLI). He has set up a clinic, the Health Nucleus, where, for $25,000, you can have your genome and microbiome (the bugs in your gut) characterized, along with a total body MRI, bone-density scanning, hundreds of blood tests, analysis of cognitive function, and so on. Google’s director of engineering, Ray Kurzweil, who believes in a future where humans will become immortal, is one of HLI’s advisors. Although Venter is planning to expand HLI’s customer base, for the moment the market is the wealthy, for whom the promise of health is ‘the ultimate luxury item’. HLI is slowly building a database from these rich consumers, linking their fully sequenced genomes with all the other phenotypic and clinical data gathered by the $25,000 ‘physical’. Venter, whose long-term plan is to sell these data to pharmaceutical and insurance companies and health-care providers, is admired as a pioneer of ‘digital health’.

  Digital health, also known by a slew of catchy phrases such as ‘E-medicine’, ‘eHealth’, ‘Medicine 2.0’, ‘iMedicine’ and ‘Health 2.0’, is an umbrella term used to describe a number of new technology-driven developments in medicine. These include the use of biosensors to monitor health, tele-medicine – carrying out medical consultations via digital media, the digitization of individuals’ genomes, and the use of social media to create ‘communities’ of patients. Digital health appeals mainly to those who need health care the least: the young and the rich. It is driven by a new cadre of techno-utopians, who proclaim themselves as ‘creative disrupters’ of the old order. Enthusiasts argue that digital health will empower the patient, end the traditional patriarchalism of the medical profession and drive down the costs of health care. There is political support for digital health: the US Affordable Care Act (‘Obamacare’) promotes tele-consultations and patient self-monitoring. The surgeon and former junior health minister Lord Ara Darzi, in his 2018 report on NHS funding, warns that ‘having grown up in the age of the Internet, artificial intelligence and Big Data they
[the next generation] will not stand for an analogue health and care service.’ Darzi is particularly entranced by the ‘convergence revolution’, a phrase which emerged from the Massachusetts Institute of Technology (MIT) in 2011, and which modestly announced itself as ‘the third revolution in life sciences’. A 2016 report from MIT claims that ‘truly major advances in the fight against cancer, dementia and diseases of aging, still rampant infectious disease, and a host of other pressing health challenges will only come from a novel research strategy that integrates biomedical knowledge with advanced engineering skills and expertise from physical, computational and mathematical sciences, an approach known as Convergence.’

  Digital health has been described as a paradigmatic shift from ‘mechanical’ medicine to ‘informational’ medicine, with the focus on generating data from the human body. Techno- boosters routinely use the phrase ‘digitizing the body’. The American cardiologist Eric Topol is one of the leading ‘creative disrupters’. A classic Cartesian, Topol proposes a new bio-digital model, which he calls the Human GIS (Geographic Information System), consisting of multiple ‘omes’: phenome, genome, transcriptome, microbiome, epigenome, and so on. Technology already available on smartphones allows us to monitor all sorts of physiological variables, such as heart rhythm and blood glucose, and Topol boasts that he prescribes more apps than drugs. His brand of digital health is unashamedly consumerist: Topol’s bestselling book on the subject is entitled The Patient Will See You Now – implying an upending of the old power imbalance between patient and doctor.