The English Health and Social Care Information Centre recently reported a record number of patient complaints for the 12-month period from 1 April 2013—31 March 2014. The total tally was 174,872 complaints and the largest single source was complaints about inpatient care. In a country where people apologise for getting their feet stepped on, most patients do not complain about poor medical care and this figure is likely to be the tip of the iceberg.
So who is to blame for this epidemic? The West in general and the English National Health Service (NHS) in particular is seeing the beginning of a perfect storm in which several forces are converging. The first component is our increased life expectancy (lifespan), which has not been mirrored by an increase in healthy life expectancy (health span). People are now living longer in spite of accumulating health problems. Patients survive heart attacks, only to require multiple vascular interventions. Patients live with cancer longer, at huge expense, requiring close monitoring and frequent imaging.
The second component of the perfect storm is patient expectation. It is paradoxical that although we now live longer than at any time before in history, we worry more about our health than ever. People are no longer content to see if that stubborn cough or sore throat will settle in a few days. After all, it may well be the beginning of something serious! Furthermore, they would rather have someone else, a 'qualified person', telling them that they have nothing to worry about. If their insomnia then turns out to be the first sign of a brain tumour, at least there is someone to sue.
Many of the major IT companies are also developing smart watches with the ability to monitor health parameters and turn healthy people into nervous patients concerned about extra heart beats or poor quality of their REM sleep.
In the case of the English NHS, the third component is that politicians are unwilling to pour further money into a health service that they see as inefficient. I guess that by throttling funds, they are hoping that a more efficient service will emerge. Sadly they are mistaken and instead services are increasingly managed on a shoestring. Wards are kept open with the bare minimum of nursing staff. Support services such as audiology, speech therapy, physiotherapy and occupational health are told that they have to cut expenditure by up to 20%
As the above three factors are beginning to exert an irresistible force on the English health care system, managers' and politicians' eyes are increasingly turning towards the Pandora's box that is 'the marketplace'.
When I first arrived in England some 30 years ago, hearing aids, dental care, retirement homes and eyesight tests were all free. However, it was soon realised that these services could be taken care of by private providers. As our creaking NHS is finding itself subjected to the unyielding effect of the above three forces, it is inevitable that this Pandora's box will be opened. Naturally, the NHS could never stop providing free emergency care for patients with serious acute disease or cancer, but this leaves plenty of scope for private providers in the marketplace. Why not ask pharmacists to see patients who develop a sore throat, wake up with a headache or simply feel tired? Pharmacists could charge patients either directly for giving them advice or indirectly by incurring a fee for the medicines that they recommend. Parents who find that their children have wonky teeth, can’t sit still in the classroom or simply don't seem to develop as well as their siblings, will in the future have to pay to have their children seen to. But why stop there? Why should the NHS provide joint replacements for free when instead it could supply patients with walking sticks? Why should the NHS provide free cataract extractions in both eyes when operating on just one eye is enough to allow people to read a book? Osteoarthritis and cataracts are neither emergency care nor cancer! Furthermore, why shouldn't patients pay for more expensive medication themselves? If patients don't like their angiotensin receptor blocker, they may opt for an angiotensin-II receptor blocker that has a different side effect profile! If patients are prepared to pay an extra €30.000 for a cytotoxic agent that gives them hope of an extra few months' survival, why stop them?
The marketization of our lives is becoming omnipresent. Soon it will be possible to purchase everything. I can see three reasons why the free rein of market forces will be bad. Firstly, there will obviously be people who cannot afford care. Parents who do not have the funds or knowledge of 'the system' will not be able to obtain medication for ADHD or pay a psychologist for cognitive behavioural therapy. I predict that we will in the future see more evidence of what can go wrong when children are left unsupervised on our streets.
Secondly, I would miss the fact that when I recommend a treatment to a patient, both of us know that I do not stand to gain personally from the advice. In most parts of the world, patients do not have this reassurance and may be tempted to seek an alternative and perhaps cheaper opinion. Patients seeking multiple opinions and then choosing the one that suits their own ideas best will not necessarily lead to better health outcomes.
Thirdly, the 'haves' and the 'have-nots' will live completely separate lives. They will live in different parts of the city, their children will go to different schools, they will travel to work by different means and their leisure time will be spent in different places. I don’t think that this is good for society. Democracy itself will be under direct attack as those who can afford to pay for political influence and lobbyists will seek to buy the policies that favour them. Why not—it's the marketplace!
In the meantime, I keep staring at those X-ray machines in the knowledge that when my own cataracts have reached maturity, and I can no longer read a book, my optician will swiftly point me in the direction of a private ophthalmologist without any involvement of the NHS.