In this month’s BJGP we feature some major themes in contemporary health care — the national consultation on organ donation, the rising tide of antibiotic resistance, child health, including childhood obesity, and the roles of other professionals, working alongside doctors, in general practice. Clinical topics include personalised medicine, the early detection of dementia, the management of lupus in young people, the value of exercise in diabetes, and the difficult and growing problem of severe nut allergy. And that’s not even half of a morning surgery! The intensity and complexity of modern-day general practice will be taken for granted by most of our readers, but needs to be communicated more widely, particularly to the press and to policymakers, who consistently and systematically undervalue the difficulties entailed in providing high-quality primary care, and the skills and knowledge required to do so.
General practice and the wider NHS now face unprecedented problems. Pressures on services this winter have exposed a seriously under-resourced and understaffed service susceptible to system failure, and only a few steps away from a complete failure to cope. It is hardly surprising that the Centre for Policy Studies has called for the establishment of a royal commission on the NHS as the only way of saving it.1 It is perhaps more surprising that this hasn’t happened before. For well over a decade concerns about the politicisation of the NHS have been articulated. In 2006 Fiona Godlee, the editor of the BMJ, proposed the establishment of an independent NHS with a politically independent board, analogous to the governance structure of the BBC.2 Last year the House of Lords report on the Sustainability of the Health and Social Care system took up the theme, criticising the short-termism and lack of proper planning of successive governments, and concluding that the NHS was not sustainable in its present form.3 The Lords report proposes the establishment of an Office for Health and Care Sustainability, and, recognising the relationships between the sectors, urges the re-unification of government responsibilities for health and social care. Discussions are taking place in Westminster about a cross-party approach to the NHS, but have yet to crystallise into a plan of action. Brexit must be a huge distraction.
The problems of a politicised NHS have been well rehearsed, although the temptations to tinker and avoid radically re-thinking health care have their causes beyond the constraints of parliamentary cycles and the ambitions of governments to be re-elected. The sensitivities around the NHS are so extreme, the public attachment to its altruistic principles so strong, that the most well-intentioned suggestions about restructuring the funding system (‘privatisation by stealth!’) or introducing co-payments (‘creating a two-tier health service!’) are howled down. The idea of a hypothecated ‘Health Tax’ has been repeatedly talked out. But look across the Channel, where countries on our doorstep have better health outcomes, with much the same levels of expenditure, but do not operate what we would recognise as a national health service. In his great poem ‘Easter, 1916’, WB Yeats wrote about the leaders of the Easter Rising, asking if an ‘... excess of love bewildered them till they died?’. I can’t help thinking that an excess of love for the NHS can get in the way of clear thinking about the future of health care in the UK. The question should no longer be about what sort of NHS we want, but what sort of health system we need to provide the best health outcomes for our population.
This question requires an urgent answer. Whether we like it or not, communications technology and commercialism are already transforming doctor–patient contacts in primary care by providing alternatives to NHS GP appointments. The same forces will generate more non-NHS services, which citizens who can afford them will use instead of the NHS. Some bold and imaginative thinking, which transcends party politics, is now needed.
- © British Journal of General Practice 2018