75 years of the NHS: but how many of our patients do we still keep sick?

Giles Dawnay

doi:10.3399/bjgp23X734793

Anniversaries are always useful, not only for moments of essential celebration but also crucial reflection. Any being or structure that can survive 75 years must have benefited from a healthy mixture of luck and judgement to have been able to keep going and therefore must be respected. However, once the cake, platitudes, and fizz have settled there comes an inevitable look to the horizon. Where do we want to go from here?

The letters N, H, and S in combination tend to provoke some sort of visceral reaction in almost every member of the UK. For some it is the bedrock upon which our version of society is built; for others it is the keystone of an increasingly powerful ‘nanny state’ that removes personal responsibility and an ability to take one’s health into one’s own hands. Any period of history is inevitably defined by the tension between the collective and the individual, and tradition versus progress. There exists a multiplicity of perspectives within this framework on what sort of health system any functioning political system should have.

PROGRESS AT THE COST OF SIMPLICITY

Talking to more experienced colleagues who have witnessed far more of the NHS than I, one theme repeats again and again: the sense of great progress yet ever greater complexity. Now, there are so many more possible investigations, diagnoses, and treatments than ever before. With this comes choice, delay, waiting lists, budgets, media interpretation, and, ultimately, patient expectation. But how often do we actually look for simplicity in our treatment models rather than the ‘latest’ innovation?

This is perhaps never more pertinent for our roles in primary care. Many of our patients have chronic diseases who we can now maintain, chivvy along, and eke the most possible life out of. Mainly this is done because of our powers of prescription rather than persuasion. A 10-minute appointment leaves little time to truly access behaviour change, yet plenty of time to sign a script. Taking diabetes as an example, in the UK there are 4.3 million people diagnosed with diabetes. Registration figures for 2021–2022 are up by 148 951 from 2020–2021, and more than 2.4 million people are at high risk of developing type 2 diabetes in the UK.¹ This is estimated to rise to 5.5 million by 2030, which would be roughly 9% of the population.² Yet almost each month there seems to be another new diabetic medication available. How then can we explain the rise?

Diabetes nurses repeat the same advice ad infinitum about lifestyle, diet, and exercise. Anecdotally, they estimate that approximately 25% of their patients show improvement. Their days are generally fraught, with repetitive, frustrating conversations with patients who hold them accountable for their condition and little job satisfaction. Yet their role is so vital, so important. So the drugs keep being given out and the HbA1c keeps rising. It is estimated that the worldwide diabetes drug market was worth 29 billion dollars in 2021 and is expected to be worth 61.6 billion by 2030.³ Clearly, then, the drugs do not work, unless you are at the business end of the pharmaceutical industry (Obviously they do in certain areas of diabetes; I appreciate that.)

What then would happen if we decided upon a radical and different strategy? What if we just stopped prescribing antidiabetic drugs to people? What if we told them their diagnosis and said it’s up to you to change your life to sort this out? How much do our prescriptions act as a form of societal permission to maintain a current, yet unhealthy lifestyle? Imagine saying, ‘This is what you’ve got to do, this is what will happen if you don’t. Come back in a year and let us know how you’ve got on.’ The DIRECT Trial is already producing promising data that this approach can work.⁴

What would happen to our obese patients with high blood pressure if we didn’t prescribe antihypertensives and told them the only way to lower their BP was to lose weight? (Again, I appreciate this couldn’t be a strategy for everyone.) All of us in the NHS want to help people; we wouldn’t be here otherwise. But, and I only use diabetes as an example, how much of our work now inadvertently keeps a proportion of our patients sick? How much have we let the shimmer of progress blind and distract us (Semaglutide) from the basic building blocks of sustainable health care?

The NHS is undoubtedly a success, yet it sags and suffers under its own bloated weight from endlessly trying to keep giving. At what point do we stop, and begin a culture of truly sharing the burden of responsibility with those we claim to be looking after?