It has been the quite the year for self-assured authors diagnosing what fundamentally ails the NHS. Former health secretary Jeremy Hunt (Zero: Eliminating Unnecessary Deaths in a Post-Pandemic NHS) wants to stop doctors making mistakes. Former Conservative party deputy chairman Michael Ashcroft and journalist Isabel Oakeshott (Life Support: The State of the NHS in an Age of Pandemics) can barely disguise their loathing of the venal medics, feckless managers, malingering health tourists and bottomless money pits that fatally blight the NHS. I await another former health secretary Matt Hancock’s forthcoming tome with bated breath – not least in the hope that he reveals the secret of how he found the energy to conduct an office-based extramarital affair while ostensibly managing a pandemic.
The latest author off the blocks is Prof Sir David Haslam – former chair of the National Institute for Health and Care Excellence, former president of the Royal College of GPs and of the British Medical Association. Haslam has, as far as I can tell, no political axe to grind, no track record in government to buff and defend and – most refreshing of all – a deliciously plain-speaking way with words. Side Effects: How Our Healthcare Lost Its Way and How We Fix It is the real deal, a superb analysis of the thorny, intractable, endlessly sidestepped issues that bedevil 21st-century healthcare. Don’t be put off by the title. In our superficial, cakeist, post-truth era, it is genuinely exhilarating to read a proper, heavyweight analysis framed in prose as blunt, on point and devoid of spin as Haslam’s.
The recently retired Cambridgeshire GP has a reputation among medics for getting straight to the heart of things. He once summed up how to have a good bedside manner in the magnificently clipped imperative: “Shut Up. Listen. Know Something. Care.” It’s hard to argue with that. His approach in this book is equally uncompromising. He eschews the grandstanding, pontificating and emoting into which discussions about the NHS too often descend, instead asking wryly: “What is it that we are really trying to achieve through our healthcare system? And if we have a goal in mind, are we going the right way about trying to achieve it? If you have infinite wealth or live in a country with an unlimited healthcare budget, then these questions won’t apply to you. But my guess is that you don’t.”
To underline his point, Haslam points out how spectacularly expensive many modern treatments have become. Eculizumab, for example, a drug used to treat a rare blood disorder called paroxysmal nocturnal haemoglobinuria, cost £340,000 per patient per year in 2015 – or a total lifetime cost of £10m for each person with the disorder. In 2019, the US Food and Drug Administration approved what was at the time the most expensive drug in the world, a one-dose gene therapy developed by Novartis for spinal muscular atrophy with the eye-watering cost of $2.1m per patient. Only a fool, or perhaps a politician, would pretend we can afford every groundbreaking, extortionately priced drug without compromise. In healthcare systems in which funding is finite (in other words, all of them), trade-offs are unavoidable. How, then, we go about deciding which conditions are treated and which are left untreated is “not about rationing – it’s about rationality”, Haslam argues. He elaborates: “Do we know what the endgame is, or do we just keep on buying more of the expensive products because we feel it would be immoral to stop?”
Side Effects forces us to face up to – rather than ignore or deny – the realities of balancing the vast sums that can be spent on a single, seriously ill patient against the “distressing conditions in which many frail and elderly people live out their final years, often as a result of lack of adequate funding”. It is all too tempting, Haslam recognises, to dismiss as abhorrent the act of attaching a price tag to a person – as though their worth can be measured in pounds and pence. A human life, surely, is priceless? No amount of mere money or stuff comes close? But anyone who is actually involved in the real, messy world of healthcare knows full well this is nothing but rhetorical posturing. At the moment, for example, in the NHS we are seeing young patients dying in the back of ambulances stranded on hospital forecourts, unable even to enter the hospital – and this is not inevitable, it is a political choice. The government, and by implication the electorate who voted them into office, made a conscious decision to live with these deaths.
Only once we concede that expectations will always exceed capacity in healthcare, Haslam argues, can we properly address how best to make tough decisions. Are patients sufficiently involved in this decision-making? Are sufficient resources directed into preventive medicine? Are we over-medicalising ordinary life, perhaps because the private sector stands to make a fortune from selling pharmaceutical “cures” for inherently human conditions such as grief or loneliness? Do we wrongly prioritise the eking out of a few more months of life with expensive cancer drugs above ensuring that tender, high-quality, end of life care is available for all who need it?
This brilliant book offers no glib solutions, only thoughtful suggestions, but the questions it poses are electrifying. In the end, they boil down to the most profound and intractable question of all: how do we wish to live and to die? Haslam wouldn’t dream of answering didactically. He merely mentions in passing that he happens to agree with the quote, often attributed to Mahatma Gandhi: “The true measure of any society can be found in how it treats its most vulnerable members.” Indeed. In a society such as ours, deeply and divisively riven with socioeconomic gradients in health, let us hope future governments agree.
Rachel Clarke is a palliative care doctor and the author of Breathtaking: Inside the NHS in a Time of Pandemic
• Side Effects: How Our Healthcare Lost Its Way and How We Fix It is published by Atlantic Books (£20). To support the Guardian and Observer order your copy at guardianbookshop.com. Delivery charges may apply
