The Blog

Entitled Demanders - The Future of the NHS?

The NHS is about what people need and not what they want. That's the intention with which it was set up, and indeed that is how modern medicine is set up. And the boundaries between what folk need and want have become totally blurred.

Like many of you reading this, I was saddened by Liz Jones' Mail on Sunday article from last weekend. As someone who understands only too well the complexity of working in the NHS, but also trying to constantly better understand the needs of patients, I felt I had to throw my hat into the ring.

I'm not going to go on about Ms Jones as that would be pointless and frankly dull. In fact I would like to thank her for highlighting a very important problem. She beautifully illustrates the world of the entitled demander. In my mind, things have got progressively worse since Tony Blair came and left Downing Street. Despite his initial good intentions for the NHS, there has been a creation of public demand so powerful and so voracious for health care services, that it is unsustainable in the long term. Jones' article, I feel, is a symptom of how a significant proportion of people in the UK feel about their health service.

Think about it. If you don't use a service very often, you feel aggrieved when it doesn't give you what you want or expect. That's part of the problem we face. The NHS is about what people need and not what they want. That's the intention with which it was set up, and indeed that is how modern medicine is set up. And the boundaries between what folk need and want have become totally blurred. At the coal face, I can tell you, it feels at times as though everything is urgent and everything needs sorting out immediately for everyone - from catarrh through to serious cancers. So who's to blame?

Don't get me wrong. It's not all the fault of politicians and promises in party manifestos. Media is also very much to blame. And I write this as a doctor who leads a fairly active media life.

Many of my patients, for instance, watch medical TV programmes which feature treatments which are only available in the private sector. These shows don't always spell that out, so unsurprisingly patients expect to access this kind of fast track private service on the NHS. There are numerous examples, mainly involving cosmetic conditions and cosmetic surgery.

Then of course, the public hear about a new medical advance on the news, or in a certain newspaper, not realising that it's only available to a certain group or not going to be available for many years. For instance you can't be considered for a gastric band or bypass (popularised by many TV personalities such as psychic Sally Morgan and Anne Diamond) unless you are of a certain body mass index. In years gone by I have had numerous conversations like this:

"Can't you just refer me for one of those gastric bands, doc?"

"Er, no... sorry... I'm afraid you don't meet the criteria in terms of your weight and height... you're not actually heavy enough in fact..."

"OK, what about liposuction then? I saw it on telly the other night..."

"You can't routinely get that on the NHS I'm afraid - it's only for very special cases which aren't cosmetic"

The patient tuts and leaves feeling fobbed off. And why wouldn't she? She's been unwittingly conditioned to believe she's entitled to all this.

In essence we need better signposting for people and that will mean a big push for family doctors to interface with patients at a local level around the land, via patient participation groups. Better information on self-care and who to see when is vital.

To scientifically - or perhaps I should say mathematically or even economically - illustrate this issue of patient demand, I am going to leave you with an apocryphal study from 2002 by the great Amartya Sen. The bottom line is that when he compared how much illness was reported in the USA compared to Bihar (one of India's poorest states) the Americans reported illness far more, despite first world healthcare and the latest technology and despite the figures showing that illness is far more common in Bihar. The reasons behind this outcome are, of course, complex.

Add to all this the fact that modern medicine, still based largely on the biomedical model of disease, does not have all the answers for those folk with what are considered to be medically unexplained symptoms, and we are heading for troubled times unless there is a radical rethink with both patients and various healthcare professionals working in partnership. We are all patients, after all, and nothing in this world is more important than health.