The decision by The BMJ to further try to enforce its separation from industry is somewhat at odds with the essentially wholly private sector leadership of pharmaceutical R&D. The lay perception of the #BMJ might be of a respected medical journal, but in fact it’s a USD120m+ revenue international publishing enterprise with 50+ journals. While potential conflicts of interest are important to consider, assess and account for, to assume that industry connectedness is entirely or even somewhat negative is shortsighted and destructive given the increased complexity of R&D. And The BMJ is part of that same health care industry, happily profiting off its back. To put in place yet more barriers to prevent leading investigators articulating the clinical meaningfulness of their trials is surely counter productive. As they address diseases ever more specifically and in ever smaller more segmented patient cohorts, it seems folly to try to stymie the debate that should ensue from these trials’ findings. The BMJ seems to have overlooked the fact of the multi million dollar business that it has become, that open access is increasingly democratising science, that peer review should be about what you’ve done not who you are, and that Impact Factors aren’t perhaps what they once were.
Straightforward pharma-bashing on one level but given that this is a UK column written through an ostensibly religious lens by Canon Fraser, it’s hardly being charitable in not mentioning pharma’s increased commitment to, eg rare diseases and CSR over the last few years. And, jarring with the principles of Fraser’s position (freedom of choice being a core tenet of Christianity) – it seems to overlook any notion of personal responsibility… for example he doesn’t consider that if people tried a bit harder to manage their diets and didn’t impose such high obesity-related costs, there would be more public resources freed-up, to be deployed in targeting those areas on which pharma quite legitimately can’t focus heavily. The author probably has a pension, it’s highly likely some of that balanced portfolio is invested in health care. Yes, it’s an opinion piece, and yes it’s in a left-leaning vehicle but even in this context it’s still a bit of a shame that shortsighted, unbalanced dogma persists about an industry and sector that has worked through a difficult few years.
Going by almost daily anecdotal evidence the UK’s NHS is not a system in whose care you’d look forward to putting your life. On the other hand its sacrosanct nature is part of the national psyche. The recent publication by the US Commonwealth Fund, which attracted significant coverage in the UK acted as a lightning rod for the ‘it’s not broke so don’t touch it’ brigade. And while interpretation of its findings leaves something to be desired by the mainstream press, let alone the public it should be noted that the analysis was undertaken through the lens of the US health care system. So pretty much anything else is going to look relatively good. Nevertheless the NHS tops out on multiple measures and commenters have leapt on these findings as valid reasons to leave the NHS well alone, heaping vitriol on anyone who talks of reform, and more particularly on any suggestion of private involvement.
Don’t touch what’s not broken is the mantra. Except that the real issue is that the NHS is very broken but just manages to deliver in spite of its hamstringing. So why does any attempt to reshape the NHS inspire this response? Without comprehensive reform the NHS will die. What the public doesn’t understand is that the destruction of the NHS is not going to be due to effective use of public private partnerships. For the last two decades billions have been wasted by meddling, tweaking, restructuring, devolving and recentralising and etc. It’s a mess, and as the report notes, the UK lags on health outcomes. When you look at the world’s best health care systems (and I mean best in terms of health outcomes – not ‘best’ in the sense of the usual sentimental, untouchable infallibility notion of ‘best’ that is ascribed to the NHS) they are mostly partly privatised – or at least more integrated with private partners than is the NHS – and partly co-paid.
Take Singapore or Australia as examples – spend on health is similar or lower than the UK and outcomes are better. There are more pragmatic aspects to health care provision that this report doesn’t really touch on. In the UK a GP appointment can be nigh on impossible to get, which drives urgent cases to the emergency room – which wastes resources. At least in markets with a moderate co-pay you can see a primary care practitioner when you want, and importantly out of office hours. Again, reducing indirect economic costs. Specialist referrals tend to be much faster too and because private care is more widespread, it is more accessible and more affordable.
Societally, privatisation has tended to be stigmatised in the UK because of a focus on the bad (British Rail) over the good (British Airways) and the suspicion that national assets have been sold off at below value to enrich the few. However, if regulated, privatisation means managers perform roles at which they are expert. The NHS has for years had highly paid and totally disconnected managers interfering with clinicians’ ability to carry out their work. A lot of the criticism has been about managers interfering with clinicians, yet one of the biggest recent changes – the creation of 211 Clinical Commissioning Groups (CCGs), has placed about 60% of the NHS budget in the hands of local doctors and health workers. Some CCGs have figured out ways to realign the incentives of hospitals, which are often paid per procedure, with those of GPs, who aim to keep people healthy and at home.
For me the single most telling point in this report is the placing of the UK in 10th out of eleven on the ‘healthy lives’ measure. A healthy life of course is very much a personal choice and way beyond the remit of the NHS. However it is evident that much of this self-inflicted unhealthiness is what is burdening the health care system in the first place. People need to start to take a degree of responsibility for their own long-term health as a starting point for unburdening the system.
Even the USA has lately taken a more proactive and collaborative approach to fixing its horrendously inefficient and outrageously unaffordable healthcare system. So yes, as commenters say, the NHS has some of the best clinicians in the world. But if it continues to be run as it is it will fall over. The problem of the NHS won’t be solved with a ‘don’t touch’ approach, by ring-fencing it and pouring unlimited amounts of money into it. It needs to be disassembled and rebuilt fit for the present day.