Feature

Paying for poor policy

When public policies work against good health the NHS picks up the bill, explains Richard Lawson

The chronic problem of inadequate services in the NHS comes not only from under-funding but also because it is expected to meet needs created by rectifiable social conditions.

In all the industrialised countries, health workers complain that health services are underfunded. We in the UK lie at or near the bottom of this particular heap, being fifth from bottom in the OECD stakes on total healthcare per person, third from bottom in total health expenditure per person (from a 1960 base), and bottom on total health expenditure as a percentage of GDP.

Although it would clearly be desirable to increase the funding enjoyed by the NHS, more money is not the whole answer. There is no sense in giving course after course of antibiotics to children whose repeated respiratory tract infections are caused by dampness in their home, nor in giving antidepressants to a woman whose depression stems from the fact that her husband is unemployed. We must keep treating, but we must not lose sight of the fact that medicine does not operate in a vacuum. The social and environmental conditions in which patients find themselves determine the level of illness they experience, and therefore the level of spending in the NHS.

Like most GPs toiling away at the sharp end, I was not best pleased to find that health promotion had been dumped on my plate along with all the other NHS changes — and that government was refusing to do its bit to help.

Health promotion à la ‘reformed’ NHS puts all the emphasis on the lifestyle of the consumer. The process rapidly runs up against contradictions. For instance, people are to be urged to take more exercise. Fine. But not if air quality warnings are telling people that the town’s air is in the poor category, since both asthmatics and non-asthmatics do themselves no favours by pumping litres of dilute sulphuric acid through their airways. Similarly, people should be urged to leave the car at home and cycle. Great theory, but in practice after they have had one close shave with a juggernaut they reach for the car keys again. Individual lifestyle modification is not the whole answer, government policy must also be modified.

Unemployment, work stress, social breakdown, poverty, substandard housing and environmental pollution all cause health problems. In some cases the costs of these problems are already known, in others they are not difficult to work out, and in others again they are impossible to quantify, but we can be pretty certain that they are there.

Unemployment is known to increase GP consultation rates by unemployed people and their families by 20 per cent. The bill for this and associated factors adds up to £173m per annum — some 2.5 per cent of the annual budget for GP services. The excess mortality caused by unemployment costs the state between £1bn and £4bn. The cost to the NHS for treating illnesses caused by substandard housing has been estimated at somewhere between £1bn and £2bn. And so on through the whole sorry saga of government neglect of poor and vulnerable people.

Environmental pollution adds to the burden of ill health with a large number of small effects on health. Taken by themselves, individual pollutants often do not reach levels of statistical significance. Taken together — which is the way we actually do take pollutants, day in and day out — there has to be a significant effect.

Time and again, the immune system appears as a common factor in ill-health from extrinsic causes, whether social, economic or environmental. The immune system is a final common pathway acted upon by stimuli as diverse as stress due to social hierarchies at work, allergens like moulds in damp housing, and the 70,000 new chemicals that have found their way into our environment over the last two or three generations.

Any disturbance of health may be brought to the attention of the health service. As soon as patients go through the door of the health centre, costs are incurred. Since financial cost is now king in the new model health service, this gives a handle for change. To say that people are being made ill as a result of policy will be met with a shrug, or with stout denial. But if we can say that more than £2bn of NHS money is being wasted each year in treating illnesses caused by rectifiable problems in society at large, there is a chance — just a chance — that the government may pay some attention.