BMJ  2007;334:19 (6 January), doi:10.1136/bmj.39066.541678.B7

observations

LIFE AND DEATH

In defence of a National Sickness Service

A reconstituted National Health Service that prioritises prevention of sickness would fail all those who are ill now

It has become commonplace to describe our current healthcare arrangements as a National Sickness Service and to call for a transformation to a genuine National Health Service that would prioritise prevention above cure. This is the sort of facile sloganeering, beloved of politicians and policymakers, that systematically ignores the implications of the rhetoric. The proposed transformation is already shifting the focus of health care away from the needs of the sick towards those of the well, from the old to the young and from the poor to the rich. Is this really what we want or need?

Societies fail whenever someone who succumbs to a treatable illness causing pain, suffering, or premature death is unable to avail themselves of effective treatment because of the lack of money to pay for it. In the context of heightened social solidarity immediately after the second world war, UK society set out to ensure that this situation would not arise again through the creation of the NHS. In 1948, Aneurin Bevan expressed this resolve: "We ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world—put the welfare of the sick in front of every other consideration." The proposal to move away from a National Sickness Service undoes this over-riding commitment to the welfare of the sick.

Relieving suffering is an enduring moral imperative; the contemporary obsession with maintaining health is part of the persistent, but recurrently illusory, human dream of controlling the future. The present day manifestation of this dream is mediated through science, with the new holy grail being a long life, devoid of suffering, and ending in extreme old age with rapid decline and death, also miraculously devoid of suffering. The pretence that this is deliverable by a reconstituted National Health Service betrays all those who are suffering here and now.

Those who promulgate the dream vastly underestimate the role of luck and contingency in human health. They want to believe that health is a simple opposite of sickness, that it is in the gift of medical science, and that it can be delivered to order. Health becomes a commodity like any other, and it is clear that the rhetoric is underpinning the rapid commercialisation of healthcare and the exploitation of sickness and fears of sickness for the pursuit of profit. Doctors are colluding with politicians and journalists in the systematic exaggeration of the power of preventive medicine, with the dangerous and misleading suggestion that more can be done to promote health through reconstituting the health service than through reforming society. Despite all the emphasis on diet and exercise, the most powerful determinants of health remain wealth and happiness. The more equal distribution of hope and opportunity achieves more than the life long prescription of cholesterol lowering drugs and the stapling of stomachs. The emphasis on lifestyle risk factors for health implies that those who have had no luck are somehow morally deficient. This is both unnecessary and vindictive.

None of this is to deny the importance of preventive health interventions within clinical encounters, where there is much which can and should be done. Recent smoking cessation interventions have been very successful but, even with smoking, more can be achieved through taxation and by minimising smoking opportunities at work and in public places than through cajoling individuals. Immunisation campaigns and similar public health interventions have been hugely beneficial, but the current trend to define risk factors for ill health as diseases in themselves and therefore to define disease on the basis of a biometric number rather than an understanding of suffering is deeply worrying and is actively turning people into patients.

A National Health Service committed to prioritising the prevention of sickness above its treatment would accelerate the pursuit of biometric risk factors for this or that disease and the development of statistically effective treatments for each one in turn. This process legitimises investment in the wholesale drug treatment of healthy people and the increasing costs of this begin to pose a very real threat to the provision of universal health care systems that are available and accessible to all. No universal healthcare system, funded through taxation, can possibly pay for the pharmaceutical treatment of all risks to health. An excessive and unrealistic commitment to prevention of sickness could destroy our capacity to care for those who are already sick; everyone, in time, must become sick and die.

One of the ambitions of preventive health care is that it will reduce the gap between rich and poor, but health inequalities reflect wider societal inequalities and cannot be solved by a health service operating within a persistently unequal society. As Peter Skrabanek asked many years ago, why does poverty matter only when it creates illness and disease? Why are we not appalled by poverty because it is "cruel, demeaning and unjust" long before it manifests itself as ill health? Through recent advances in psychoneuroimmunology, we begin to understand how the chronic psychosocial stress of finding oneself at the bottom of society's pile leads to compromised immunity, disordered metabolism, and premature disease. The primary solution should not be medication but a genuine commitment to fairness and justice in a humane society.

An excessive commitment to prevention of sickness could destroy our capacity to care for those who are already sick

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