Intended for healthcare professionals

Feature NHS at 70

Back to the future: aspects of the NHS that should never change—an essay by Iona Heath

BMJ 2018; 362 doi: (Published 25 July 2018) Cite this as: BMJ 2018;362:k3187

Frugality can be harmful

In her essay on NHS culture Iona Heath looks back to a culture of frugality which she feels is the way to avoid the trend to overdiagnosis and overtreatment in contemporary medicine[1]. In fact, that frugality was very harmful.

In an essay I wrote in 2000 I described how that culture of frugality was harmful to the care of patients with cancer[2]. Each professional group saw its obligation to protect other diagnostic or therapeutic services from excessive workload leading to a failure to recognise what capacity was required. I subsequently wrote an editorial in which I commented on the limited progress that had been made in the following decade and the fact that there were some hopeful signs[3].

That editorial was peer reviewed. The following quotations come from an anonymous reviewer.

“British cancer care lagged and lags despite the fact that the UK was/is one of the leading nations for academic oncology. The deficiency was not in the ‘in-house excellence’ which UK Inc held, but in the access of citizens to that excellence…As a closely located [Ireland] but external observer of these events, it sometimes seemed that some UK colleagues thought it at least disloyal to the NHS, and perhaps actually treasonous to admit that deficiencies existed.

“Dr. Crawford correctly identifies the quirky British GP system and its sentinel-like gate-keeping function as a principal barrier. Such gate-keeping cannot by definition enhance the quality of care of patients. It is a cost-containment exercise par excellence. It is this system which allows the UK to have such an extraordinarily low number of specialists per head of population compared to all of your European peers. It consistently surprises me how accepting most UK hospital consultants are of this profound numeric abnormality.”

1] Heath I, Back to the future: aspects of the NHS that should never change—an essay by Iona Heath. BMJ 2018;362:k3187

2] Crawford SM Cancer in the UK- A question of culture. Eur J Cancer, 2000; 36: 1909-12.

3] Crawford SM Cancer care in the UK: updating the professional culture. Postgraduate Medical Journal, 2011; 87:243-244

Competing interests: No competing interests

27 October 2018
Michael Crawford
Clinical Lead for Research
Airedale NHS Foundation Trust
Skipton Road, Steeton, Keighley, West Yorkshire, BD20 6TD