Can the NHS be saved?

We know the NHS is in crisis. Before the election, many of us heard politicians discussing how they were going to fix the NHS. I don’t know about you, but I felt most had run out of ideas.

After spending nearly five decades working as a doctor within the NHS, I have a few ideas about what needs to be done. Perhaps they might not be what you expected and to be sure, they are not what politicians are telling us we need to do.

My main point is that you can’t fix the NHS from the inside.

I believe the answers to the problems facing the NHS lie largely outside the NHS and I will explain why. Sure, there’s lot that can be done to improve the NHS from the inside but sadly the billions of pound already pumped into it have made little difference.  That’s because this is not where the major problems lie, and if we focus purely on this, it will be like moving the deck chairs on the Titanic. The NHS will still sink.

I believe there are two massive problems, largely unrecognised and certainly underemphasised, which are driving the NHS into meltdown.

The first is very simple: the numbers don’t add up. We have seen an immense increase in population at the very same time as we have lost over half our hospital beds. This is a recipe for disaster.

When I started working in the middle of the 1970s there were approximately 400,000 hospital beds (and even then, beds were sometimes in short supply). This went down to 300,000 by 1987 and to 200,000 by 2005. It now stands at about 163,000.

Put another way hospital beds have gone from 5.9 per 1000 in 1990 to 4.0 in 2011 to 2.9 in 2010 to 2.43 today. Simply put, we don’t have enough hospital beds and the situation is getting worse.

At the same time, the population in the UK has been going in the opposite direction. It stood at 47 million when in the mid-1970s and after twenty years it increased slightly to 48.5 million.  The population then exploded, reaching 55 million by 2016, now standing at 58 million.

Immigration has made up at least 60% of this growth accounting for an extra 7 million people in the UK over twenty years. Whatever your thoughts about the rights and wrongs of this, it needs to be taken into account and planned for. To be precise, we would have needed to build at least 13 new hospitals or produce 2,500 more hospital beds to cope with this increase. This hasn’t been done and now the inevitable has happened. The NHS is desperately short of beds.

There is a second major cause of the crisis threatening the NHS: the inexorable rise in chronic disease. This is not just happening in the UK; it is threatening every other health care system in the world with bankruptcy. You may think I ‘m exaggerating but European countries have spent an extra £40 billion annually in the last decade and in the USA health spending has increased from 6% of GNP in 1970 to 18% in 2020. This is simply not sustainable.

Chronic disease has been estimated to be responsible for three quarters of all health costs in the USA and two thirds of this is thought to be preventable (by a change of lifestyle if we went to 1970s levels of health). Chronic disease has gone from affecting 30% of adults in 1980 to 60% today in the US (and 12% have a staggering 5 or more chronic diseases). We are not far behind. Modern medicine has surprisingly little to offer for chronic disease.

What is causing this rise in chronic disease?

It is due to the huge increase in what is known as metabolic disease (88% of the US population have some metabolic dysfunction). This is the forerunner of many other chronic diseases (see below) but most notably obesity and diabetes.

The biggest change I have seen in health in my lifetime is the increase in obesity. The average person today is 1 stone 10 pounds heavier compared to a person living forty years ago. Obesity has gone from a mere 3.5% in the 1970s to 28% today with 60% of the population being either obese or overweight.  This has happened in nearly every country, affecting both sexes, all ages and all racial groups. It has got worse with each generation.

The main driver for this has been change in diet. More specifically, a change to a diet of ultra-processed food (UPF) which now make up 70% of foods found in supermarkets (90% of which also have added sugar). UPFs are artificial foods packed with sugars, adulterated fats and largely untested chemicals. UPFs are associated with increased rates of diabetes, cancer, inflammatory bowel disease, heart disease, mental health problems, (especially depression), Alzheimer’s disease, fatty liver and a range of other diseases.

The massive Global Burden of Disease study identified poor diet as the number one cause of disease worldwide, reducing life expectancy by nearly 10 years (nearly twice the effect of smoking). The OECD estimates that the cost of obesity to the UK taxpayer has been estimated to be £74 billion in lost earnings and NHS costs each year. Again, this is unsustainable.

If we don’t do something about our food then the NHS will sooner or later collapse. Despite 689 published government policies on obesity and 14 specific strategies, they have all failed and obesity has continued to increase. These failures are largely due of the influence of the food industry.

And yet some simple changes could make a huge difference. The taxpayer is paying vast sums to subsidise unhealthy foods (these include soya, corn and sugar which are found in virtually all UPFs) whereas healthy foods receive no such subsidies. Between 1989 and 2005 the price of junk food dropped 26% in the US whereas fruit and vegetables went up 75%. Stopping these subsidies (as has been done in New Zealand) and using the money to support healthy food is in everyone’s interest.

There is overwhelming support, shown in focus groups, for controls on ultra-processed foods and perhaps surprisingly, many in the food industry privately admit that government controls are needed. In Central and South America putting warning labels on UPFs has proved a simple and highly effective policy in reducing UPFs.  And yet here the government has shown no appetite to tackle the food industry.

The key point here is that two-thirds of chronic disease is preventable. The root cause is an avalanche of diet-related diseases. At the end of the day, if we seriously want good health and an NHS that functions, we need to produce and promote good food (as happens in Japan) and stop producing and promoting the foods that are making us fat and  ill.