Second Opinion: NHS crisis - what crisis?
Just as every winter the shock appearance of snow creates chaos on the roads and railways, so the annual arrival of flu precipitates a crisis in the National Health Service. In fact, in GP surgeries and hospitals it was pretty much bank holiday business as usual - crowded waiting rooms, patients on trolleys, corpses piling up in the mortuaries, wards short of nurses, and doctors complaining about the public.
Though the number of flu cases fell short of epidemic proportions, the Christmas crisis had one novel feature. According to the Sunday Times, the thing that most annoyed doctors was the young men in their twenties who called ambulances to take them to hospital for treatment for their flu (10 January). This is clearly the inevitable consequence of the high-profile medical campaign for men, especially young men, to get in touch with their feelings and to take their health more seriously (see LM, December 1998/January 1999).
Far from exposing the breakdown of the old NHS, the winter crisis reveals the emergence of the new NHS. The contrasts are striking. Whereas the old NHS worked in a fairly straightforward way to treat diseases and care for the sick, the new NHS has a more complex mode of operation. On the one hand it devotes considerable resources to making people ill - and then it urges them to look after themselves.
The wave of demand for medical attention over Christmas was encouraged by the intensive media focus on a number of cases of meningitis, the early symptoms of which are often indistinguishable from those of flu or a number of other viral infections. Though the incidence of meningitis has remained fairly steady in recent years, the fact that each case acquires national celebrity means that every living room now boasts an expert in the diagnostic technique of inspecting a suspicious rash through a glass. Not much use in confirming meningitis, in which the rash is often a late sign, this technique is highly effective in generating anxiety about the diverse blotchy rashes that accompany numerous minor viral illnesses, especially in children.
In addition to promoting health scares that terrify many parents into bringing their children up to surgeries or to hospital casualty departments, doctors also encourage their patients to take up screening and preventive procedures. These often result in people who thought they were well discovering that they are in some state of latent disease (with a raised blood pressure or cholesterol level, an abnormal smear or a breast lump, for example).
The major medical investment in the promotion of lifestyle changes, backed by the authority of the government in the name of health, is another potent source of illness. For example, the current craze for 'going to the gym' to take exercise in the cause of greater vitality often leads to muscle strains requiring further medical attention. The vogue for condoms popularised in the great safe sex crusade leads inexorably to demands for the 'morning after' pill - especially over bank holidays following Christmas parties. The onset of a serious new year cough immediately following the resolution to stop smoking is as familiar as the bitter complaints from old people who have come down with colds despite having the flu vaccination earlier in the year.
While the government is happy to promote disease awareness in the hope that it will lead people into virtuous lifestyles, it is not so keen on funding the expanding range of medical services required to cope with the demand generated in this way. Here the Portsmouth Hospital Trust shows the way forward: in response to a shortage of nurses over Christmas, it encouraged local people to come into hospital to look after their relatives. It is not clear whether the authorities intend to request further public assistance in carrying out surgery or other forms of medical treatment.
For those who escape the familiar infections, the new NHS offers a whole new range of disorders. Conditions such as repetitive strain injury, post-traumatic stress disorder and chronic fatigue syndrome (aka ME) now afflict thousands, leading to prolonged absences from work and substantial demands on health services. Here the authorities' commitment to encouraging self-reliance is tempered by their endorsement of a range of stress-related disorders that often appear to offer an alibi for a wider loss of morale and motivation.
In all these ways, and many more, the new NHS encourages people to become patients. When a number of factors interact to intensify demand at a time when services are restricted, the result is the sort of crisis that occurred over Christmas. The perception of crisis in a quiet week for the press leads to a heated debate. Voices from the old left demand more resources for the NHS; those from the old right insist that more rationing is the answer. New Labour's 'third way' is to propose a little more money for token projects and to proceed with a lot more rationing.
There is no better symbol of the gulf between the new NHS and the old system than the changing character of doctors' home visiting. In the old days the deal was that GPs were available to their patients for 24 hours a day, 365 days a year, but patients never requested a visit unless they were in dire need. The standards of medical care were often low, but so were expectations; patients were deferential, doctors enjoyed social status.
Now market forces have swept away the consensus that contained demand. Health has become a moral project and medical attention a consumer good and a right - and requests for home visits, especially from the fragile new man, have risen exponentially. Farewell family doctor, hello GP co-op, locum agency and hospital casualty. Hail the 'third way' and make ready for next winter's truly millennial NHS crisis.
Dr Michael Fitzpatrick
Reproduced from LM issue 117, February 1999