New technology wonder – just arrived, from the future. How do they do that? Here it is:
SICK TO DEATH
The founder of the NHS, Aneurin Bevan, died one hundred years ago.
Under him, after a long struggle, at last Britain had a health service free for all at the point of delivery. It was 1948, just after WW2, and it was a miracle.
The second struggle was seriously engaged around 2020. It involved not only recalcitrant elements in the medical hierarchy, but the food industry lobby, the educational establishment and most importantly, the population at large.
It was easily as challenging as Bevan’s fight to establish the NHS.
Many of you are too young to remember those bitter times, when private corporations were eating into the NHS seeking easy profits; when it creaked under the pressure, when it seemed doomed. None of you are old enough to remember what it was like for your grandparents before the NHS, when good health care was reserved for the rich.
Historical changes seem sudden, indeed arbitrary. They arrive unexpectedly out of a clear blue sky. But when we look closer we see a more complex picture. A qualitative break with the past is usually preceded by small forays and experiments, ways of thinking which break the surface only to be laughed away, or suppressed, or dismissed as impossible, even mad or dangerous. But they bounce back, refusing to be denied. Then the moment comes for a qualitative leap. The problem is too urgent: the status quo is seen to be inadequate and new ideas take a grip.
“About 40% of the disease burden the NHS faces comes from potentially preventable conditions. And diet has edged ahead of smoking.”
– Simon Stevens, Chief executive, NHS, 2016.
This is what happened to health policy subsequently.
Although the revolutionary changes began around 2020, they had been forcing their way through since at least the start of the millennium. Small signs appeared in surprising places. For instance, the Arts Council started to work with the NHS, in art, dance and drama, with the aim of improving the quality of life experience for those in nursing homes. These people, who had just been parked there, waiting to die, were no longer bored. Crippling ailments were suddenly either forgotten or became manageable.
People had for years been voting with their feet, ignoring orthodox medicine to consult alternative practitioners. By 2020 it was so ubiquitous it could no longer be ignored. The gulf between science and magic had to be tackled. The myriad questions surrounding the word “placebo” complicated the issue. So the NHS invested considerable sums commissioning research, double blind tests at scale. This was remarkable considering the financial constraints at that time. Indeed, the policy was attacked by many medics. No doubt some money was wasted assessing quack techniques, but for the first time like could be compared with like: anecdotal evidence came under scrutiny.
There was one element so powerful that it challenges us still. By comparison, the knitting together of medical practice with social services, with education, with the arts; the shift of emphasis from disease to health, from treatments to prevention, from symptom to the whole person, were all easy compared with meeting the challenges offered by the sheer pace of technological change. The digital revolution, accelerating still, is too dynamic for any institution: no sooner have new systems begun to bed down, they need to be torn up and changed. We still wrestle with this problem. Humans are conservative, with a small c, and we find constant change uncomfortable. The medical professions and indeed the public were, and are, reluctant to change their habits. Permanent revolution is unattractive.
The Health Movement had, of course, been agitating on the sidelines of policy for decades. Many organisations had spoken out. The Soil Association, the Greens, groups of doctors and nutritionists and others had failed to persuade any but a few concerned people. But around 2020 they began to achieve lift off. It had enough energy behind it to carry the movement forward. Students like you are living with those results today as though they were the natural order of things. You take them for granted. I suppose it is a matter of celebration that you look upon the world of just two generations ago as scarcely believable. Like slavery or pregnant women being sent down the coal mines it is all ancient history.
But if this battle had been lost our society would now be in an impossible dilemma.
The bare statistics are inadequate. It demands an imaginative leap, an empathetic effort, to appreciate, let alone understand, the predicament we were in. What is under your nose and has become the norm, is invisible.
A quarter of the population was obese and over a third was overweight. These numbers were increasing year by year, leading to great misery and insupportable pressure on the NHS. People were living longer, but with incapacitating illnesses. Many needed constant ameliorative care. Diabetes, cardio vascular disease, cancers and crippling joint problems were pandemic. This was happening at a time of severe cuts in social services and community care. The pressure on A and E Departments, for instance, threatened to collapse them. The alarm had been sounded by the turn of the century.
The food industry, concerned about the bad publicity, had already begun to cut sugar and bad fats. The government’s stated aim in 2011 was to slash five billion calories from our diets. A combination of threats and pressure forced the food industry, looking to its future, to change. It was haunted by the question: if a brand had been stigmatised as unhealthy, could it ever recover, even if it changed its ingredients?
But the food industry was not the fundamental problem. Although formidable, both in resources and political clout, it could be legislated against and shamed into reform. The problem was the consumer, who the industry had enslaved. Millions were hooked. They couldn’t, or didn’t want to, spend more to eat healthy food. The price was in the present. A deadly disease caused by that low priced product was years away. It was easier to deny any connection. Of course, one could say the same about dental hygiene and dental caries, but most people brush their teeth every day.
How was a shift to health to be achieved?
Easy, processed food was cheap and available. The habit of eating fresh vegetables and fruit had been lost. Exhortations were not going to change their diet.
The forces at work were formidable. Millions were in the grip of lifelong habits that amounted to slow suicide; some were in emotional need, others addicted and unable to change. Nicotine, harmful drugs, and excess alcohol are the enemies of good nutrition and health; large areas had no local shops or markets with healthy food available at affordable prices, if at all; the political system had been colonised by corporate power, much of it multi-national; there were other problems competing for attention, not least an economy still stuck in first gear. Sheer inertia was a drag and drained initiatives of energy.
But the arguments about the NHS would not go away. The fight over privatisation was bloody and unresolved. Demands that people should be forced to take personal responsibility for their own health increased, with the corollary that hitting them in the pocket would concentrate their minds on prevention and deter them from seeking medical intervention for trivial reasons. Though this solution was popular with the more prosperous BUPA sections, the majority continued to want the NHS, the closest institution to a national religion, as some wit remarked.
Costs continued to soar as the nation’s health continued to fail. It was becoming a nightmare for each political party and none could see a way out. People were living longer but in chronic ill health. They needed and demanded health care. Whenever it was cut there was a political price to pay. But it was eating more and more of the nation’s income, at the expense of other needs, even though the NHS was cheaper than other countries’ systems.
Something had to give. For decades all attempts at tinkering had failed. The original ambition of Aneurin Bevan, in 1948, was that the cost of the NHS would go down, not up. He reasoned, and many experts agreed, that when, for the first time, all people had access to medical attention, they would become healthier. With adequate housing, money to put food on the table and full employment, the working poor would need medical attention less. But Bevan, remembering the Thirties and living in post war austerity and rationing, did not, could not, envisage the consumer revolution and the food industry’s willingness to accommodate it. He did not see that soon the country would start to eat itself to death.
But that’s where we were. An aging, sick population was eating the NHS away. Obesity, leading to life threatening diseases, was invading the bodies of younger and younger people. Type 2 diabetes was slowly incapacitating more and more victims. Some cancers were now treatable, but many were increasing. Arthritis was crippling more and more, especially older patients. Depression was incapacitating people of all ages. Dementia was becoming an epidemic. And so on. For all the medical advances offered by technology, and the brilliance of the surgeons, the NHS was overwhelmed. Indeed, the cost of these advances and the increased budget for pharmaceutical drugs were part of the problem.
It took a long time, but when the penny finally dropped, change was breathtakingly fast. I leave you to consider the fact that it was not health that provoked the changes. It was money. The drain on the country’s finances was becoming severe, and increasing every year. The electorate remained adamant in its affection for the NHS. A drastic rethink was needed. Even the conservative Treasury demanded one.
Compulsion was not an option. The arguments revolving around individual liberty and resistance to an oppressive state were properly powerful in Britain. Compulsion was felt to be impractical and unacceptable. It would effectively impose a police state. Not even the consumption of tobacco, a proven killer, had been made an offence, and the arguments about the drug laws continued to rage. Persuasion had not worked and compulsion was unenforceable.
This philosophical debate did not did not swing the decision. It was merely necessary mood music. The decision was taken, and the powerful forces opposed to it were silenced, or at least muffled, out of political necessity: the human and economic cost of failing health had become unbearable.
The analogy would be a nation at war. Drastic, collective measures had to be taken. A deadly enemy had to be defeated. The population, slow to act and dragging its feet in reluctance, finally realised that there truly was “an enemy within”. Reluctantly, but with accelerating urgency once the penny had dropped, people changed, or at least willed the change. The power of habit and addiction, had not changed. But change was willed in a negative way. This provided an opportunity.
The following policies dovetailed together, avoiding the individual freedom question.
First, a group was set up to urgently reinvent the whole curriculum from nursery school, through infant and junior school, with suggestions for secondary education. Its members were medical doctors, nutritionists and educationists. Their brief was to be radical and fundamental and they did not disappoint.
The whole of the school day, absorbing all subjects, would in future revolve around nutrition. The assumption was that children are interested in their stomachs. The resulting curriculum, with some modifications, is what all of you grew up with. It is normal now. But at the time it was revolutionary. Fortunately most teachers embraced it, although there were some initial difficulties persuading Academy schools to come on board.
So, as you remember from your own schooldays, children measured and weighed food, went shopping and did the maths. They cooked, learning some physics and chemistry. They learned where the food came from, why climate affects which foods grow where, how some food originated in one place and became a staple in another, and so on. Geography, biology and history were taught as they satisfied their curiosity about food. Each school had a vegetable and fruit garden tended by the children. They cooked and ate its produce. Each school had access to a playing field; exercise was a daily practice.
They were also offered reasons for good nutrition and told in social studies the long term consequences of absorbing unhealthy habits. These lessons proved particularly useful. Children were shocked to see what could happen to them if they refused to care for themselves, the pain, the restrictions on movement, the early deaths. Once the connections were established, they were sold intellectually on the need for a healthy life. They could see what had happened to many of their own families.
The task was to instil good habits, so that the daily practices became automatic. It was assumed that instilling good habits from an early age would lead them naturally to lead a healthy life. It all would become as natural and as automatic as brushing ones teeth every morning.
Some of these changes were just historical adjustments. There had been cooking in schools for girls since the mid Nineteenth Century and later for boys in some schools. Thatcher stopped it, substituting food technology. But in the new century cooking for boys and girls had been making a comeback. Similarly many schools had gardens by 2015. In the middle of the Twentieth Century most schools had playing fields or at least access to them. Since the 1980s many had been sold off, although that policy had been unpopular. It was expensive to reverse it, but the expense was thought to be necessary.
The Health Movement embedded these changes and made them central to school life. You are used to the Greens and the Soil Association playing a leading role in education. But up until the health revolution they were marginal, at best.
By now the Health Movement is accepted. Your children will experience this curriculum, just as you did. No one questions it any more, except at the margin. The cries of indoctrination and state control are now muted, because they had no traction. It was accepted that we bring up our children within a cultural framework that contains our ideas of morality and health. No one wanted to be accused that their children became chronically sick adults because of neglect. So if the evidence supported the new curriculum, its critics were in difficulty. Thus it was comparatively easy to bed down the schools part of the programme. The challenge was to sustain it through the many years before we could show its worth.
The food industry’s lobby was well resourced and influential. Its rearguard action to defeat the proposals was disguised by expensive PR, although some elements within the industry acknowledged it had to change. It was a similar fight to the one in the previous generation with the tobacco industry and the ongoing one with the carbon industry. The increases in taxation became an issue. Opponents suddenly became friends of the poor, saying they would suffer if taxation went up. But in the end a Finance Bill passed which surprised even the most ardent advocates of change. Perhaps the Treasury had noticed the shift in mood. It was certainly wrestling with the task of financing a bloated NHS. Maybe the extra tax take was too attractive to resist.
To howls of disbelieving anger, the tax on sugar and unhealthy sugar substitutes and on various chemical additives was increased to a punitive level. The food industry lobby had expected a small tax as a token gesture to placate the health lobby. But this level changed the industry. In addition, the Chancellor further increased alcohol and tobacco taxes. In other legislation the punishment for the use of transfats was increased.
Taxation was a blunt instrument, clumsy and imperfect. But the howls of protest showed how effective these measures would be. The food industry predicted economic ruin, as this country moved away from international norms. It quoted treaties on free trade and predicted legal difficulties. The industry’s defence as protectors of poor people, who liked what it produced and were too poor to afford fresh fruit and vegetables, became shriller. It became the defender of the principle of individual freedom, a noble defence amplified by the traditional press.
The response was that we couldn’t stand by and watch people commit suicide. They must be helped to embrace health. The nation could no longer subsidise their bad habits. It was a re-run of the tobacco war.
After these proposals cleared Parliament the fun really started. It was not just a matter of adjustment for the food industry. It involved a rethink from first principles. Much of its profit was tied up in sugar laden fast foods. Now they were expensive compared with healthier alternatives. From agribusiness, through big chemo and pharma, to the manufacturers, to the supermarkets everything had to be rethought. Some businesses were severely reduced. But for many, new possibilities arose and businesses adapted, seeking alternative profit making opportunities. The more nimble thrived. Within five years this shocking revolution, the end of civilisation as we know it, became the boring norm.
The punitive tax on the food industry led in the end to a change in the food industry’s range of products. Business logic prevailed. The industry needed to retain and satisfy its customers. Within two years the supermarkets’ lines changed to healthier alternatives. Co-operative enterprises were encouraged and subsidised if they opened in deprived areas. There were pockets of our cities with no food shops selling any fresh food, no fruit or vegetables or fresh fish. They only stocked lines with a long shelf life, food usually full of chemical preservatives. Within a year people who had no way to travel to an out of town supermarket and who had been dependent on these small shops, were offered a full range of fresh food within walking distance. This was paid for by the extra tax on the food industry’s unhealthy lines.
Soon the nag effect of children started to bite, again like the response to tobacco. They began to demand healthy food at home. Of course the usual traditional unhealthy food was still craved. But this sugar saturated food was now expensive. It was a treat for poor people.
The cynics claimed that health was being bought, that the changes were all about money and profit. But that was an over simplification. True, in a society still dominated by big business, the health movement had to go with the flow. But it was not only based on fiscal panic. There was an ideological change beginning to get a purchase. It owed much to the quiet, consistent determination of the wider Green movement. Remember, the tiny Green Party had suddenly grown into a major party with substantial representation in Parliament. It was underpinned by a general rejection of market fundamentalism, which had dominated all policy for forty years. The long economic depression and austerity, beginning in 2007, had radicalised even the most unpolitical, who were increasingly outraged at inequity and the criminal greed of the City. The rebirth of socialist and communitarian thinking and the rejection of unbridled capitalism underpinned all the Health Movement’s proposals. Without these profound changes in how people envisioned the world, the financial imperatives would not have convinced. Remember, the political system had been colonised by financial capital and big corporations. These forces, through the sheer weight of money, had power: directly over MPs, many of whom were their employees or representatives; through sophisticated lobbying and Public Relations; and through the conservative media. Agribusiness, food manufacturers and supermarkets had collective clout.
But the majority of the people were behind these drastic changes. It was asserted that guilt was the motive, guilt at their own indulgences, obesity and chronic illnesses; guilt in the face of criticism that they were bad parents. Plus confusion at their own inability to change. Whatever the reasons, the politicians woke up to recognise that this unsolvable financial crisis might be solvable in a way painless to them, if it was with the grain of their constituents wishes. Taxation for health was just an extension of laws on tobacco use, after all. Corporations discovered too late that they were being jilted.
Hand in hand with these measures, the consumption of drugs, even heroin, was decriminalised, although trading in them was still an offence. We reverted to the old policy, abolished in the 1970s, of GPs issuing prescriptions to addicts. Public money was saved from the budgets of the police, the judiciary and the prisons.
Addicts were now patients not criminals. Even with the extra burden on doctors and social care staff, there was soon a net gain for the Treasury. It had been recognised that legal chemo highs could be brought to market quicker than they could be criminalised. The task was to reduce the demand. Healthy, well nourished people, are less likely to be drawn to addiction, just as good nutrition reduces mental ill health. The problem was not just what junk was going in, but also what was lacking.
There had been many reorganisations of the NHS and no one working in it looked forward to yet another one, especially one as drastic is this. But the fact everyone had to face was that we did not have a National HEALTH Service. We had a National SICK Service. Reorganisation would not be enough. A new institution was needed.
First, the curriculum of medical schools was reformed, root and branch. The traditional focus was on sickness, on tight specialties and on pharmaceutical drugs. The surgeon was top dog. Now the emphasis was on health, what health was, how to achieve and sustain it. Preventative and functional medicine came to the fore. Students went back to the idea of treating the whole person. The unnecessary use of antibiotics was not only discouraged. It was made illegal. It was argued that this law would be unenforceable, but as with the use of seat belts, patients soon accepted the new convention, and doctors consequently were relieved of pressure to prescribe. Giving medical schools the burden of leading the health revolution was a risk. It would be years before we would see a pay off. But the key to general acceptance of this revolution was in the leading teaching hospitals. Change the attitude there and you change the whole profession.
Medical students were trained to guide people to take charge of their own wellness, right into extreme old age. The distinction was made between chronological age and biological age. Some branches of medicine, who saw the writing on the wall, were firmly opposed, especially some surgeons. Many in cardio-vascular medicine, for instance, challenged the changes. The pharmaceutical industry financed a powerful lobbying campaign to defeat this “new medicine” which it described as unscientific.
There were problems. Some are still unresolved. For instance, personalised lifestyle adjustments based on gene profile analysis faced problems with confidentiality, insurability and the possibility of unexpected and unwelcome information eg paternity. Progress was gradual and participation was voluntary as we made our way through ethical minefields.
There were unexpected gains. Emphasis in schools on learning effective self-management was mocked. But neuroscience had taught us that structural changes occur in the brain in response to states of mind. A variety of meditation techniques became a routine part of the day in schools, with dramatic results. It was inexpensive and successful. The mocking stopped. You think of it as routine and you take into your student and adult lives.
Resources were poured into pre and post natal care and training, beefing up existing policy with more staff. This mirrored a similar reversal in education. Resources were taken from higher education budgets and allocated to infant care and education. We had known for many years how important the first few years are for later development. Now, despite the howls of protest from the Universities, policy reflected that knowledge.
In fact another change of focus had already begun. It fitted perfectly with the ones I am now describing. The big hospital culture was giving way to medicine in the community, medicine that linked with social care and enlarged GP practices. These reforms rode on the back of these changes.
The key was money, as it always is. Where it was available and where it was withdrawn. To adapt Nixon’s inelegant formula, if you get them by their wallets, their hearts and minds will follow. If that seems to you to be crude and inappropriate, you do not understand the viciousness of this fight. Generations of practice by important and self important senior medical figures was being overturned. As Bevan himself discovered when he created the NHS, as a body they are formidable. Instead of stuffing their mouths with gold, in this case the reformers withdrew the gold and redistributed it. Even the most recalcitrant consultants followed, or took early retirement.
So gradually a partnership was formed with the general population, in which the medics encouraged and guided people to preserve their health. In enlarged GP practices patients could have small procedures and the chronically ill would have access to social care and some medication. But the emphasis was on diet, exercise and the correct nutritional supplements. The cost savings on prescription drugs increased each year.
Although the NHS budget rose for a while, after two years it stabilised, and then went down at an increasing rate for two decades. It is now going down slowly. No doubt at some point it will plateau.
This has partly been helped by the advances brought by the digital revolution. Self monitoring of health indicators became easier and more widespread. More and more, even old people, only saw a doctor once a year, for more sophisticated monitoring tests. They self managed their own health.
There were, of course, other factors at work. After years of bad tempered complaint the distorting consequences of PFI were faced. The Treasury, responding sourly to political pressure, took over all debts, although it refused to amortise them. Instead it issued the same debt back to the hospitals, but at much lower interest. In addition, the NHS benefited around this time from a reaction to the cult of “management” that had distorted economies around the world since the 1970s, especially in the USA and the UK. In 1983 the NHS spent 5% of its income on management; the USA spent nearly 27%. By 2015 the UK was spending around 15% and the USA, over 30%. Add to that the burden of extra transaction costs caused by piecemeal privatisation and you have a substantial burden of dead capital. This was heroically reduced parallel with and as a part of the Health Revolution. Many thought it impossible. The managers were like limpets on the structure of the NHS, and the management consultants were feeding royally. But the leaders of the medical professions had endured enough. They took the power back, but this time they also took responsibility.
In addition absenteeism and the number of days off work through sickness has markedly reduced throughout the economy. Employers are now firm advocates of the changes. Mental health, for long the Cinderella of medicine, has improved. The use of psycho-pharmaceuticals has been reduced and ECT has been abolished. Various “talking cures” and the targeted use of nutritional supplements are now common. Increasingly, our prisons had housed two groups: drug offenders and those suffering from mental illness. This tendency had accelerated since the turn of the century. As the health changes began to get a purchase, these groups decreased. Not only did the cost of prisons come down; now, no longer inhumanly overcrowded, the authorities had a chance to do sensible work in education and rehabilitation, on the Scandinavian model.
Meanwhile, in schools, the next generation continued its own revolution. Each child had full bloods taken every year. This caused much debate and some mirth. It was criticised as a waste of resources. The country was renamed The Vampire State. It was certainly expensive. But the results offered, if not a map of health, certainly many clues to what deficiencies might be threatening future ill health. Each child was then prescribed different or additional nutritional supplements to the regular supplements given as a matter of routine. They were especially important in the early years, partly to combat deficiency but also to supplement the diets of those in impoverished areas until healthy food became available. For some children, the food they cooked collectively at school and their regular supplements constituted the only diet: what they ate at home was useless or doing them harm. After these early years, it all settled down. It is no longer remarkable.
Before 2020, the years of WW2 were the only years in our history when everyone was adequately nourished. Pre 1939, many of the poor could not afford to feed their children or themselves. Diets were impoverished. Increasingly after the war, people were tempted by a sugar diet, seduced by junk food and they lost the craft of cooking wholesome meals. During the war there was no junk food, but the rationing made sure that everyone had the basics. All over the country people were “digging for victory” in gardens and allotments, growing vegetables and tending chickens.
In the last generation, we woke up to health as a positive goal, as everyone’s birthright. Science supplementing common, traditional good sense, has prevailed.
I’m not usually pleased when faced with a group of students who are insouciant, but today I’m pleased that you take these changes for granted. I’m glad that you can look forward to a healthy and active old age.
And I’m glad that we now, at last, have a National HEALTH service.
You should thank those who drove these changes through, knowing it would be difficult and knowing they would not personally benefit.
It is your task now to accept, not deny, the force of change which technology will continue to impose, to use it for the common good and to reconcile it with institutional arrangements that take full advantage of it.
Health is better than sickness; prevention is better than cure; traditional wisdom married to advancing technology is our passport to health.
© Tony Garnett Jan 2016