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The NHS of the future: prevention or cure?

Janet Thompson
RGN ONC BSc(Hons) MSc PGCE
Independent Medical Writer

Linda Kenward
RGN BSc(Hons) BA(Hons) MSc PGCert
Lecturer in Nursing
Mentorship and Academic Practice
Open University

The NHS has radically evolved from being a safety net based on health needs, regardless of the patient's ability to pay, to a service based on rights, wants and personal choice. However, with an infinite demand for healthcare provision but a finite amount of resources, has the safety net been stretched too far?

The original philosophy of the publically funded NHS, envisaged by Bevan in 1948, was to provide a basic safety net for all, irrespective of income or class.1 Since this time, public demand and rising expectations, combined with medical, genetic and technological advances, pharmaceutical developments and skills acquisitions have stretched the basic safety net beyond its original aim.

The scientific medical model recognises the expertise of health professionals and reinforces the belief that medical treatments restore health.1 The media perpetuate this view, as demonstrated by the high adrenaline health dramas they depict and the dramatic health headlines that capture the nation's attention. However, this model has been criticised for medicalising normal processes, such as pregnancy, and exaggerating its role in health gains (improvement in sanitation, diet and social advances account for the majority of health gains).2 This model was sidelined by the introduction of a more holistic approach to care in the 1980s. This approach sought to enable the patient to be an active partner and participant in their care, but in more recent times it seems to
be gaining renewed authority.

Health improvement is the latest in a series of different strategies being employed that places emphasis on anticipatory care and self-care promotion with a shift away from hospital services to community-based care provision. Prevention of illness aims to save medical costs, but there has been very little evidence to support this supposition. On the contrary, in the long term, costs are increasing as new diseases emerge and old ones, such as tuberculosis, return.

The world's population is globalising (increase in flow of people, goods and services across borders) and swelling at a startling rate, and people are living longer with an associated increase in long-term conditions such as dementia and diabetes. Alongside the healthcare costs, there are associated unsustainable claims on pensions and personal care provision.3

The current English government's response to these issues has
been to reduce the costs incurred by the state and increase personal responsibility. Self-care seemed to be an empowering and enabling feature when first proposed. However, latterly it seems to have become a financially driven imperative that has nothing to do with empowering individuals, but a return to the top-down medical model where people are “encouraged” to look after themselves as the state system is no longer up to the task.

Whether personal choice should drive NHS services or whether the NHS should be more prescriptive about what it is offering has stimulated a lively and controversial debate for nursing staff. Some of the topical issues are discussed below.

Drug addiction
Britain has the worst drug addiction rate in Europe.4 Babies born to drug addicts can end up having to be put into care, resulting in huge financial and social costs. It has been suggested that drug addicts should be offered financial incentives to receive long-term birth control or be sterilised (as they do in the USA).5 Nurses experience anguish when torn between professional duty and ethical dilemmas when they try to balance the patient's rights and responsibilities with those of a baby.

The Human Rights Act, however, prohibits governments from making this kind of decision for people as it is seen as a form of social engineering. If allowed, the possibilities could become endless: proposing the same thing for people who are disabled, homeless, on benefits or even stating that, unless parents can afford children they should not have them!

Alcohol abuse
Illness and injury caused by excessive drinking account for more than 3% of the entire health service budget (£3bn a year).6 The burden of misuse impacts upon all parts of the health service with those who drink excessively using primary care services more then other patients.7 Maybe it is time that those who require hospital treatment due to alcohol-related injuries were charged for their care.

The problem with charging patients who drink to excess is problematic. It could be argued that those who smoke, self-harm or are obese should also be charged for their care. Individuals make unhealthy choices for a variety of reasons. It is assumed that everyone is in the position to make healthy choices, but this is a dangerous and incorrect assumption.

Successive government policies have constantly shifted the balance between personal responsibility and blame. The nurse's role is to act as the patient's advocate, empowering and supporting them, to enable the patient to take responsibility and make the right choices easily. To do otherwise would be disempowering, victim blaming and promoting guilt.

All patients should be treated with dignity and humanity, regardless of the choices they make. Much of this debate centres around wrong choices and punitive measures implemented to ensure that individuals are “nudged” into making the right choices.

Fertility
With a finite amount of NHS funding, it has been argued that those who want reversal of sterilisation should not be given the operation freely. Patients make an informed choice; therefore, they should have to pay the costs if they change their minds at a later date.

The problem is that informed decisions are based on current information and an appraisal of the current situation. There is an assumption that life will not hold any nasty surprises. Naturally, for some this is not the case and they may find themselves embarking on new relationships or dealing with the death of a child. Not all health boards or authorities will pay for reversals. Many individuals do fund treatments when situations change, but reversals are not necessarily successful and individuals have to live with the consequences of their past decisions and the associated mental trauma.

Fertility treatments are a luxury that the NHS cannot afford and are sometimes not thought through. A recent case in question was when a childless couple with a history of mental illness was given free fertility treatment, only to have the baby taken from them when they were unable to look after it.8 This case demonstrated that the emphasis is on rights rather then responsibilities.  

Nurses appreciate that patients with mental health issues are no different from those with physical problems. Many patients with mental health issues are able to be capable and caring parents. The problem is that when wrong decisions are made, they are costly in terms of physical, psychological, emotional and social problems for all involved, including nursing staff.

Financial incentives
Financial incentives are being used to nudge people into giving up poor health choices such as smoking, taking drugs and overeating. There is no evidence to demonstrate that these strategies work and many are convinced that they only serve to reward bad behaviour.9

Doing nothing to help or motivate smokers and those who are overweight to change their unhealthy lifestyles will cost the health service more money, as a consequence of the health related illnesses, such as cancers and chronic obstructive pulmonary disease (COPD), which require treatment.

Recognising and rewarding positive behaviour changes enables people to experience the health benefits which, it is hoped will reinforce and motivate the maintenance of positive behavioural changes.

Nurses as role models
Many nurses are overweight and are, therefore, poor role models. Positive behavioural change should start with them. Maybe nudging them to lose weight, dismissing those who fail to lose weight or possible not employing overweight nurses in
the first place.

Conversely, some would argue that they do not want to be confronted by slim nurses who do not empathise or understand obesity problems. Patients may view slim nurses as moralistic and judgemental, and avoid services as they feel guilty and perceive that the services are not meeting their needs.

Conclusion
These are some of the controversial concepts currently taking place. Depending on the extent to which you believe health (drug taking, obesity, smoking and drinking) to be a personal responsibility and the wider determinants of health (social, economic and environmental factors) to restrict and limit a person's choices will affect your personal response to these issues and how you respond to the patients in your care. 
Although health improvement is the current political rhetoric, alongside a more person-centred and enabling approach, evidence demonstrates that the scientific medical model is being highly promoted and is reinforced within the political agenda of Westminster; demonstrated by frequent references to taking personal responsibility, “Nudge
wherever possible and nanny only where necessary”.10

This serves to deflect from the recognition that more holistic approaches seem to have met with limited success, thus saving the government embarrassment by shifting blame for poor health onto the public. Perhaps practitioner power - commissioners of services and gate keepers of care alongside the promotion of the internal market place and nudge tactics will succeed to protect the overstretched safety net of the
health service!

References

  1. Baggot R. The historical context of public health. Palgrave Macmillan: London; 2000.
  2. Mckeown T. The role of medicine: dream, mirage, or nemesis. The Nuffield Provincial Hospitals Trust/Blackwell: Oxford; 1976:158-160, 178-180
  3. United Nations Population Division. World Population Prospects: The 2008 Revision Population Database. Available from: http://esa.un.org/unpp/index.asp
  4. Britain has the worst drug addiction rates in Europe. Available from: www.telegraph.co.uk/news/uknews/1549028/Britain-has-worst-drug-addiction...
  5. Drug addicts, sterilisation for cash. Barbara Harris - save our babies. Available from: www.telegraph.co.uk/health/8071664/Drug-addict-sterilised-for-cash-but-c...
  6. Taking a stand. interview by Fergal Keane (sterilising drug users). Available from: www.bbc.co.uk/programmes/b00qhmfm
  7. Cost of alcohol consumption to the NHS every year. Available from: www.telegraph.co.uk/health/healthnews/5561217/3bn-cost-of-alcohol-to-NHS...
  8. University of Birmingham School of Psychology. The Birmingham untreated heavy drinkers project: report on wave 1. Birmingham: University of Birmingham Press; 1998.
  9. Outrage at fertility treatment for vulnerable couples. Available from: www.cphpost.dk/news/.../49008-outrage-at-fertility-treatment-for-vulnera...
  10. Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ 2009;
  11.  National Institute for Health and Clinical Excellence (NICE). Should incentives be used to encourage healthy living? London: NICE;
  12. Can we nudge to good health? Available from: www.bbc.co.uk/news/health-11874158
  13. Practitioner power or poison chalice. Available from: www.imt.ie/opinion/2010/11/practitioner-power-or-poison-chalice.html