No doubt this essay will raise hackles but I have often said that I am prepared to say things that other folk do not dare to think. I have been appalled in the last two years at how the hospital side of the NHS (I cannot speak for the primary care side of the fence except in generalities) has become obsessed with money. In financial terms money is supposed to follow the patient, but in reality the patients will get whatever the money can buy (or, in hard times, cannot buy). A large number of my colleagues have become infected with the virulent plague that turns them from caring for people into ruthless money-saving machines, and so interfere with all sorts of clinical necessities, like seeing follow-up patients, prescribing drugs and treating patients as people and not as diseases. I understand the temptation; I have nearly fallen for it myself, when trying to wear a management hat. But let us then pursue this approach in a logical and complete way, and see where we end up.
Much money is expended on very old, very sick and very demented people who get acute illnesses and end up in hospital beds being made “better”. If one asks “For what purpose?” there is no good answer; often these poor husks of people will be sent back to the care home they were admitted from (or transferred to one because the home situation is unsupportable). There has developed what perhaps is an unhealthy obsession with making sure that anything treatable is treated. Thus an 89 year old with a urinary tract infection who does not really want to go on living, confused and in renal failure, is given large doses of gentamicin as the infecting organism is only sensitive to that, and ends up with worse renal failure and possibly deafness to boot. Even if the doctors have agreed that all is hopeless the patient is then left to die by natural decay, which may take days or longer. Pain relief is kept to a minimum because great care is taken not to do anything that might actually cause death. So patient, relatives and staff all hover, waiting. It is a most unpleasant business (I know; this happened to my mother). Inevitable unconsciousness develops and still they linger on.
How much kinder it would be in this situation to do something positive to advance the inevitable outcome. And this is what we should do to save bed days, care costs and so on. It is actually the best answer to saving money in the NHS (except, perhaps, for giving chemotherapy at £60,000 a pop to prolong life by two or three months). But we cannot; Harold Shipman perhaps must carry some of the blame. My mother’s death was slower than I would have liked; her actual death was in the middle of the night, so we were not there, and I would have preferred it if we had been. Planning the time of death would have saved much distress and sadness. But at least it was quiet and painfree, unlike that of the mother of one of my colleagues left screaming in pain during her last days (I might add in her own hospital) for whom the excuse was that the syringe driver medication had been written up – except that it had not actually been given).
We should not prolong the horrible existence of many folk, in my view, but certainly once death is clearly inevitable then we should certainly not prolong its process.
In March 2013 an article in “The Times” suggested that 30,000 lives a year might be saved by screening the middle-aged for killer conditions (heart disease, obesity etc). My reply was published.
The prevention of 30,000 deaths a year will not be achieved by screening the middle-aged; that is far too late. The problems of obesity and smoking (and their attendant diseases – in particular heart problems and diabetes – are set in childhood behaviours and lifestyles, and the way forward is to screen, and educate, young people.
Anyway we wouldn’t be saving lives, but postponing deaths. “Saving” lives is of no benefit if they are sick lives; people with major health needs, in surviving longer, will cost the NHS more.
 The Times, 6th March 2013