In 30 years the Cost of Medicine will Fall

Today the NHS celebrates its 70th birthday. It is a wonderful, special and remarkable institution, but according to many working in the NHS, as well as external observers, it is in a perilous state. The problem is money. The government has agreed to increase its funding but there is never enough.

The general wisdom is that this is how it will always be. You have heard the argument. We are living longer and require more medical intervention and the increasing hi-tech interventions are much more expensive.

But is that right?

It is probably right over 20 to 30 years but beyond that, the technology may actually reduce the costs as we have seen developments that may buck the high costs trend.

For example, surgical techniques are changing. Have you heard of nano-surgery? These are tiny scalpels which could be injected into the body and then manipulated into position by the huge magnets of CT scanners. In position, they can remove whatever needs removing. If it sounds a little like science fiction, then I must tell you that it is here now.

In 2015 Kings Hospital in London announced it was using NanoKnives for the treatment of liver and pancreatic tumours. The needles are moved into position and then a large electric current is passed between them to kill a tumour. It requires less time in hospital, is far less invasive and overall cheaper.

And, on the topic of robots increasingly they are being used by surgeons who sit in the side of the operating theatre looking at a screen as if they are indolently playing a computer game. It won’t be long before they aren’t even in the same country.

But the biggest saver will be the use of big data linked with Artificial Intelligence (AI). The last time you might have heard of big data was with the Cambridge Analytica debacle a few months ago. Put all that to one side. This is a good use of the technology.

Let’s start with the diagnosis. There are many news stories about the diagnostic use of AI, such as the one below. This just happens to be the latest from the BBC website.

In the last week, it was reported that an artificial intelligence system recorded a 2-0 victory against elite physicians in two rounds of a competition in Beijing to diagnose brain tumours and predict the expansion of brain hematomas, or bruises.

BioMind, developed by researchers from the AI Research Centre for Neurological Disorders and Capital Medical University, made correct diagnoses in 87% of 225 cases in about 15 minutes. A team of 15 doctors from top hospitals across China achieved 66% accuracy in 30 minutes. The AI system also made correct predictions in 83% of brain hematoma expansion cases, outperforming the physicians, who had only 63% accuracy.

In the UK an AI system recently passed its doctor’s exams scoring a very good result at 87%

That’s the AI bit now add big data. Soon we will all wear devices which measure a range of vital functions. Think of a better and more comprehensive Fitbit. It may even be implanted soon after birth. This device will continually send our medical performance to a large database and AI machine. The state of the system we call our bodies will be monitored real-time, just like a mechanical system.

Aircraft engines are continually monitored so that they can be repaired before catastrophic failure. And, just like the engine soon, our physical state will also be measured constantly. When something untoward is seen the AI system will step in and tell us to see a physician. If we do need surgery it will be easier, not least because we have found the problem earlier.

And, if there is major system failure there are significant developments in personalised medication based on our genome which are more effective than generics. Failing that soon we will be saving cells as we are born so that we can grow new organs later in life. No more waiting for a donor for a deteriorating organ.

Doctors are always telling us that prevention is the best cure and that is exactly where we are heading. The focus of medicine will, at best, be prevention or at worst, early detection. We will never prevent all illnesses, but hospital visits will become more focused and the pressure on the NHS reduced.

I love the NHS and happy 70th birthday. Your future may be very different to all that the naysayers would have you believe.

Solve Your Problems at Source

Early in my career, I remember sitting in my London office when I received a call from a client in the north of England. There had been a complaint from a female member of the client against one of my consultants. This was well before #MeToo but the complaint was similar. My consultant had been just a little too forward and upset her.

Although we were over 200 miles away with different plans for the afternoon my business partner and I did exactly what we thought was right. We were in a car and driving north within 30 minutes. It was a long drive, we had nowhere to stay, but the problem had to be addressed.

By the time we arrived on site, the problem had almost gone. The consultant had apologised, and it had been accepted. The client had forgiven the incident which was not as serious as it had first seemed.

We logged into a hotel and in the evening over dinner reminded the full team of their responsibilities and the standards of behaviour that were expected of them. The next morning, unshaven and in the same clothes, we went to our client, again apologised and explained what we had done the previous evening.

A potentially significant problem had been diffused and we returned to London.

It was about two weeks later when we received the letter that asked us to bid for new work and extend the existing work. We won that work as well.

Speaking to the client he said that we had been chosen not just for the quality of our project but the speed and focus of the way we had addressed the problem.

It was a salutary lesson. Everyone makes mistakes and to deny otherwise is stupid. What is important is how you address and resolve problems and issues.

I thought about this as I read the awful story that over 450 older patients at the Gosport War Memorial Hospital in England whose lives had been shortened by excessive prescriptions of Morphine and Diamorphine. An inquiry found doctors at the hospital gave patients dangerous amounts of these powerful painkillers. Despite a long report, there will be more information as a criminal investigation is now underway.

After the sadness of the early loss of so many lives what is as depressing was that there were warnings from nurses and many others over a 20-year period. The families of the deceased had been complaining and making noises and regulators, health commissioners and even the police had been looking but doing nothing.

We can never condone the doctors at the heart of this tragedy. We must though reflect how these supervisors of our safety have conducted themselves. The quality of a system or institution is measured by how it responds when things go wrong.

Not only must the perpetrators been brought to account but so must the system and those in the system who failed to respond. The whole structure of the NHS has been found at fault.

Guns, Butter or the NHS?

I started my study of economics at university.  ‘Guns or Butter’ were almost the first words I heard in my first Macroeconomics lecture. It was used to represent the production possibility frontier and I couldn’t understand the fuss. An economy could make nothing but guns, nothing but butter or a combination of the two. All those combinations were the limit of the country’s productive capability and that was productive frontier.

I understood the principles and had thousands of unvoiced questions.  This was nothing like the real world, but they were the professors and I was on my first day. Never mind. I listened, learnt some simple formula (after all I was doing mathematical economics and never had to write an essay) and picked up 15 marks in the exams. That was my purpose of sitting there. Do enough to get a good degree, play rugby, date, and not rock the boat.

Now here I am replaying the questions dismissed forty years ago, but now it’s a choice between a whole host of things and the NHS.

For my non-UK readers, the National Health Service or NHS celebrates its 70th birthday on the 5th July this year. The NHS was born out of the idea that good healthcare should be available to all, regardless of wealth. At its launch by Bevan at its heart it had three principles, that are it:

  • meets the needs of everyone
  • is free at the point of delivery, and
  • is based on clinical need, not ability to pay.

It is a British institution and while many Governments have tried to tinker with it, at its core it is untouchable, and rightly so.

I have written often about the NHS. I think it is wonderful and I love it.

I have experienced the alternative. I was in Dubai for nearly 5 years, where there is no health care, when I became ill. I couldn’t afford to do anything about it. It led to a hurried and permanent return to the UK to get treatment. In Dubai, before you can see a doctor you have to give a credit card number and there is a preauthorisation. That is not unique to Dubai. It is the norm throughout the world.

Since I returned, the NHS has taken me into their bosom and looked after me wonderfully. Whatever anyone else may say doctors, nurses and all the ancillary services are still caring and committed to care. I have met wonderful people. Ann, an international triathlete in the CT unit, Paula a diabetic nurse, Nikki my dietician, are among the many I now greet and meet almost as friends when I walk around the hospital.

(On another day I may look at the possible impact of Brexit on the NHS. There are so many Europeans supporting it I am unsure how long it would last if they all went home.)

The National Health Service is free at the point of service and is funded totally through taxation and does not discriminate against anyone, but it is under tremendous pressure. It needs more funding.

But let’s be honest it is not the NHS that is at fault it is our expectations. It is not because the NHS is wasteful, but medicine is becoming increasingly expensive, medicine is getting better at keeping us all alive and well. The demand is increasing and the cost of delivering treatment more expensive.

If we want the three principles fully implemented, with no rationing, no waiting lists, all the drugs possible then we have a problem. To meet fully all our varying needs the NHS could absorb all our GDP and for the first time the question of Guns or Butter has a reality. It could be one or the other.

Let’s get some data as I always like numbers but with recent NHS spending increases, up to date data is hard to find. But is we go back a couple of years the UK spends under 10% of GDP on health care while Switzerland, France, Germany, Sweden, among many others spend much more (up to 11.5%). The message is clear. We have prioritised health lower on our priorities than most of Europe.

Boris Johnson, our eccentric Foreign Secretary recently suggested that we add a further £5 billion to the NHS budget. As GDP isn’t growing something must give way if we want to fund health provision.

For reasons I don’t want to go into now, when I left Dubai, my life was in two suitcases. That was it. Two suitcases. The rest I gave away or sold for next to nothing. I know personally about budgeting and cutting the cloth appropriately. At first it was heart breaking. It was an insult to my ego but after a time it became liberating. To have nothing, to own nothing (other than my computer and 18-year-old SLK) releases a lot of angst.

If you have to cut close to the bone what goes are all the vanity spends that we keep, sustaining our image. The real essentials are a few photographs and memories.

I am not suggesting that the UK needs to cut so far back but with GDP capped and growing between 1.5% and 2.5% we need to make some decisions around our national ego, what we support and what we finance.

Let me start the discussion and ask this question. Do we still need to spend so much on defence?

The other major responsibility after health is defence. The UK spends approximately 7% of GDP on defence, or approximately 70% of what we spend on health.

The relatively high share of GDP on defence reflects the UK’s world military role. We have been in Iraq and Afghanistan in numbers far greater than almost anyone else than the USA. It is that ‘world military role’ that I want to consider.

The UK has a nuclear deterrent, the Trident programme and I will say from the start that I have been in favour of the programme since its inception. I have wanted each parliament to vote for it, as they have done.

The world military role ‘led to the acquisition of a nuclear deterrent (Trident), nuclear-powered submarines, Type 45 destroyer warships, aircraft carriers, F-35 carrier-based aircraft together with strategic air tankers, Typhoon jets, heavy lift and attack helicopters and an army with an expeditionary role (

Trident represents, at its most expensive, the British role in trying to keep the world safe. It is a deterrent that with the USA will stop the nuclear war against the Russians or North Korea. That is the dialogue, but is it still true?

There must be some truth in in deterrence. If I have a visible burglar alarm the probability is that it is the unalarmed house next door that gets burgled. If I carry a big gun, then no one messes with me.

We assume that we will not launch a first strike and so we are saying that we will only retaliate. The trade-off is Moscow for London or St Petersburg for Leeds. I know that I would rather be at the centre of the attack than inflict the same on another 10 million people and who would want to survive a world covered in clouds of atomic dust.

Honestly, I don’t care about an argument on deterrence. We can’t change the policies of America or Russia so let them have their stand off but do the British need to maintain a world role?

We are where we are because of our history. We conquered and ruled the world through military prowess. We stood alone and proud against the Nazi push across Europe and whether through guilt at our history or pride at WW2 we feel a responsibility to have a global role. Trident is symbolic and keeps the Great in Great Britain.

But there is a cost.

The nuclear deterrent system is composed of three parts: nuclear warheads which are mounted on Trident II D5 ballistic missiles which are launched from Vanguard-class nuclear powered submarines. Trident will cost around £100 billion, at 2012 prices, over the next 35 years.

Once I owned a very large house, two cars, land, a comfortable and privileged life style, and now, I have none of those. They may all have gone but I hope I am no less respected. I am not judged by those I respect on my possessions but my thoughts, words, and actions.

The UK could do the same. We don’t gain our global respect because there are four submarines cruising deep under the oceans with nuclear missiles always ready and pointing at Moscow. We gain respect because we have a compassionate and caring society that looks after its sick and unwell.

I don’t know. I am only asking the question. What is it? Guns or the NHS?

If you have a comment, then please send me an email at and I will reflect them in a later blog.

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Many thanks