Discworld author criticises NHS priorities

Monday, August 18th, 2008

Discworld author Terry Pratchett has criticised a decision to limit the drug Aricept through the NHS to people in the later stages of Alzheimer’s disease, saying that the decision not to give it to early stage sufferers, but to provide free treatment for obesity and sexual impotence, indicates the NHS “priorities are not right”. He thinks this is in part due to the disease affecting old people who are “softer targets”.

His words will strike a chord for many who are ill. It does seem odd to a lot of people that obesity, in the majority of cases down to people eating too much and exercising too little, results not in psychological counselling being offered on the NHS but pills that make it difficult for the body to absorb fat from food, and even stomach staples. Certainly the presentation of obesity as illness—even resulting from a genetic predisposition—is claimed by those highly critical of the approach to provide some with an excuse for eating more than their bodies need, or a reason to rush to the doctor for a quick-fix solution that doesn’t address the workings of the mind that dictate to them that they should hide away and eat ten chocolate bars one after the other.

Whether they’re being fair or not doesn’t matter to the people expressing such views. Feelings are rarely considered other than one’s own.

Impotency in many cases is psychological in origin as well, and only sometimes due to physical issues. It can be a symptom of other serious illnesses going on elsewhere in the body, including the mind. But now there are pills to bypass any investigation into actual causes.

The NHS has long had pills that allow the need to identify causes to be set aside. It dispenses anti-depressants to millions of people each year, yet the overwhelming majority of those suffering mental health problems would benefit from changes in circumstances—a new job, for example, or help with debt management, or making new friends, or taking up a hobby—even spending more time outdoors instead of parked in front of the telly. People invariably choose to take up smoking, albeit usually resulting from peer pressure, and yet many millions are spent on persuading smokers to quit, turning them into social pariahs, giving them nicotine replacement patches and gums, and providing them with organised self-help groups. Yet many smokers give up by… simply giving up, and going through withdrawal.

None of the above observations are meant to take away from the devastating impact obesity, impotence, smoking, and mental distress have on people. There are many millions who undoubtedly benefit in the short- and long-term from being prescribed drugs. But it’s so much easier, as I’ve tried to demonstrate above, to be critical of people getting help who aren’t actually dying—at least, not yet—and whose situations are perceived, in the large part, to be self-inflicted. Whether that’s true or not doesn’t make people pause, however, before issuing blanket condemnations.

The drugs are often meant to be temporary, helping people through the early stages of quitting smoking or providing them with some weight loss to show them why eating less is better for their health. I for one don’t actually think that the solution is to stop funding anti-obesity, anti-smoking, or mental health initiatives and medical treatments. There are sound reasons for the NHS doing what it does. But there are times when certain treatments aren’t appropriate, when counselling would be a better start to changing lifestyles. Where Alzheimer’s disease is concerned, or cancer, or HIV, or any number of debilitating and progressive diseases, the only real option is to provide the best medicines currently available. Telling sufferers the drugs aren’t ‘cost-effective’ is always going to be a slap in the face. It’s cold marketing-speak, but the NHS is an organisation, not a living, breathing, sometimes sympathetic human being. A certain dispassionate coldness is necessary. Decisions have to be made.

What we need are better judgements by doctors, a huge expansion in counselling services, and more money for the NHS. It always needs more money, of course, and so difficult decisions have to be made. Pratchett’s criticism serves to show us that a debate needs to go on in public about the priorities of the NHS, not behind closed doors by an elite group of medical professionals, and not conducted by politicians keen to secure attention-grabbing headlines and find new ways to cut taxes or reorganise just for the hell of it.

The NHS in recent years has become preoccupied with prevention rather than cure, leaving those who need cures—or at least, palliative treatments—feeling they’ve gone past the point of no return, as far as the NHS is concerned. And that’s wrong. Prevention is better than cure, there’s no doubt. But why can’t we have a focus on stopping people getting ill in the first place and helping those who have become ill? In part, people don’t want to pay more taxes—but when they develop an illness, and find they can’t get the best treatment under the NHS, they change their views quickly.

And that’s the sad dilemma. When people don’t need the NHS, they don’t place anywhere near the same value on it as those who do. And as the majority of the population at any one time is healthy, it will remain the case that most people pressing for the NHS to get more money will be disregarded.

Pratchett has given a million dollars to research into Alzheimer’s disease, and that’s fantastic—but it’s understandable that he had nothing to say about it, and no money to contribute to finding a cure, until he developed the disease himself. That’s not to criticise him, what he’s done is great, but it is to simply point out a stark fact of what it means to be human. We don’t tend to concern ourselves with things outside our experience. It’s our shared blind-spot, and the reason why global warming, an extinction-level crisis, is ignored or prevaricated over—it’s the ‘global’ in global warming that makes it impossible for many to get to grips with the issues. We aren’t global creatures. We are parochial and small-minded by design.

Unfortunately, this is why people living with degenerative conditions invariably feel uncharitable towards fat people, smokers, and those suffering from impotence, mild forms of depression and mental illness. You can’t blame them. But neither can you blame all those other people, either, for the NHS deciding it’s more important to spend money on prevention than it is on treatments and cures. And we can’t entirely blame the workings of the NHS, either, for it relies upon finite resources. The money is worth less with each passing year unless more is injected into the system, and the NHS can easily swallow up any amount of cash injected into it. And let’s not forget that the NHS has to operate on three levels: prevention, treatment, and research. How the money is shared out between these three is the contentious topic under constant debate.

But the NHS is undoubtedly in the 21st Century conducting a huge experiment directed by politicians in the main. It presents the goal of maintaining health as more important than working to restore it in those cases where it has been lost to illness. Whether it manages to reduce smoking and obesity, and improve the nation’s mental health, remains to be seen. What is known is that as time goes by many more people in pain, and dying, are finding the drugs that could improve their lives denied to them on the basis of cost. And that’s never going to be news that’s well-received by anyone, is it?

categories: healthy planet, in the news