Modern expectations of medicine

When I became a doctor in 1981, we spent about £11 billion a year on the NHS, equivalent in today’s money to about £800 per person. In 2025/26 the total NHS spend is about £209 billion, estimated at £3550 per person. This isn’t because we’re keener than others on spending money on doctors and nurses: health expenditure in the US has increased from about $5000 (£3700) in today’s money to about $15500 (£11470) per person per year over the same period. So, there’s no doubt we’re getting more medicine, but is it better medicine?

You get what you pay for

In most things in life, you get what you pay for. If in the UK we’re now spending roughly four times as much as we did in 1981, are we getting better health care now than we did then? If in the US they’re spending over three times as much as in the UK, are they getting better health care? The top selling new car in the UK in 2026 is the Ford Puma, which costs just over £20k. For £60+k various Mercedes, BMWs and other luxury brands are available. Are those in the land of Trump sitting in posher medical motors than we are, accelerating away from the traffic lights quicker than us and scarcely noticing the bumps in the road?

Expectations of life

These have changed enormously. My grandparents, who were in their 60’s when I went to medical school, expected life to be tough. Why? Because it was tough. The only time my dad’s father ever got cross with me was when we’d been out with his dog, Jock, to catch rabbits (unsuccessfully). On the way home we met several of his friends and each time he stopped to talk. None of them could walk normally or breathe normally. I was not happy with the lack of rabbit and the delays. ‘Why can’t anyone in this village walk or breathe normally?’, I said. All had been miners: their lungs were wrecked from coal dust and fags, and their limbs broken in accidents in the pit or pit yard, treated with rudimentary splints.

These expectations fed into expectations about medical care. As a houseman I was asked to speak to the family of a man I’d sent off to ICU because he was too ill to manage on the ward. Of the many things I thought they might ask, I wasn’t expecting, ‘you do know he’s 62, don’t you?’ They were surprised we thought it worth doing much ‘at that age’. He left hospital under his own steam about a week later.

Things have changed. Within the last week I’ve had two conversations with the family of a man in his 80’s with diabetes, a bad heart and bad kidneys, who’s been admitted to hospital for the third time in six months with a chest infection and is getting weaker day by day. They can’t accept that the end is nigh.

The good

Some expensive medicine is definitely worth paying for.

I don’t think there’s any branch of medicine where there haven’t been substantial improvements in the last 45 years. If you had trouble with gall stones in 1981, removing your gall bladder required a 15-20 cm incision and 7-10 days in hospital; now it can usually be done as a day case with instruments that look like knitting needles leaving a few marks less than a centimeter long. If you had a heart attack you had morphine for the pain, were kept in bed and perhaps were given drugs - which provided very little if any benefit - to try to keep the heart rhythm steady; treatments to open up blockages in the coronary arteries were not yet on the menu. If you developed rheumatoid arthritis, you were given high doses of anti-inflammatories and ‘disease modifying’ drugs of limited effectiveness, both with significant toxicities. As a small boy I remember thinking my grandmother’s hands looked as though someone had beaten them with a hammer. Such deformities aren’t seen any more with use of biologic drugs. Speaking of which, these have revolutionized the care of many cancers.

The bad

It’s possible to spend a lot of money on medicine without getting any real benefit. With many billions of dollars at stake, it’s no surprise that drug companies are brilliant at showing their products work. Sometimes (as above) they really do, but a good advertising campaign can create a need if not. The advertising budget is generally inversely proportional to the benefit.

The Commonwealth Fund is an American organization founded by Anna Harkness in 1918. Its mission today is to promote high-performing, equitable health care systems by supporting independent research. What does it say about the US system? A portrait it painted in 2024 is not a pretty picture. The key findings are summarized as follows: ‘The top three countries are Australia, the Netherlands, and the United Kingdom, although differences in overall performance between most countries are relatively small. The only clear outlier is the U.S., where health system performance is dramatically lower.’

Spending a lot of money clearly doesn’t guarantee success, but before anyone in the UK gets too triumphant, we ranked 8 out of 10 on health outcomes.

The ugly

Ugliness can take many forms.

The dying of my patient with a chest infection is uglier than it could be. The inevitable has been obvious for many months. As I say to my trainees, ‘the destination is known and can’t be changed, our job is to plan the route as best we can’. It’s not yet been possible to negotiate an entirely palliative approach, so we’ve (with some difficulty) agreed limits to escalation and wait. More medicine has caused more misery, and – because we’ve been talking about costs – incurred more expense. A lose-lose situation.

Last Tuesday, in my outpatient clinic, I saw a man in his late 70’s referred because his kidney function was gradually getting worse, but at a rate where the guidelines for GPs say, ‘referral is recommended’. His daughter brought him in his wheelchair (he couldn’t walk following a stroke) and did most of the talking (because of his dementia). The main difficulty, she explained, was getting him to take all his tablets (12 regular medications), which she said were causing side effects. I thought his kidneys were working better than pretty well every other part of him and no further kidney tests were needed, also that it would be best for him only to take tablets to prevent or control symptoms. Many daughters are horrified by such advice, but thankfully I’d judged her right and she wasn’t. Polypharmacy in the elderly is often a loss for the patient, although a win for the drug companies and those who judge the quality of medical care by boxes ticked.