In his message to mark the 60th year of the NHS, Gordon Brown resolves that we will all live healthier lives, stop smoking, drink less, exercise more. As a reward, the health service will still treat us should our personal regime inexplicably fail and we fall sick. This generous offer is to be made in a patient's contract spelling out “the rights and responsibilities associated with entitlement to NHS care”.
Some protest that this could mean smokers or the obese being denied healthcare. But such “ethical rationing” is already happening. Mr Brown's plans for a more “personal and preventative service” involve a bigger risk to us all. They mark the next step in an unhealthy trend, begun under Margaret Thatcher and accelerated under Tony Blair, to make it a role of the NHS to send people to the Naughty Habits Step.
Where the “old-fashioned” health service merely treated the sick, today's NHS seeks to beat well people into shape as clean-living citizens through advice and guidance. As Michael Fitzpatrick, an East London GP, observed when such contracts were first proposed, they involve “a major shift of general practice away from the treatment of patients who are ill towards the regulation of the lifestyles of the population”.
These unwieldy plans can only further undermine the efficiency of the health system, the role of doctors as clinical professionals, and most importantly, the autonomy of individuals. They turn the purpose of healthcare on its head. As René Dubos wrote in 1960, “it is part of the doctor's function to make it possible for his patients to go on doing the pleasant things that are bad for them - smoking too much, eating and drinking too much, without killing themselves any sooner than is necessary”. There must be more to life than healthy living. Amid the talk of rights and responsibilities, one that gets ignored is the individual's right to make the “wrong” choices.
The other fact often missed out is that we already live longer, healthier lives than ever before. So why not leave us alone to enjoy it?
Modern clinical care is capable of wonders, and the health service should stick to that. How about an alternative, informal contract for the 60th anniversary of the NHS: we promise to come to you when we are sick, if you will pledge only to try to cure what ails us.<<
