Can less ever be more? As we contemplate a frugal future, the question grows ever more relevant. The Economist Intelligence Unit warned last week that all health systems face "financial meltdown" thanks to the ageing of the population and the increase in chronic disease, and that the over-riding challenge is to find ways to restrain spending.
The words "NHS cuts" never sound good, especially from a Tory-led government. But not all cuts are bad. We know, for example, that we have more accident and emergency departments and more children's heart surgery centres than can be clinically sustained to provide a safe service.
This is not because we have too few doctors and nurses to run them but because we have too few patients. That is, patients with the right injuries/illnesses, of the right degree of severity to maintain the right level of skill in the doctors treating them.
Very severe injuries, of the sort that happen in high-impact road accidents, are too rare to maintain a full A&E unit with trauma centre on every town corner. And congenital heart defects requiring highly skilled surgery are too rare to maintain 11 children's units across the country.
Fewer of these units thus means safer, as well as cheaper, care. But its an idea that does not play well with the public – or with doctors. So last week we saw Andrew Lansley defer a decision again on the closure of the A&E department at Chase Farm hospital in Enfield (its now 17 years and counting), and the Royal Brompton Hospital took the unprecedented step of suing NHS managers trying to find a solution to the conundrum of too many children's heart surgery units.
As these proposed closures are only the first moves in a long game, their interruption does not bode well for the NHS's future. Which prompts a further thought: can rationing ever by acceptable?
We know many medical procedures are outdated or unnecessary. Tonsillectomies and hysterectomies are examples – often no treatment, or a simpler, less invasive procedure would have been preferable. Yet what should be easy savings are still difficult to achieve. Changing doctors' habits is hard.
An impassioned plea from a paediatrician at Boston University School of Medicine in The New England Journal of Medicine takes this a stage further. In a paper titled "Daring to practice low-cost medicine in a hi-tech era" he begs his colleagues to do less – fewer tests, less aggressive treatments.
"The meaning of 'first do no harm' has changed for us – we feel that doing everything is the best practice," he writes.
His appeal echoes that of the great Ivan Illich, who argued in Medical Nemesis, published in 1975, that medicalisation of so many of life's vicissitudes caused more harm than good. A decade later he wrote: "Today's major pathogen is, I suspect, the pursuit of a healthy body."
More medicine is not better medicine. Less medicine can mean more health. Will we hear that message fall from Mr Lansley's lips? It would be a bold advance – but don't hold your breath.Reuse content