Should we worry about cholesterol?

It has become the received wisdom that cholesterol must be reduced to prevent heart attacks and that drugs known as statins are the best way do this.

There is some crazy logic and bad science behind this. UK government heart advisor Professor Roger Boyle suggested every man over 50 and every woman over 60 should take a daily statin. This approach has been taken to ridiculous extremes with some “experts” recommending that statins be put in the water supply or be handed out with the ketchup at burger bars.[i] The American Journal of Cardiology recently published an article suggesting that statins should be offered in complimentary packets with burgers. One of the authors, Dr. Darrell Francis, stated: “It’s ironic that people are free to take as many unhealthy condiments in fast food outlets as they like, but statins, which are beneficial to heart health, have to be prescribed.” Dr Francis is supported by a grant from the British Heart Foundation.

Many doctors in the UK are insisting that statins be taken as a preventive measure even by people, including children, with low cholesterol. When I lived in London, before the financial crash, dinner party conversation invariably revolved around house prices as ageing baby boomers plotted “Ski-ing” – “Spending the Kids’ Inheritance”.

I was surprised in Sri Lanka to hear a dinner-party guest, who clearly thought herself sophisticated, unashamedly discussing her bowel movements and haemorrhoid surgery. I soon learnt that Sri Lankans of all classes were somewhere on a spectrum between health-conscious to hypochondriac. Everyone “knows their numbers” as they say in the States. A conversational gambit might be, “I have cholesterol. How high is yours?”

There was a time when I had never heard of cholesterol and my ignorance did me no harm.

Many years ago I became a small cog in the prestigious machine that is the Study of Health and Stress carried out by Professor Sir Michael Marmot at London University.[ii] I discovered that my cholesterol levels were “at the high end of the normal range”. I was given a leaflet telling me what foods I should avoid in order to reduce my cholesterol. As I was practically a vegan at that time I did not see that there was much scope to make my diet more Spartan. No-one suggested I should take any medication.

In London I was told by my doctor to avoid cashew nuts, avocadoes and prawns. In Sri Lanka I was told to eat as much of them as I could.

What is cholesterol?

Why has cholesterol become a villain? What is it anyway? As Jenifer Anniston used to say: “Here comes the science.

Everybody “has cholesterol” – without it we would die. Cholesterol is a steroidal alcohol that helps provide structure to the membranes of all animal cells, an indissoluble molecule, a natural substance produced by the liver. Living creatures incorporate cholesterol into their cell walls to make them waterproof and to protect them against injury by oxygen. This is particularly important for the normal functioning of nerves.

Cholesterol is not something we want to clear our bodies of because 70% of our brain is made of fats and cholesterol. Cholesterol circulates in the blood stream in water soluble particles called lipoproteins.

Good and Bad

Those dinner party scientists will nod sagely and tell you that there is “Good” (HDL) and “Bad” (LDL) cholesterol. High density lipoprotein (HDL) carries cholesterol from peripheral tissues in the arterial walls to the liver. From the liver it is excreted with bile. Cholesterol is transported from the liver to peripheral tissues including those in blood vessels. When cells need extra cholesterol they call for the low density lipoprotein (LDL) to deliver the cholesterol into the cell’s interior. Between 60% and 80% of cholesterol in the blood is transported by LDL.

Why then does the common wisdom condemn LDL as “bad” and deem HDL “good”?

Risk factors and cause and effect.

People who suffer from heart disease may display a number of characteristics. Among these may be a high level of LDL. It does not necessarily follow that high LDL causes heart disease. Perhaps some mental confusion has arisen because of a misunderstanding of the term “risk factor”.

Gary Younge wrote in the Guardian in another context: “Because two things are co-related it does not mean that one causes the other. Shark attacks and ice cream sales both rise in the summer. That does not mean that ice cream attracts sharks or people react to fear of sharks by eating more ice cream”.

Being overweight is a risk factor in heart disease. Losing weight lowers LDL. A sedentary life style predisposes a person to heart disease. Exercise lowers LDL. Smoking is bad for the heart. Smoking increases LDL. Stress is bad for the heart and increases LDL. If heart attacks happen more often to people who smoke, who are overweight and suffer from stress it would be wise to give up smoking, lose weight and relax.

A US study was reported in the journal Chemistry and Industry. The study found that statins given to control cholesterol could increase the numbers of people with Parkinson’s disease. People with low levels of “bad” LDL were in excess of three times more likely to have Parkinson’s than people with high cholesterol. Now, one should not conclude from this that we need to take medication to increase our LDL because that will prevent us from suffering from Parkinson’s. The fact that people who have Parkinson’s tend to have low LDL indicates that low LDL is one of the risk factors predisposing people to Parkinson’s. It does not mean that low LDL is a cause of Parkinson’s.

It would not be wise to blame LDL for heart problems and to take drugs as quick fix to attack it while carrying on with an unhealthy life style.

Good diets and bad diets

It has become received wisdom that that animal fat is bad for the heart using the analogy of clogged-up drains.The road to hell is paved with false analogies.

Is “common sense” supported by the evidence? In Kenya the Masai believe that vegetables are suitable food only for cows. They do not consume much else but meat, milk and blood. They do not have heart attacks and their cholesterol level is 50% below that of most Americans.

In 1953, Ancel Keys published a paper in which he argued that there was an upward trend in the number of deaths in the US from heart disease. He stated that five times as many Americans as Italians died from heart attacks. Using data from six countries he claimed to demonstrate a close correlation between deaths from heart attacks and total intake of animal fat. The villainous ingredient in animal fat is cholesterol.

Keys made much of the beneficial effects of a Mediterranean diet. However tasty the food might be, Keys created a myth here. In Italy, the incidence of heart attacks is 2.5 times greater in Crevalcore than in Montogiorge, even though the average cholesterol was the same. Throughout Greece the diet is similar but people who live in Corfu are 16 times more at risk of a heart attack than people in Crete.

A WHO study shows low mortality and high mean cholesterol levels in all locations in France. Dr Bernard Forette and a team of French researchers found that the death rate for old women with very low cholesterol was five times as high as that for old women with very high cholesterol. These studies do not show that high cholesterol means early death or that low cholesterol ensures longevity.

Professor Marmot did a study of Japanese immigrants in the USA. Those who became used to the American way of life but preferred Japanese food, had heart disease twice as often as those who ate high fat American food but maintained Japanese traditions. This suggests that heart disease was not caused by cholesterol but had something to do with more general aspects of lifestyle.

There is a strange tendency for studies to be distorted to support the case for lowering cholesterol when the raw data might indicate the reverse. The most blatant example of this is the study undertaken in Framingham, Massachusetts. Many of the townspeople had their cholesterol levels tested over many years. The coronary vessels of those who died were tested. The conclusion of the researchers was that cholesterol levels predicted the degree of atherosclerosis. However, only 14% of all those who died were examined. The correlation was only a weak 0.36. Almost half of those who had a heart attack in Framingham had low cholesterol. Women with low cholesterol were as likely to die as those with high levels.

The Multiple Risk Factor Intervention Trial measured the cholesterol of 300,000 middle aged American men. The researchers concluded that the risk of a heart attack for someone with a cholesterol level above 265 was 413% higher than the risk for someone with cholesterol below 170. This shocking conclusion is undermined by the brute fact that 99.4% of the 300,000 did not die of a heart attack. 98.7% of those with the highest cholesterol levels were still alive after six years. The difference in the number of deaths between those with the highest and the lowest cholesterol levels was 1%.

In the huge INTERHEART study on 30,000 subjects in 52 countries, the effect of many modifiable risk factors on heart attacks was studied. Smoking led the list, but total cholesterol and LDL were not even listed, perhaps because the outcomes were not the ones desired by some of the sponsors of the study, which included AstraZeneca, Novartis, Aventis, Abbott Labs, Bristol-Myers Squibb, King Pharma and Sanofi-Synthelabo.6

Dr Kroop, in the Netherlands, studied men who had extensive atherosclerosis and cholesterol of at least 312. All were treated with simvastatin. Half were treated with a drug that chemically removed most LDL. The researchers were confident that they could retard or reverse atherosclerosis. There was no correlation between cholesterol lowering and angiograph changes.

The most helpful book for the layperson on the history and science of all this is written by a layman, Anthony Colpo, who provides an impressively compendious synthesis of a mountain of research and provides copious notes and references so that one can check his sources.[iii]

Side Effects

There is much anecdotal evidence of side effects from statins. For example, statins have been associated with pancreatitis, tendon problems, depression, sleep disturbances, memory loss, sexual dysfunction, cataracts, osteoporosis, peripheral neuropathy, hemorrhagic stroke and rare cases of interstitial lung disease.

Dr. Beatrice A. Golomb has carved out a niche investigating side effects of statins, particularly in women, urges caution. She claims that studies so far have not demonstrated a survival benefit for women, lower-risk men and men and women older than 70.

Impaired memory and thought are more likely to have a profound effect on seniors’ independence, while muscle weakness from the medications could make them more vulnerable to the perils of falling.

I myself felt very low and disorientated when I was taking statins five years ago. I felt better when I stopped and my cholesterol reduced dramatically.

Which doctors?

“There’s a huge literature of not-very-good studies” that link statins to a variety of problems”, said Dr. Richard H. Karas, director of preventive cardiology at the Tufts Medical Center in Boston.

You can pretty much find any disease, given the millions of people taking statins,” said Dr. Gregg C. Fonarow, a professor of cardiovascular medicine at UCLA.. But when the results of randomized trials are pooled, “you don’t [usually] find statistically significant differences between the statin and the placebo.”

I threw this question open to debate on my blog at Open Salon, to which a large number of practising MDs contributed. One of my Open Salon doctors was dismissive about my citing rhabdomyolysis as a possible side effect of statins. “If you have a 50% chance of having a deadly stroke in the next year are you ‘healthy’? What if you have a 20% chance? What if you have a 10% chance? What is ‘healthy’ anyway? A better question is: ‘At what point are you willing to run the 1:10K chance of rhabdo (reversible with cessation of the drug btw) in order to reduce your chance of a debilitating stroke?… Hey, your choice. For me, between a stroke resulting in death or permanent debilitating weakness, vs a laboratory abnormality that will go away when I stop taking the drug, I know which one I’d pick. Never mind that way more people get strokes than get rhabdo from statins. I’ve seen exactly one case of statin-induced rhabdo and I-don’t-know-how-many awful strokes.” Rhabdo is a very serious condition. It occurs through trauma from natural disasters such as the Blitz and earthquakes. It also occurs in people who abuse recreational drugs. Rhabdo has recently afflicted Redskins’ defensive tackle Albert Haynesworth. Rhabdomyolysis is a significant cause of acute renal failure, and may account for as much as a quarter of the cases of this condition. Rhabdomyolysis patients who experience acute renal failure may have a mortality rate as high as 20%. The condition also causes vomiting, confusion, coma and abnormal heart rate and rhythm. Furthermore, damage to the kidneys may lead to a marked decrease or absence of urine production, usually about 12–24 hours after the initial muscle damage. It is not a straight choice between having a stroke and having rhabdomyolysis.

In the August 21 2003 issue of the American Journal of Cardiology, [iv]Dr H Brian Brewer Jr, a senior scientist at the NIH (National Institute of Health), wrote: “No cases of rhabdomyolysis occurred in patients receiving [Crestor] up to 40 milligrams”. This evades the fact that eight cases of rhabdomyolysis were reported during clinical trials of Crestor. The LA Times obtained FDA records under the Freedom of information Act. These records show that one patient got rhabdomyolysis while taking only ten milligrams. FDA records show that 78 patients got rhabdomyolysis taking Crestor during its first year on the market and two died. Baycol was withdrawn from the market after at least 31 reports of fatal rhabdomyolysis, an adverse reaction involving the destruction of muscle tissue that can lead to kidney failure. A new study by researchers from the Tufts University School of Medicine in Boston, judged Crestor to be the most dangerous of the popular cholesterol-lowering statin drugs, because of its effects on muscles and kidneys.

Whores for Big Pharma

Dr Brewer dismissed fears of side-effects. While making recommendations on behalf of the NIH Brewer was being paid by the companies that sell the drugs.

These doctors who are blasé about the effects of statins are avoiding a core ethical issue. We might accept the side effects of a drug if they are less serious than an illness that is being cured. We might accept iatrogenesis if the benefits outweigh the costs and we were really ill to start with.

All drugs act upon the liver and kidneys while passing through the body doing good work. It is a rather different matter to take iatrogenic risks with healthy people including children.

Why is low good?

Lowering cholesterol in itself might have harmful effects. Dr Joseph Mercola, writes in Huffington Post: “What if your cholesterol level is too low? Brace yourself. Probably any level much under 150 — an optimum would be more like 200. Now I know what you are thinking: “But my doctor tells me my cholesterol needs to be under 200 to be healthy.” Well let me enlighten you about how these cholesterol recommendations came to be. And I warn you, it is not a pretty story. This is a significant issue. I have seen large numbers of people who have their cholesterol lowered below 150, and there is little question in my mind that it is causing far more harm than any benefit they are receiving by lowering their cholesterol this low.”

One large study conducted by Dutch researchers found that men with chronically low cholesterol levels showed a consistently higher risk of having depressive symptoms. This may be because cholesterol affects the metabolism of serotonin, a substance involved in the regulation of your mood.

On a similar note, Canadian researchers found that those in the lowest quarter of total cholesterol concentration had more than six times the risk of committing suicide as did those in the highest quarter.

Dozens of studies also support a connection between low or lowered cholesterol levels and violent behavior, through this same pathway: lowered cholesterol levels may lead to lowered brain serotonin activity, which may, in turn, lead to increased violence and aggression.

Dr. Ron Rosedale points out: “If excessive damage is occurring such that it is necessary to distribute extra cholesterol through the bloodstream, it would not seem very wise to merely lower the cholesterol and forget about why it is there in the first place. It would seem much smarter to reduce the extra need for the cholesterol — the excessive damage that is occurring, the reason for the chronic inflammation.”

Statins’ aim is not true

Statins work by blocking 3-hydroxy-3-methylglutaryl coenzyme A reductase, an enzyme in the liver. Unfortunately statins cannot be specifically targeted on that but as collateral damage also inhibit the synthesis of many important intermediate metabolites.

Statins have been shown to deplete the body of a coenzyme known as CoQ10, a powerful ant-oxidant which is a crucial component of mitochondria and is essential to producing almost all of a cell’s energy requirements. High levels of CoQ10 are found in healthy heart tissue. Statins, by reducing CoQ10 have been shown to be linked to an increase risk of congestive heart failure which is the fastest growing cardiovascular disorder in the USA.[v] The only cure is a heart transplant.

Creating illness for profit

Sally Fallon, the president of the Weston A. Price Foundation, and Mary Enig, PhD, an expert in lipid biochemistry, have gone so far as to call high cholesterol “an invented disease, a ‘problem’ that emerged when health professionals learned how to measure cholesterol levels in the bile.

Professor Donald Light, a professor of comparative health policy at the University of Medicine and Dentistry in New Jersey, US, in a paper presented to the 105th Annual Meeting of the American Sociological Association, claims that 85% of new drugs offer few if any new benefits — but they carry the risk of causing serious harm to users.

He said the pharmaceutical market was one in which the seller knows much more than the buyer about the product, and takes advantage of this fact. “Current incentives for research produce a few drugs that substantially improve patients’ chances of getting better or avoiding death but a large number of barely innovative drugs each year…are of little benefit and consume about four-fifths of all drug costs. The incentives and institutional practices around testing and regulatory review predictably result in approvals being based on trials so biased and poorly run that no one knows how much better or worse new drugs are.” [vi]

An estimated 85% of new drugs offer few if any new benefits while having the potential to cause serious harm due to toxicity or misuse. “Sometimes drug companies hide or downplay information about serious side-effects of new drugs and overstate the drugs’ benefits,” said Professor Light.  One study of 111 final applications for approval found that 42% were missing data from adequately randomised trials, 40% were supported by flawed testing of dosages, 39% lacked evidence of clinical efficacy, and 49% raised concerns about serious adverse side-effects.

Physicians were “double agents” – promoters of the new drug, yet trusted stewards of patients’ health. When patients complain of adverse reactions, studies show that doctors are likely to discount or dismiss them, according to Prof Light.

Prof Light highlighted the marketing of statin cholesterol-lowering drugs as a good example of Pharma hype. Company-supported clinical researchers and medical writers created a global market by manipulating a complex set of relationships between heart disease and saturated fats and cholesterol had been converted into the simple message that “cholesterol kills”.

Yet two major trials of statins found little evidence that the drugs reduce the risk of heart attacks. In contrast, they showed an increased total risk of harm to health and death from the drugs despite the lowering of cholesterol levels.

One major meta-analysis, which pooled the findings of a number of studies, found that “statins were not associated with reduction in the risk of all-cause mortality”.

Another trial led by a statin manufacturer was stopped early so that adverse side-effects were not recorded. Since the first statin was launched in 1987, it has been a boon for Big Pharma. Pfizer’s Lipitor achieved sales of $10 billion a year, becoming the world’s best selling prescription drug.

This is an example of the marketing genius of the pharmaceutical industry. Why restrict your profits by selling medicine only to sick people? The market is unlimited if you target healthy people.

Cholesterol-lowering drugs now generate $25 billion a year for the drug companies. Sales have soared because of the huge increases in the number of people classified as having “high” cholesterol. In 1990, the official US guidelines for measuring high cholesterol meant that 13 million Americans “needed” statins. In 2001, the guidelines were re-written and the potential market was immediately increased to 36 million. Five of the fourteen authors of the new definition of what constituted high cholesterol had financial ties to the drug manufacturers.

In 2004, a further redefinition expanded the potential market to 40 million. Eight of the nine experts on that panel were taking money from the drug companies.[vii] Why stop there?

Why not ignore the cholesterol levels completely and give statins to everyone in the cause of prevention? The ambition of the drug companies is to market statins to everyone, even small children, whether they are at risk of heart disease or not, whether they will benefit from the drugs or not. A recommendation from an influential doctors group that some children as young as 8 be aggressively treated with cholesterol-lowering drugs has triggered debate because there are no long-term studies for children.[viii] Barbara Hutten and colleagues from the University of Amsterdam’s Academic Medical Centre randomly gave the statins or a placebo to 214 children, between eight and 18, with a genetic condition called familial hypercholesterolemia (FH), which causes very high levels of low density lipoprotein cholesterol, commonly called “bad” cholesterol, from birth onwards. Dr Hutten said: “Our data support early initiation of statin therapy in FH children, which might yield a larger benefit in the prevention of atherosclerosis later in life. In our opinion, physicians should consider statin treatment for all FH children who are eight or older.” Ultrasound scans were used to measure the wall thickness of the carotid artery in the neck – a recognised method of checking the narrowing of blood vessels. The findings, published in Circulation, the journal of the American Heart Association, showed that the earlier statin therapy was started the less the arteries thickened. The researchers say that the artery wall would grow 0.003 millimetres thicker for every year that the start of treatment was delayed.[ix] The children were treated for at least 2.1 years and the longest for up to 7.4 years. No serious side-effects were found but the trial was too small to be sure about the safety of the treatment and the researchers said further trials were necessary.

“There may be some pressure to start them on drugs to make these numbers better,” said Dr. Thomas B. Newman, an epidemiologist and paediatrician at UC San Francisco. He also worries that the acceptance of drug use would shift the focus of treatment away from diet and exercise.[x]

We have to be skeptical in our skepticism because there is also a thriving little industry of people making a living from attacking The “cholesterol myth” and pushing their own books and remedies. Witch , sorry which, doctors do we believe? I put this question on my blog at Open Salon, to which a large number of practising MDs contribute.

Many qualified doctors oppose the cholesterol conspiracy. Perhaps the pioneer was Uffe Ravnskov.[xi] The initial response to my queries was along the lines of: “Doctors have had extensive, intensive and expensive training. They also keep up with the latest research and developments. The layperson should do what the doctor says.” I asked specific questions: “Do you think that cholesterol is a serious health risk or do you agree with those other qualified medical practitioners who think that the danger from cholesterol is a myth? “Do you think that stains should be prescribed to people who have low cholesterol?”

When pressed with the argument that many well-qualified doctors seriously doubt that cholesterol is a problem at all and question the wisdom of promiscuously prescribing statins, one particular doctor, Amy Tuteur MD, abdicated from a position of lofty certainty and said it was unfair if we don’t recognise that doctors are fallible. “In other words, treatment recommendations are being issued in a state of imperfect knowledge. Therefore, they are constantly being revised. The same thing applies to statins. In order to know whether they work, who they work for, what the side effects are and what the long term consequences of statin use are, we need to have 50 years of data on millions of people. We don’t have that, and we won’t have it for decades. Only time will reveal the truth about statins, positive or negative. Until then, all of us have to muddle along with the limited (but growing) information that we have available.”

Another doctor tried to absolve doctors from any blame for the growing ineffectiveness, through over-prescribing, of anti-biotics. “We’re taught not to do that. But see how long you last when faced with a screaming parent making a scene in the ER because you won’t give her kid abx for a viral infection.”

Blame the patient

I sensed a disturbing theme emerging: blame the patient. Doctors are all-knowing and patients should do what they are told. If anything goes wrong it is the patient’s fault. However, the doctor gives in when the patient is demanding anti-biotics and that is why anti-biotics are becoming ineffective?

I consulted my friend Dr Barbara Schumm who has been practising medicine in the UK for many years. She told me: “In British medicine we have the notion of NNT which is ‘numbers needed to treat’ i.e. the number needed to take the medication to prevent one event. Usually that figure is in the hundreds. If this concept is used to explain risk, very many patients feel that they would prefer to take the chance rather than take medication every day of their lives with no clear gain. There is an element of ‘the Emperor’s Clothes’ in all of this and certainly all the vested interests in the drug industry are reluctant to be honest about their findings”.

According to the Hippocratic Oath, doctors should not perform unnecessary surgery or take unnecessary risks by prescribing treatment of dubious value and possible harm. Under the spurious banner of “prevention” possible harm is being done, anxiety is being created, resources are being misdirected and fortunes are being made. Is it ethical to spend billions on the possibility of slightly reducing heart disease in the affluent west when all over the world millions are dying from the diseases of poverty?

[i] American Journal of Cardiology, Volume 106, Issue 4 August 2010 http://www.ajconline.org/article/S0002-9149%2810%2900870-2/abstract

[ii] Study of Health and Stress, Marmot, Michael, http://www.workhealth.org/projects/pwhitew.html and http://www.ucl.ac.uk/whitehallII/

[iii] The Great Cholesterol Con, Anthony Colpo [iv] American Journal of Cardiology [v] Langsjoen, PH & AM, Biofactors, 2003

[vi] http://www.physorg.com/news201250202.html

[vii] Selling Sickness. Moynihan, Ray and Cassels, Alan, Allen & Unwin, NSW 2005.

[viii] http://articles.latimes.com/2008/jul/09/science/sci-statin9/2

[ix] http://www.independent.co.uk/life-style/health-and-families/health-news/eightyearolds-could-be-given-cholesterol-drugs-460560.html

[x] http://www.thehealthierlife.co.uk/natural-health-articles/heart-disease/statins-heart-disease-lipitor-side-effects-children-77623.html

[xi] The Cholesterol Myths New Trends Publishing Washington DC 2000. Conspiracy theorists may raise an eyebrow at the fact that the cover of Dr Ravnskov’s book is designed by Sally Fallon and she contributes a flattering blurb

The Healthcare Business in the UK

I posted a version of this on Open Salon in February 2010. Further “reforms” seem to be stalling.

I have been fortunate in that I have had few encounters with the UK National Health Service (NHS) as a patient. The encounters I did have were all related to head injuries. When I was about four years old I fell down the stairs while attempting to play the ukulele and landed on my head. That was the end of my musical education. The only time I ever scored a try playing Rugby, I contrived to get kicked in the head at the same time and had to be stitched up.  Some years later, while leaving a hostelry (sober, I might add) in Manchester with a group of friends, we were unexpectedly set upon by a gang of ruffians and again I was kicked in the head. One of our company fared worse, suffering a broken jaw.

I know something about the NHS from the inside. After graduating from university, I worked as a hospital porter for six months. I was originally hired because the hospital lifts were being replaced and I had to carry patients to and from the operating theatre. My duties also included assisting at post-mortems and taking corpses on my own to the mortuary in the middle of the night. This was more of an education than university.

That hospital was originally built as a brewery in the 18^th century. It was an NHS institution, but private patients were treated in what was called the “new building”. It had been built in the 1930s. When there was a cardiac arrest on the public wards we had to run over to the “new building” and collect the necessary equipment which we then trundled through underground passages to the old building.

Since I worked there, those premises have been closed and the hospital has moved to a state-of-the-art skyscraper. Is this better? More about state-of-the art modern English hospitals later.

I also know something about the NHS on a more scientific basis having done many studies as part of a Department of Health team looking into day-to-day practices and assessing how efficient they were. This was at the time when the Conservative government, through Secretary of State Kenneth Clarke, was introducing NHS “reforms” designed to make the provision of healthcare more “business-like”.

The English love to complain about the NHS and perhaps compare it unfavourably with what they imagine things are like elsewhere. When I was visiting the United States I developed a severe, and possibly serious, eye-condition. I received excellent care and friendly and concerned attention at a clinic in Baker, Louisiana, and the costs were covered by my travel insurance. I needed to continue treatment for six months after my return to London. Greenwich Hospital was drab and unfriendly. Luckily, I kept a diary note of my appointments as the reminder letter I received in the post was virtually blank because the hospital’s printer had run out of ink. The receptionist looked at this and said: “If you could read this there can’t be much wrong with your eyes”. The doctor was rather brusque and gave the impression that he had more important things to do than deal with me. When I pressed the point that the American doctors had told me to mention that I was also suffering back pain and this could have a bearing on the eye-condition, he became quite angry and told me to forget about it.

Although many people complain about similar incidents, there is in the UK also a deep affection for, and pride in, the NHS. Paul Addison wrote in 1985 about people who had grown up with the NHS: “While critical of this or that aspect of the service, they are profoundly glad of its existence and appalled by the prospect of its destruction. But, however genuine, their appreciation is limited in one respect. Much as they value the NHS, they do not remember what the health services were like before it started.”

The historian, Peter Calvocoressi, wrote in 1978: “For its customers it was a godsend, perhaps the most beneficial reform ever enacted in England, given that it relieved so many, not merely of pain, but of the awful plight of having to watch the suffering and death of a spouse or a child for lack of enough money to do anything about it. A country in which such a service exists is utterly different from a country without it.” Professor Rudolph Klein described it as “the only service organised around an ethical imperative”. He also wrote: “At the time of its creation it was a unique example of the collectivist provision of health care in a market society”.

Health Minister, Aneurin Bevan, was an unexpected choice to be the man to establish the NHS in 1948. He was an ex-miner from Tredegar in South Wales, a militant trade unionist who had been a dedicated Marxist. He was an inspiring orator in spite of a stutter. Despite his working class background he acquired sophisticated tastes and wealthy friends. Brendan Bracken called him to his face a “Bollinger Bolshevik, you ritzy Robespierre, you lounge-lizard Lenin”.

The revolutionary thing about the NHS was its universalism and the fact that it was paid for from central funds. It was open free of charge to upper, middle and working classes. In effect, Bevan nationalised the hospitals, which had previously been operating under a hodgepodge of different administrations and funding arrangements. By doing this, Bevan brought hospital consultants into the scheme. Lord Moran, Churchill’s doctor, was very helpful to Bevan in winning them over. As Bevan put it: “I stuffed their mouths with gold”. Under the NHS, the consultants would be paid for providing their services to hospitals and also carry on their private practice, even using NHS beds for their paying patients.

The free market alone would not provide adequate health care. General Practitioners (GPs) had to be persuaded to set up practices in poor areas. As small businessmen they would naturally be more attracted to wealthy areas in which they could make more money. In present-day Detroit most of the conurbation’s poor are excluded from healthcare because GPs have moved to the suburbs where they can earn more. Winning over GPs was more difficult than co-opting hospital consultants because they were anxious about losing their independence and becoming salaried public servants. During my time studying the NHS I found that there was a general opinion among hospital doctors and nurses as well as NHS management and civil servants that GPs were difficult and fractious. They eventually joined the NHS when offered a salary plus a larger amount in “capitation fees”, that is, payments based on the number of patients on their books. In spite of this there has been tendency to put more healthcare work to locally-focused GP surgeries and away from hospitals.

One of the key provisions of Bevan’s Act was Section 21: “It shall be the duty of every local health authority to provide, equip and maintain, to the satisfaction of the Ministry, premises which shall be called ‘Health Centres’.” The socialist vision was that the centres should house GPs, dentist, chemists and also receive visits from hospital consultants. Preventive and curative medicine would be equally important and in time all primary care would be provided within them. It is ironic that Bevan exerted none of his political skill and socialist fire to bring this about, probably because he knew he could not defeat the medical profession’s entrenched opposition, but a conservative government, widely accused of trying to wreck Bevan’s creation, brought local primary care centres into being in the 1990s.

Funding a universal health care system was always going to be difficult. Sir Kenneth Stowe was Permanent Secretary at the time I was at the Department of Health. After his retirement he made a speech in 1989 in which he put some questions that he would have liked to put to Beveridge and Bevan in 1948. “How did you get the costings so wrong? Didn’t anyone listen to the Treasury? Prescription charges had to be applied within three years of the NHS coming into existence. Wouldn’t it have been better to go for viability rather than have everything free when, in fact, nothing is free?”

The service certainly cost more than expected. Four million dental cases a year were projected but the actual figure was eight million. The cost of ophthalmic services was estimated at one million GBP in the first year and the actual cost was 22 million. Bevan said: “I shudder to think of the cascade of medicine which is pouring down British throats at the present time. I wish I could believe that its efficiency was equal to the credulity with which it is being swallowed.” Another stutterer, George VI, could not understand why people should get free teeth paid for by the taxpayer. He pointed to his elegantly shod, in-bred feet and asked why the masses should not get free shoes also. His Majesty seemed unaware of the irony of the fact that his own shoes and everything else he had was paid for by the taxpayer. The taxpayer might echo Faron Young’s immortal words: “I bought the shoes on your feet”. Bevan and Harold Wilson made dramatic resignations from the Labour government on the grounds of principle when Chancellor Hugh Gaitskell introduced charges for teeth and glasses.

Stowe was responsible for the Thatcher government’s white paper Working for Patients, which he said was long overdue in its “willingness to break the monolithic structure and make a start at least on dumping some of the structural garbage”. “Even more important is the acceptance and promotion of diversity in institutions in the shape of Trust-owned and managed hospitals with the freedom to buy and sell services to meet the needs of the communities they serve”.  The Thatcher administration’s aim was to make the NHS more “businesslike”. To this end it drafted in businessmen from the retail trade, from Marks and Spencer and Sainsbury’s. Sir Roy Griffiths, from the latter company, in his report on health service management wrote: “If Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be looking for the people in charge”.

A problem that I saw at first hand from the very early days of Working for Patients was that implementing the reforms entailed recruiting armies of accountants and managers. Vast amounts of money seemed to be spent on that rather than patient care.

The short-hand term for what was proposed in Working for Patients and put into practice by Secretary of State for Health Kenneth Clarke in the 1990s was “the NHS reforms”. The Blair government carried Clarke’s policies even further and Gordon Brown was a firm supporter of public-private financing in all areas of service provision including health care.

The Blair government kicked off in 1997 with a White Paper entitled: The new NHS,
modern, dependable. Blair said in his foreword: “I know that one of the main reasons people elected a new Government on May 1st was their concern that the NHS was failing them and their families. In my contract with the people of Britain I promised that we would rebuild the NHS. We have already made a start. The Government is putting an extra £1.5 billion into the health service during the course of this year and next. More money is going into improving breast cancer and children’s services. And new hospitals are being built. The NHS will get better every year so that it once again delivers dependable, high quality care – based on need, not ability to pay.”
He claimed that things were going to be different under New Labour. “It replaces the internal market with integrated care. We are saving £1 billion of red tape and putting that money into frontline patient care.” The New Labour mantra was “modernisation” but was this any better than Harold Wilson’s much-derided “white heat of technology” in the early 60s? In the light of what has been reported in the UK press only this week, Blair’s promise of “new technology that links GP surgeries to any specialist centre in the country” elicits a hollow guffaw.

The BMJ (British Medical Journal) called the White Paper a compromise and was not impressed by the claim to be replacing the internal market. “The rhetoric is that the internal market, which supposedly resulted in damaging competition, has been abolished. In reality, competition was weak, the purchaser-provider split will remain, and purchasers will still have some choice between providers.”

The main change promised by the White Paper was related to primary care. The chief responsibility for purchasing health care  moved from the previous 100 health authorities, 3600 fund holders, and 90 total purchasing pilots to 500 primary care groups each covering “natural communities” of roughly 100,000 people. Primary care groups were to consist of groups of general practitioners (around 50) and community nurses which were intended to hold a budget for virtually all hospital and community health services for the area plus the cash-limited part of the general medical services budget—for example, for prescriptions and practice staffing. Health authorities would continue to purchase only selected specialist services, and fund holding was to be scrapped from April 1999. The plan was for primary care groups to develop in four stages over the next five years: at a minimum they could leave all purchasing to the health authority and have an advisory role only; at a maximum they could purchase almost all services and merge with community trusts to form primary care trusts providing all primary and community health care. The overall budget for patient care was to be cash-limited, and the primary care groups would be able to keep any savings made. Management costs of the health authority and fund holders were to be pooled, capped, and shared out between the health authority and primary care groups.
The BMJ saw the main effect of Labour’s policy to be: “softening the harsher edges of the internal market by increasing collaboration and openness; involving all general practitioners in commissioning/purchasing; and strengthening central control over the quality of, and access to, clinical care. They rest on several beliefs, which, as in all policy-making, are the messy product of political values, aspiration, practical judgment, and evidence: that competition in the NHS has generated bureaucracy and inequity; that the most promising way to manage scarce NHS resources is through devolving budgets to clinicians; and that existing systems to monitor the quality of clinical care (Royal Colleges and General Medical Council take note) are poor.”

The BMJ sounded a prescient warning note: “There are also notable omissions. For example, there is nothing new on overall funding of the NHS except that the changes in themselves will save £1bn in bureaucracy over five years—a fiction since developing the primary care groups will need high start-up costs. At best these reforms could give the service a real chance to manage scarcity better—through effective managed care. At worst they could just be the internal market with its motor removed, while perennial problems which undermine support for the NHS— haphazard rationing, financial deficits, the ‘winter crises’, and lengthening waiting times—go unaddressed.”

Whilst the stated purpose of NHS Foundation Trusts was to devolve decision-making from a centralised system to local communities in an effort to be more responsive to their needs and wishes, others saw the change towards semi-independent hospital boards as a move towards privatisation of the health service. Some contended that NHS Trusts went against the spirit of the principles laid out by Bevan. Others said that it would lead to a two-tier system, as in Canada. Although the quality of healthcare in Canada is excellent, the WHO has shown that it has the longest waiting times for any developed country. A further concern was that NHS Trusts would copy the USA (those drafting the reforms were much influenced by American thinkers) in seeing some illnesses as more profitable than others, and concentrate on those at the expense of others.

It was unfortunate for the UK and the NHS in particular that Blair and Brown were fixated on the idea of the Public Private Finance Initiative. If I go into all the details of that, this post will be even more intolerably lengthy. PFI (these days sometimes called PPP) can be summarized as Public Pays Private Profits. The “risk-taking” entrepreneurs of the private sector are on a certain winner. They will not enter into a contract with the government unless all the risks are covered. They put in incomplete tenders underestimating the costs and then the taxpayer makes up the shortfall and the companies rake in the profits.

Let Carlisle NHS Trust Hospital stand as an emblem of PFI in the NHS. Nick Wood, the chief executive of the North Cumbria Acute Hospitals NHS Trust, resigned a few days before a damning report was published by the Commission for Health Improvement (CHI). The CHI report coincided with criticism of the hospital by the public service union Unison, which is opposed to PFI hospitals. It published a dossier of complaints from members, including lack of beds and sewage bubbling out of theatre sinks when nurses were scrubbing up.

Another design flaw was a glass atrium which heated up in summer because there was no air conditioning. Sir Stuart Lipton, head of the government’s Commission for Architecture and the Built Environment, said: “The present round of PFI is effectively sub-contracted obligations. It is not that the buildings are being built inefficiently, but the contractor has got nothing to do with the medical process – they are two separate functions, which effectively should be one”.

David Hinchliffe, chairman of the House of Commons Health Select Committee, was also concerned about the design of PFI hospitals. His committee uncovered a number of problems:

• confusing layouts
• corridors being too narrow to be able to turn a hospital trolley round
• difficulties for nursing staff actually seeing patients because of the layout of the wards

The Health Secretary at the time, Alan Milburn, invited the Prince of Wales to be design champion for the new hospitals. Mr Hinchliffe was not impressed. “I don’t know what experience Prince Charles has of working in hospital kitchens, or taking clinical waste to sluice areas, or removing bodies from hospital wards to mortuaries. If he has got experience in that then I think he would be ideally suited to offer advice to the government.” I should have been offered the job because I have experience of those things as well as being adept at cleaning human bones out of the incinerator.

In December 2006, the Guardian revealed that half-year accounts for NHS hospitals, ambulance services and mental health organisations showed 121 NHS trusts across England overspent by £372.4m in the first half of the financial year. At least a dozen NHS hospital trusts were technically bankrupt, with no chance of meeting a legal obligation to balance their books. Data provided by the Department of Health under the Freedom of Information Act showed 103 hospital trusts across England expected to end the year with accumulated deficits of £1.6bn, caused by overspending since 2001.

The financial rules governing NHS Trusts were described by one NHS finance director as “a nightmare from Alice in Wonderland”. Their financial difficulties became impossible to manage because of a mistake made by the Department of Health and the Treasury in 2001, when they put NHS trusts under a financial regime known as Resource Accounting and Budgeting (RAB). The new system was designed to regulate spending by Whitehall departments, but had a devastating effect when it was applied to overspending hospital trusts. If a trust spent £105m, but had an income of only £100m, it would end the year with a deficit of £5m. The new rules sliced £5m from its income in the following year and obliged it to make a £5m surplus. That required the trust to cut its spending from £105m to £90m. Trusts faced with this triple whammy could not achieve the target without damaging patient care and so their deficits escalated. Many took corrective action, including sacking staff, closing wards and reducing the time patients spend in hospital, but the Guardian identified a group of trusts that had passed the point of no return.

Nigel Edwards, policy director of the NHS Confederation, said “Financial recovery would imply such damage to patients that no sensible person would go for it. They would not compromise the survival of the people they serve.”

One of the reasons for the financial difficulties of the NHS is the incredible amount of money the government has wasted on IT systems rather than patient care and funding for more practical areas of the NHS. Whilst a new IT system may improve some areas it is a luxury that is not anywhere near the priorities of most NHS employees and is also vastly expensive. The other problem with the government’s IT investments is that they have an uncanny ability to make a hames of it. The Independent newspaper reported on January 21 2010 on  the failings of Labour’s most costly programme, the mammoth £12.7bn IT scheme to revolutionize the way the health service worked. But far from heralding a new age of efficiency, the National Programme for IT is now widely perceived as the greatest government IT white elephant ever. As well as the huge costs involved, suppliers have walked away, projects are running years behind schedule, while medical professionals have complained that they were never consulted on what they wanted the new system to achieve. The Independent has learnt that just 160 health organisations out of about 9,000 are using electronic patient records delivered under the scheme. The vast majority of those were GP practices. New figures have also revealed that millions of pounds have been paid out in legal fees. Alan Milburn, the former health secretary, said in 2001 that everyone would have access to their health records online by 2005.

In August 2011, it was announced that the NHS was to abandon the national database of patients’ records, as originally envisaged by the previous Labour government in 2002. The cost of the fiasco was £6.4bn with a further £4.3bn  needed. As the Independent editorialised: “But we must not forget that each botched IT project also represents a private-sector shortcoming. Many firms have promised a great deal but not delivered. The PAC today rightly singles out CSC and BT for criticism for their inability to live up to their contractual commitments over the NHS IT projects. These businesses have been – and continue to be – rewarded for failure.”

The move towards Primary Care Trusts (PCTs) has not been easy. The Health Service Journal reported on 21 January that most PCTs will be unsustainable because just 10 per cent have successfully reduced emergency admissions. The CEO of Peterborough PCT recently resigned because of budget deficits.

The NHS is also likely to suffer because of factors beyond its control. The world financial crisis will have an impact as the government struggles to balance the books. NHS trade union Unison has warned against punishing public services for the excesses of “greedy bankers”, following the government’s Budget statement in 2009. King’s Fund (a healthcare think tank) chief economist John Appleby says it is very hard to see how the NHS can escape a real-terms cut. A real-terms cut would be a major adjustment for the NHS, which received annual real-terms growth of 7.4 per cent from 2002 to 2008. KPMG (financial consultants) head of healthcare Alan Downey says it is likely the cuts would mean the NHS will need to scale back its ambitions. “Noble aims are things which aren’t going to be pursued over the next ten  years. It’s going to be about retrenching back to what are seen as the priorities. The target to reduce health inequalities could be dropped, particularly under a Conservative government with less commitment to equality.”

Recent events seem to confirm that the NHS has never been clearly a national or a local service, and existing trends seem to lead to the worst of all worlds: the disadvantages of central control, and local differentiation without any genuine local autonomy. As the NHS is arguably the most national service in the British welfare state, it is possible that the heyday of the national welfare state may be over.