Wisdom or Shame: deciding the future of the NHS

When did you last read the Rime of the Ancient Mariner? Up till last Friday it was some 50 odd years ago since I did. My beautiful well-read wife J had never read it until last Friday evening when we read it together. Even if you haven’t read it, I’m sure most readers will be familiar with some of its lines. The most well-known is likely to be ‘water, water everywhere, nor a drop to drink’. We were prompted to take a look by my telling J of a story I had seen earlier in the week about an albatross named Wisdom. Aged 70, she is the ‘oldest known wild bird in history’. Wisdom is a female Laysan albatross, and on the first of February she hatched her 37th chick. Reading the story, I was struck by a number of things.

For example, the word albatross is often used (at least metaphorically) to mean a psychological burden that feels like a curse – more of which later.  

I also wondered about the amazing scientific curiosity of the ornithologist and biologist Chandler Robbins who first banded Wisdom in 1956. She outlived him; he died in 2017. I marvelled at the longitudinal study he started and which still continues to this day. This scientific patience and endurance is all the more important given albatrosses only breed once in every two years.  

Despite the fact that Spring has once again brought with it the welcome sound of birdsong in the morning, it seems we need every new chick we can get these days. The RSPB have reported that there are 40 million birds fewer now in the UK than there were back in the 70’s. In the US, bird numbers are down by nearly 3 billion birds. Climate change and disappearing habitat are thought to be the prime reasons for this decline in bird numbers. I read last week that coffee drinkers might be guilty of contributing to both the disappearing habitats and the decline in birds.

For hundreds of years coffee was cultivated in countries such as Brazil (and many other South American countries), and Africa under the canopy of mature trees. This coffee was often referred to as ‘shade coffee’. The tree canopies provided a brilliantly health-giving habitat for many species of birds, some of which migrate each to the UK. But when was the last time you heard a cuckoo call?

Since 1970 coffee production has developed more sun-tolerant coffee plants, which can be planted in higher-density open spaces created by felling the trees. The situation throws up a dilemma for coffee drinkers, economists, and environmentalists alike. Many of the world’s coffee producers participate in global schemes aimed at supporting developing economies. However, modern coffee production is still damaging our planet. But where would many of us be without that first cup of coffee in the morning? Speaking from experience it’s better to keep a low profile until that first coffee is consumed. You can buy ‘shade coffee’ from the RSPB online shop, see here.

Coffee wasn’t the only focus of dilemmas I heard about last week. Another was around the future provision of comprehensive healthcare. It is unlikely that, in the short to medium term, we will be able to restore health and care services to their former pre-pandemic levels. Dealing with the Covid19 pandemic brought many healthcare professionals face-to-face with stark choices about who should receive what care and where. When I say stark, I mean literally who might receive life-saving treatment and care and who might not. At both the hospitals I’m involved in clinical ethics committees were set up to provide a forum for such difficult decision-making. Thankfully, whilst the NHS creaked under the weight of Covid infections, it wasn’t overwhelmed and mercifully, such decisions were few and far between. Other countries have not been so fortunate.

I imagine that many doctors faced with such decisions might well have seen their knowledge, experience, and skills as being, like that Ancient Mariner’s albatross, a curse rather than a blessing. Given the devastation of the UK economy caused by the costs of dealing with the pandemic, I think we as a society are likely to be facing equally challenging decisions over who gets what treatment, where and by whom. In my discussions last week, we were challenged to undertake a slightly Netflix version of the famous Bernard Williams challenge of deciding who Jim would choose to kill to save the lives of 19 others – see here. The choices we were given included killing the wealthiest, the oldest, the person with cognitive challenges, anyone but the women and children. In the event the majority of the participants chose to kill off the oldest person. I won’t say who I voted for, but interestingly, in the UK it was the oldest in our society that we chose to protect first from the devastation of Covid19.

The older members of our society were those that were seen to be most vulnerable. The pandemic revealed the extent of inequality across the UK. Whilst this was helpful, it’s important to remember that the world didn’t start on 31st Jan 2020, when the virus arrived in the UK. We have known about the social determinants that impact on population health and wellbeing for many, many decades. The NHS itself was set up to address social injustice and health inequalities. Yet here we are nearly 73 years later and many of these issues have still not been tackled. The Budget last week didn’t mention social care, or the growing needs of those living longer with complex and long-term conditions.

Unlike the Ancient Mariner’s colleagues whose decision-making was based upon superstition, ill-founded beliefs and the need to scapegoat, those commissioning, funding, and providing health and social care services will need to rely upon good public health data and evidence to underpin decisions over future service provision. Making this data and analysis transparent will lead to new concepts of reasonableness in future decision-making. This is not an easy task. The erosion of trust in our politicians, in the popular understanding of science and in our sense of communitarianism has been enormous. However, we need to find a way of restoring this trust and quickly. Failure to do so will lead to us health and social care professionals being condemned to wear an albatross of shame around our necks, because we will have let this and future generations down. If we get it right, however, we can look forward with hope that like the Wedding Guest in Coleridge’s tale who patiently listened to the Ancient Mariner story and ‘a sadder and a wiser man… ...rose the morrow morn’.