Artificial Healthcare. My A&E shift in the year 2045.
My work ID badge still says
‘NHS’ on it, but this stands for “Network Health Solutions”, the name of the
private healthcare company I’m employed by. Heading into work, I try and smile
for the younger doctors coming on shift with me. I know they are probably
smirking a bit at having to work with an old codger like me, but in my heart, I
know they have many tough years ahead of them.
So, what happened to the good old NHS? It had been broken for many years, but the inevitable and final collapse happened in the winter of 2028-29. The public had put up with a failing service for a long time, but this was on a different scale. Dismay had replaced the post-pandemic apathy of the early 2020s. Most hospitals around the country had declared “major incidents” after shocking numbers of patients were dying while stuck in ambulances outside the A&E department, some for more than a day. Those same ambulances weren’t available to attend emergencies, so scores of people were dying in their own homes from things like strokes and heart attacks, while the scenes of serious road traffic accidents went unattended by paramedics. Mortuaries were becoming overwhelmed. Crowds of angry relatives gathered at hospitals. Traumatised staff were off sick in unprecedented numbers, closing many wards and departments.
The media reported a fresh horror every day while public anger mounted and eventually spilled over into mass protests.
These protests were one of
several factors that brought down the government of that time. The incoming
right-wing coalition was voted in on a ticket of promising to transform
healthcare. This was the death knell for the NHS. It was promptly dissolved and
replaced by private industry, funded for the most part by mandatory health
insurance. Like driving and mandatory car insurance, you couldn’t legally
access healthcare without private health insurance. A basic level was provided
free for those on benefits, but even they had to find £75 if they wanted to see
a GP, then try and claim it back from the insurer.
Not much changed at first
and the chaos just continued. I’ve witnessed a widening in the “health gap”
between rich and poor though, that much is clear. Rich folk, who are generally
in better health to begin with, can easily afford the best level of insurance.
They get care and have fancy investigations carried out that often, they don’t
really need. Meanwhile, the poor continue to endure the worst outcomes, as they
make do without expensive insurance.
It's many such poorer folk
that I see every day in A&E. It costs £25 to attend A&E, but that’s
just to register and see a triage nurse. If you need to see a doctor, or heaven
forbid need some emergency treatment, the costs really stack up. For example, a
broken ankle will set you back £500 by the time you have paid for the x-rays
and plaster cast. But, if you are desperate and can’t afford anything else,
you’ll likely see someone like me in A&E. I never turn anyone away and have
got into trouble with my boss a few times for providing a “freebie” treatment
or two. My pay gets docked from time to time when I don’t reach billing
targets, but the job hasn’t completely robbed me of all compassion…
My first patient of the day
was a case like this. At 60, Sam is 10 years my junior and has no insurance.
He
was paying his monthly premiums until a compulsory genomic test for his insurance
renewal changed everything. Such genomic tests were introduced more than a
decade ago and were initially hailed as the future of personalised healthcare.
After all, a simple blood test could show if your genetic makeup made you more susceptible to certain diseases including cancer. Investigations and screening could be directed with remarkable accuracy. Sadly though, the big insurance companies have used genomic information to charge at risk individuals an absolute fortune for their premiums. Sam was one such unfortunate. Since he no longer had insurance, he also lost the health tracking watch that the company provided. This watch monitored among other things his blood pressure and stress levels, providing constant feedback to the wearer. Sam’s blood pressure had risen unchecked it seems, and this is probably why he can’t now move his left arm or left leg. He has had a stroke. Poor Sam doesn’t want to pay (or maybe can’t pay) for the CT scan I say is required. He will have to think about re-mortgaging his home now to pay for the rehabilitation and treatment he desperately needs.
My next patient is Tammy, a 28-year-old executive. She has booked in with chest pain and shows me the screen of her smartphone with further details. The “Top Doc” app on her phone is an Artificial Intelligence (AI) healthcare programme. The user simply types in their symptoms which the app then processes along with stored health data. A diagnosis and action plan are then displayed. Tammy, according to her phone, is having a heart attack and needs immediate attention in A&E.
Understandably, she is very anxious and is demanding to see a doctor. She looks very well though. The ECG test and finger-prick blood test for heart disease carried out in Triage were reassuringly normal. Discussing her symptoms, the tightness in her chest sounds a bit like cardiac pain, but there are no other concerning features. The Top Doc app doesn’t allow for such nuance unfortunately. Trying to reassure Tammy, it turns out she is extremely stressed at work with multiple deadlines to meet. She hasn’t slept well for weeks and spends several hours per day staring at a screen. She drinks about 10 cups of strong coffee per day, vapes constantly, has a ready meal for dinner most days and has no time for fresh air or exercise. I suggest that maybe her body is telling her something, perhaps it is stress that is causing the chest pain? NO! she replies. The Top Doc is way smarter than an old guy like me. If I’m not going to arrange an urgent cardiac angiogram (an invasive catheter test to look at the coronary arteries) as recommended by Top Doc, then she will dam well go to another provider that listens. Okay, looks like that’s another patient complaint coming my way then…
Sam and Tammy are both
victims of our post-NHS healthcare system, just in different ways. I can see
this across the whole population too. Life expectancy has been falling in
recent years, down now to 79 for men and 81 for women, from a peak of 83 and 85
in 2034. A sizeable part of this is due to significant numbers of people from
more deprived areas dying at a young age. We see many such folk in A&E,
dying because of drug addiction and overdoses. Many have associated mental
health conditions. Speaking of which, I’m seeing way more patients with
untreated schizophrenia and bi-polar disorder getting brought by the police to A&E,
often in extremely distressed states, since psychiatry services were
privatised.
This fall in life expectancy
hasn’t stopped the ongoing trend with our aging population. In the UK there are
now six million people aged over 80. That’s 7% of the whole population. They
are of course most likely to be frail and have chronic disease which means, as
I’m sure you have guessed, that their health insurance is prohibitively
expensive. This was the case for my next patient, Gladys, who is a delightful 82-year-old
lady. She had spent hundreds of pounds of her savings to pay for a home
nebuliser to help with her chronic lung condition, and thousands more on
carers. Her family had brought her in now as she was deteriorating, and they
wanted to enquire about “MAID.” This is the acronym for Medical Assistance in
Dying, a legalised form of euthanasia. MAID has steadily grown in demand since
Assisted Dying was legalised in the UK in 2025. It accounted for around 5000
deaths in Scotland alone last year, 8% of the total deaths there. Gladys tells
me she would like MAID as she doesn’t want to be a burden on her family. I am rather
good at “reading” patients and what is on their minds – I have had 45 years of
practice after all. Right now I can sense fear in Gladys’s eyes. I strongly
suspect she is being coerced by her family. The context here is the reality of
little to no inheritance for them if all Gladys’ estate is consumed by care
costs. I put my hand on Gladys’s arm, and tell her that I’d like to, with her permission,
start some antibiotics for the chest infection she has. I’d also like to refer
her to our social work team and have our healthcare chaplain come and spend
some time with her. I have never in my career been complicit in the killing of one
of my patients and I certainly am not planning to start now.
I am mindful of a former colleague who declined a patient’s request for MAID on grounds of conscience objection. He was disciplined shortly afterwards and sent for “remedial awareness training.” When a second, similar case occurred he ended up being referred to the GMC this time, and ultimately left clinical practice. His story is not an isolated one, sadly. You see, there is a strong economic case for euthanasia. The last year of a patient’s life is the most expensive and resource consuming one for any health service.
The big healthcare companies like the one I work for has also saved considerable amounts of money by using “virtual medical” resources. Such was the experience of my next patient, 46-year-old George. For a few weeks he had been experiencing abdominal pain and nausea. He had consulted with a virtual doctor on his smartphone and had been prescribed some antacid medication for his stomach. No better, he went back to the virtual doctor who this time prescribed some laxatives. Now starting to feel dreadful, he demanded to see an actual human doctor and was referred for an online consultation with a GP on his office computer. The GP was much more thorough and prescribed stronger
medication for a suspected ulcer. George unfortunately collapsed at home three days later and was brought into A&E. He was clearly quite unwell. George is one of the 40% of adults in the UK who is clinically obese (a figure which has risen from 15% in 1998 when I qualified) which makes physical examination quite difficult. I do however detect a hernia which has probably become obstructed, a suspicion confirmed on a subsequent scan. George will need urgent surgery, made quite risky and complex by his body size, but the robots that do the operating these days are rather impressive. Maybe this old doctor can still out-smart the fancy technology after all – or perhaps there is just no substitute for being physically examined by a medical professional.
In either case, at my age I
am relatively expensive to employ, so I’m guessing that it won’t be long before
I’m nudged towards the exit door. I am increasingly tired at the end of each
shift, so I won’t mind too much. Someday I’ll be reflecting on my career and
thinking back to the days when we had a functioning NHS at the beginning of
this century. Free at the point of need for all, irrespective of their background.
Sadly, it was neither valued nor preserved for future generations. I wish more
people had had the courage to fight for it and not simply let it wither and die
on the promise of change or of shiny new things. We can now repent this fact at
leisure in our virtual, artificially intelligent but ultimately much less
caring world.
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