Radical surgery needed - cut out the hospitals

Advanced health services use vast resources only to prolong death and hasten global warming, says Richard Nicholson.

There are two good reasons why we ought to close all hospitals in rich countries, and neither has anything to do with the perennial reorganising of the National Health Service. The first is that it is morally obscene to spend so much on healthcare for healthy populations while organising a global economic system so that those populations that have real health needs can afford little or no healthcare. The second reason is that if we are to have the remotest hope of preventing global warming getting out of control, we shall have to severely cut activity in every sector.

Rich countries have seriously overvalued their health services. They take up a vast proportion of global resources while doing little more than extending the process of dying. With poverty as one of the few absolute indicators of ill health, the real need for healthcare is in less developed countries. Yet the impression given by the intensity of debate about the NHS is that it provides something of vital importance to the UK.

Healthcare in rich countries provides perhaps the most egregious example of their overconsumption. On average, member nations of the Organisation for Economic Co-operation and Development spend 70 times as much per capita on health as the other six sevenths of the world. They are also in general the healthiest countries. Many believe that the more one spends on healthcare, the better it will be for the nation's health. Yet comparison of a country's spending with its citizens' longevity shows no clear relationship.

In the UK, life expectancy rose by just over 30 years in the 20th century. Most of the increase took place before 1950. Once the full panoply of modern medical research and the NHS became available, the rate of improvement in life expectancy dropped from 4.3 to 1.8 years per decade. Childhood immunisations probably increase it by about 18 months. The other 99.9 per cent of the NHS budget is estimated to add only two to two and half years to life expectancy.

Of course, the NHS might also reduce morbidity, but there is no clear evidence. Health services increase life expectancy by keeping alive people with serious illnesses who would otherwise die. Studies on both sides of the Atlantic have found that about half an individual's lifetime healthcare expenditure occurs in the last six months of life - in other words, a major NHS activity is the prolongation of dying.

Healthcare also contributes to morbidity by large numbers of mistakes and mishaps, many of them lethal. They probably account for 30,000 deaths a year in the UK - 5 per cent of all deaths and ten times the number killed in road accidents.

So why has the myth of the great importance of healthcare to modern society taken such firm control? Part of the answer lies in the enormous amount that the pharmaceutical industry spends on marketing. While spinning yarns about the safety and effi- cacy of their drugs, the marketeers inevitably also promote the system that delivers those drugs.

If the rich countries ever decide to take climate change seriously, these healthcare myths will have to be exploded. The real threat of anthropogenic carbon dioxide emissions, which are controllable, is that they will set off natural heating processes, such as permafrost methane release or rainforest loss, that are not controllable. To prevent these, we need at least a 70 per cent reduction in emissions within five years.

To achieve this, all activity would have to be examined critically. Healthcare is a major economic sector. Provision of healthcare in just the G7 countries cost $2.6 trillion in 2004 - one fourteenth of total global gross domestic product. As well as being dangerous to patients, hospitals and their support services are wasteful of energy and high polluters and would have to be closed.

Primary care could probably remain. If the form proposed by the World Health Organisation 30 years ago were adopted, life expectancy would drop little, much greater effort would be put into health education and having an essential drug list would dramatically cut medicine costs. Of itself, closing hospitals would reduce global healthcare inequity, but it might have a greater effect by encouraging specialists to work where the health needs are. Medical schools would become more decentralised but might develop more patient-centred teaching to fill the gaps left by the demise of purely hospital-based specialties.

In reality, however, hospitals will close for a third reason. Present political inactivity on climate change makes it clear that liberal democracies are too in thrall to economic "progress" to make the apparently backward steps necessary to keep the earth reasonably cool. Therefore, later this century, hospitals will be abandoned as famine and warfare, in a much hotter world, combine to reduce the excessive human population by between 95 and 100 per cent.

Richard Nicholson is editor of the Bulletin of Medical Ethics .