ABSTRACT
Introduction The advances in modern medicine lead to tremendous financial pressure, requiring judgements on what care should be paid for that would challenge even the wisdom of Solomon. No system in the world is immune from these pressures, as the possibilities in medicine have now comprehensively outstripped the ability of any but the very wealthiest to pay for them. Over a period of time equal to the length of a single medical career, we have progressed from the position where a patient with a myocardial infarction would be routinely cared for at home, as hospital admission did not confer any realizable benefit, to one where patients are being helicoptered to regional centres for immediate surgery. Although the modern Western answer may well confer prognostic and other benefits in the long term, it is, by anyone’s reckoning, fearsomely expensive. Again, within the same career, we have seen diagnostic imaging progress from a situation in which most small hospitals could provide most investigations at very reasonable cost, to one in which a vast number of very expensive machines are available to provide imaging at a unit cost that has a significant impact on health budgets. The challenge is further augmented by advances in therapeutics, where custom-made immunological treatments offer a realistic chance of cure from cancers that represent a certain death sentence to those who cannot afford the treatment – the problem being that the majority of the health systems worldwide cannot afford the technology. Within medicine there is increased competition between specialities. There is a growing body of evidence that properly addressing the mental state of a patient with a long-term physical condition confers significant benefit in terms of their physical state, with the cost of care being significantly reduced. Yet it remains a challenge to commission any increase in spending on mental health services – for who would vote for a service from another branch of medicine that would have the result of reducing expenditure in one’s own? Which politician is brave enough to prioritize a mental health service over a scanner?
