Medicine sits where fear meets trust, and Big Pharma - the companies that make up the Medical Industrial Complex - know that.
In this video, I explain how the 1910 Flexner Report, written in the USA at the peak of an era of toxic capitalism, reshaped medicine, why big pharmaceutical companies gained power as a result, and how the NHS is now at risk of becoming a profit gernation machine rather than a care system.
This is not about denying science. It is about asking who benefits from today's model of healthcare and why prevention, public health and social care are being sidelined.
We need a politics of care, not a politics of profit.
This is the audio version:
This is the transcript:
I want to talk about a subject which is much discussed in my household, and that is the relationship between fear, medicine, 'Big Pharma' or big pharmaceutical companies, if you want to put it that way, and the NHS and how these things have been framed deliberately by neoliberal capitalism to produce health outcomes which are now frankly contrary to our well-being.
Let's be clear. The framing of this is very much around fear and the fact that capitalism uses it as a sales tool. Medicine sits in the place where fear meets trust, and this has been known for a long time, in fact, it underpinned a report that I want to talk about, which was written as long ago as 1910. The report in question was called the Flexner Report, named after the person who wrote it, and the report was pivotal in the history of medicine because it quite literally reshaped healthcare. Most especially, it let Big Pharma capture it for gain.
Now, for a long time, and let's be clear about this, the NHS held out against that. The Flexner Report was written in the USA and had its biggest impact at first in the USA and Canada. But now, we in the UK are also at massive risk from the impact of Big Pharma on what happens inside the NHS, partly because of the choice of our politicians, who seem to believe themselves totally in hock to the big pharmaceutical companies, and partly because those companies have, in any case, captured the medical-industrial complex of this country and turned it against our well-being by literally pursuing profit above healthcare. Those are the issues I want to talk about.
Now, when we talk about fear in this issue, we talk about illness creating inelastic demand for healthcare. Patients will pay anything for hope once they're ill. They also face great insecurity at that moment, and by and large, lose their ability to decide. That's why advertisers amplify insecurity as a mechanism for increasing their sales. Finance prices risk into everything, but markets are quite different. Markets, when it comes to healthcare, monetise fear.
This is structural and not accidental, and this is how big pharmaceutical companies are now working to turn fear about health into profit streams.
Medicine, as far as they're concerned, has become the perfect market. Patients cannot judge treatment quality. They're not qualified to do so. Decisions are made urgently, and are very often emotional. Illness cannot be delayed. Once it arrives, it's there right in front of us, affecting us, or our loved ones. And doctors hold trusted authority, but they and the services that they can deliver are in restricted supply. That combination creates enormous pricing power for Big Pharma, even within the NHS.
And none of this is by chance; that's my point. The history I'm talking about goes back to that Flexner Report written in 1910, and this was no neutral product. It was commissioned by the Carnegie Foundation, a charity. So you might think, well, surely it was promoted for well-being. Hang on a minute. The Carnegie Foundation was, of course, funded by big industry at a time when, in fact, America was going through an exceedingly toxic period of capitalism, where big industry was trying to capture the entire well-being of the States for the benefit of a few people, and that report was a part of this process.
What it did was review all the activities of US and Canadian medical schools. What it said was, they did not come up to scratch. They needed to be reformed. They needed to be based on the logic of the big pharmaceutical industry.
As a result, many institutions were closed. Training was centralised in elite universities, and notice that word, 'elite'. And laboratory science, and not care, judgement or remedies not requiring prescriptions, became the dominant form of medical supply.
The logic of medicine changed. You went to see a doctor to come away with a pill, a treatment, or something else that required continuity of care by the medical profession using the products of the big pharmaceutical industry. The Flexner Report was, in this sense, a complete turning point.
Now, let's not pretend that there was no good that came from this; clearly, some did. Scientific method did strengthen some parts of medicine, undoubtedly, and dangerous quackery, which had been heavily seen in the 19th century, was reduced as a result. That was progress. Let's be clear. I don't dispute that.
And medical training did improve to some extent. Public trust, as a consequence, also grew in doctors to the point where we know doctors have frequently been amongst the most trusted professions in the UK and elsewhere. Modern clinical medicine emerged from all this. None of that can be denied.
But political economy always asks one question, and that is: who gained? After all, everything within political economy is about how power is used to allocate resources, and in this case, what we need to ask is, in a sense, who lost, because that is how we can identify the winners.
Community-based medical traditions vanished as a consequence of the Flexner Report. They were treated as old hat, irrelevant, to be considered outside the medical system. Those ideas that had sometimes worked incredibly well were no longer seen or recommended.
In particular, there were other losers. Medical schools that served women and Black students were closed, changing the balance of power in medicine in a way still not restored. This bias is still there.
Preventive approaches were most definitely sidelined. What we saw was that those things that have been known for centuries, even millennia, which actually prevented the onset of disease, were not mentioned anymore.
As a result, we've got the rise of things like ultra-processed food. In fact, nutrition, sanitation, and environmental causes of ill health were all downgraded within the medical system, or even ignored, despite the fact that, as medical history proves, these three things were the biggest contributors to the improvement in health in the 19th century in the UK and way beyond. Nothing did more for healthcare in this country than did the laying of sewers.
Natural therapies, meanwhile, were marginalised. Heliotherapy, for example, sunlight treatment, which so heavily influenced the design of hospitals and schools for a long period of time, was literally pushed aside. Once common as a treatment, which was highly effective for TB and rickets, this was now ignored. The cost has been enormous. One of the things that sunlight is incredibly good for is cancer patients, but nobody now talks about that. That's not because sunlight stopped working. It's because laboratories and pharmaceutical companies defined what was legitimate, and that's where we now are.
But most especially, what the Flexner Report brought in was an era where medicine moved from providing cures to the management of disease. Now, disease is different from illness. Illness is real. It's the symptoms you suffer. It's the consequences of those things that you feel within your body. Disease is the description that is applied to that by the medical model. They are actually quite different. And chronic disease, which can simply be a name describing a syndrome for which there is actually no known cure, became a revenue stream for Big Pharma.
Drugs managed symptoms and not causes. Lifestyle and environmental cures for illness were ignored, hence our ignoring ultra-processed foods now, and the identification of disease requiring treatment was the new priority of all medicine, and it still is. That is what your GP is rewarded for if you go to see them in surgery. If they can tick a box saying that they have identified a disease that you have, they literally get paid. That is the incentive that they have now. It was created in 1910.
Prevention was, as a consequence, underfunded, and it again, still is. Your GP is not rewarded for preventing you from getting ill. They're only rewarded for identifying why you might be ill and giving that illness the name of a disease.
Care became treatment, and not therefore health, and that was the basis of the profitability of Big Pharma; they knew that. Healthy people are not customers of that industry, but like all industries, they want more and more customers. In other words, managing illness became their marketplace. Identifying disease became the product that they sold, and pills were the solution which they wanted to peddle. Big Pharma is a business seeking to grow, and this model let it do just that.
So who funded Flexner, and why did it matter? The Carnegie Foundation funded the study, and the Carnegie Foundation was a charity, so you might think all is well and good, but Andrew Carnegie funded that charity and Andrew Carnegie got his wealth from somewhere. It was from industrial Capitalism, and we are talking about an era when industrial capitalism was dominated, as was financial capitalism in the USA, by a very few people. They were literally creating monopoly situations to extract profit from the people of that country, which gave rise to the goal of the first US president to have the name Roosevelt. This was Teddy Roosevelt, the man who was president just after the turn of the 19th century into the 20th century, before the First World War, who literally had to set out to break the power of these capitalists, so pernicious was it.
This report, funded by Andrew Carnegie's Foundation, aligned medicine with industrial science for a reason. Pharmaceutical manufacturing was, at that time, emerging. Standardised medical practice would create drug markets, which it needed to be profitable, and none of this was accidental. Standardisation of medical practice was created at scale because that scale created an opportunity for profit for the industrial complex that became the medical-industrial complex, which we are still subject to when it comes to healthcare.
As a result, medicine also became exclusive. Entry to the profession became restricted. For a long time, it was hard for a woman to get in. Elite universities dominated training, and the training system that they provided was dominated by what Big Pharma also, in turn, required them to do.
The supply of doctors was constrained.
Professional authority was centralised, and those who questioned it were normally punished, as they still are, by the way. It is the easiest way to lose your license to operate as a doctor to say that Big Pharma is wrong with regard to the way in which it suggests patients be treated.
And patients became dependent. The subjects of the doctors, not the patients of them.
This, of course, was effective at one level. For a while this worked particularly well, especially as new treatments were found. Things like penicillin and other antibiotics. We saw advances as a result, and we saw advances in other areas. Treatment of heart disease, for example, clearly made progress, but it was exclusive, and exclusivity plus fear equals pricing power, and then Big Pharma enters the scene, not just in the USA and Canada, by the way, but also here too, because Big Pharma creates our drugs.
They protect them using patent law. The consequence is that they create continuing income streams because a monopoly is effectively created by that patent. Now, I'm not arguing that this shouldn't exist for a while. There has to be a reward on their effort. But when a great deal of drug creation is actually funded using government grants, the right to hold a patent to grant monopoly has to be questioned.
In the USA, insurance systems also guaranteed payment to pharmaceutical companies and became a system of guaranteed income return in its own right. There is a whole industry of healthcare insurance, whilst hospitals became corporate assets.
Private equity now buys care providers because they are so profitable, and drug pricing has been detached from cost. Many drugs which cost very little are now priced at a great deal. Right now in the UK, the example is aspirin. You have to pay a fortune to buy aspirin in this country right now, and yet it is an incredibly cheap drug to produce, but that's because Big Pharma mysteriously has it in short supply.
Now the USA shows the logical outcome of all of this. Let's be clear. It is a provider and user of technology-rich medicine, but it has morally poor outcomes, and the NHS was meant to be and did provide another model for a very long time and thank goodness for that.
Public healthcare socialised risk.
Costs were controlled.
Doctors were meant to serve patients and not shareholders, although that has never been entirely true with regard to GPs.
Prevention became rational policy because the state saw the benefits.
There was a macro dimension to healthcare, which justified spending on issues like vaccination and care in the community.
Social security also removed fear. It meant that people were not frightened of ill health; therefore, they tackled it and dealt with it, and healthcare was, as a consequence, seen as infrastructure and not as a commodity.
This is exactly what I argue for here and on my Funding the Future blog, which you should be looking at if you're not a reader.
But none of this is easy, and what is more, all of it is threatened. The NHS is being undermined by Big Pharma right now and by the political choices of people like our Health Secretary, Wes Streeting. Flexner improved science by all means, but it also narrowed imagination everywhere. Medicine is now driven by algorithms. It is laboratory-centred. It is pharmaceutically focused. Doctors are incentivised to literally prescribe; that is their role. They're not encouraged to think, and in fact, medical training does not encourage anyone to think; it is not, in that sense, an academic discipline at all. It is more like an apprenticeship. Profit has followed fear, and anybody who challenges that within the NHS is, as I've already noted, punished; you could well lose your license.
As a consequence, the NHS has changed. We, too, have lost medical judgment: public health, sunlight as treatment, perception of diet as a cause of ill health, treatment of the environment as a threat, and we've also lost the relationship between healthcare and social care, which we once had. Indeed, we did once have a Department of Health and Social Security in the UK to link those two together, but they are now miles apart in terms of their political treatment. We gained pill dependency as a consequence, and that is not neutral.
Big Pharma controls medicine here, too, now. Not least, through training and control of university curricula. Doctors must follow their prescriptions, literally, or they cannot work. By the back door, the NHS is a Big Pharma profit generator as much as in the USA. We are a replica of them in this sense.
So what should change? Look, we need to go back and ask real questions about why we have a healthcare system. What is illness, and what causes it? Is the primary question to ask? We need to understand that, actually, we are not looking at healthcare as pills, but we need to ask about healthcare as wellness. We need to look at what it is that causes that illness in the first place, and here the primary fault lies with our policies around ultra-processed food, and frankly, a lack of physical well-being.
But having dealt with that issue, we still need to regulate pharmaceutical monopolies. We need to expand medical education so doctors can actually think for themselves and imagine outside the box of pills that they've got in front of them, that there might be other solutions that a patient needs, including a referral for enhanced social care within the community, supplied by the government, and they don't need to be treated with pills instead.
We need to integrate environmental and lifestyle care inside the NHS to ensure that we look at the whole person.
We must protect the funding for public healthcare systems.
And we must literally always imagine that we are looking at illness and not disease because disease is just a label, but illness is real and the thing from which people suffer.
We also need research into cures and not just the management of disease that generates profit. The two are quite distinct. We have forgotten what cures look like; that is not what Big Pharma does. It doesn't look for them because management of disease is what makes profit for them, and that is a big problem. As a consequence, we need to rethink all these things as part of a politics of care and not a politics of profit.
So was Flexner pivotal? Yes. It was the moment when medicine became industrialised. It was when industrially funded philanthropy aligned with corporate opportunity. It was when professional medicine became dependent upon pharmaceutical supply chains. It was the point at which Big Pharma founded its institutional basis. The Carnegie Foundation drove that reform, and those who funded industrial capitalism gained a vast new market in disease as a consequence.
Fear does drive profit when care is privatised. Flexner did reshape medicine as a result. Big Pharma has captured that opportunity. The NHS did show a humane alternative, but it no longer does. It too has been captured via the back door of Big Pharma, training, and algorithms, and all of that is wrong.
We need a public healthcare system to manage all risks and not just disease. If we can provide care, we can afford to do so. The real constraint is resources and not money, but we have got resources available, but we are not employing them for the right purpose. And as a consequence, we are being denied resources in terms of training, skills, and experience to see how medicine could now be so much better than simply being disease management most of the time.
We need to talk about health. We need to talk about wellness. We don't just need to talk about disease , and we've forgotten that for far too long now, since 1910, in fact. And we need to rethink the whole issue again because that legacy has now lasted too long. That's what I think.
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As you point out, what is effectively the medicinal supply chain has now become more like a parasite – it takes and give us enough to keep conditions relatively stable – in the process of apparent ‘getting well’ – so that it can use time to earn cash from treatments.
My conclusion?
Unforgivable.
No industry should have that much leverage over society. It cannot be trusted with it, because of the temptation for abuse. We only have to look at the Sackler family to realise that.
It is time that we stopped looking at contemporary business practice with rose tinted spectacles.
Thanks for this. Another immensely effective way to significantly improve well-being and reduce the illness supply to pharma is to change how we get around to be more active. Car dependency in ‘developed’ countries is a primary cause of inactivity. Reducing car dependency ( ‘junk mobility’ ) needs to be at the top of interventions in a politics of care. Transport policy is health policy.
We are all affected by unnatural food to some extent, with chemicals in the food and water we consume and in the air we breathe. There is also bio-weapon research, with more and more labs throughout the world, leaking bacterial diseases and viruses such as the New Lyme disease and its co-infections, some of which cannot be cured. GPs are not armed with the knowledge and tools to help. Plum Island off New York was one of those deadly labs, near the town of Lyme. We are led to believe that climate change is the cause of increased tick numbers, but America farmed ticks in Florida. At long last this research is coming to light in books by Kris Newby (Bitten, The Secret History of Lyme Disease & Biological Weapons), A W Finnegan (The Sleeper Agent) and many articles, including one suggesting that endonuclease fingerprinting indicates a synthetic origin of SARS-CoV-2. Our governments are poisoning us not protecting us.
Big Pharma tried to close down all alternative medical establishments, including herbalism, homeopathy, osteopathy, etc. More and more of us have been forced to turn to those older natural systems for help when drugs are not the answer. There is room in the NHS for both natural therapies and expensive drugs where appropriate but that would reduce the profits for Big Pharma.
Thank you for another fascinating article. I did not know about the Flexner Report, though I could write a book on this subject from my own experiences of chronic ill health and caring.
As someone who was chronically unwell from an early age and noticeably so from puberty I have had the interesting experience of having my considerable health challenges ignored by family and friends as I did not have a doctor-ascribed name for my condition. People would glaze over if I mentioned my health challenges – which I had to, as they so affected my life – and carry on afterwards as if I hadn’t spoken. Apart from a couple of close friends, no one ever asked me how I was, or referred to my health in any way. Because doctors had not given me a diagnosis (the best of them tried hard but couldn’t pin down a cause, the worst made something up and prescribed erroneous drugs that made me worse) my life experience counted for nothing.
I think most of them thought I was a malingerer and probably they still do!
(I’m happy to report that at 53 I am healthier and fitter than ever and things are still improving and without any prescription drugs).
Go well, as I am inclined to say.
A friend lives with ME and fibromyalgia- so there are named conditions, but treatment by doctors and many others has been poor.
I am glad to hear things have improved for you in the end.
I have ME/CFS. It wasn’t too bad back at the start (1992) though I did lose my job as a Cytogenetics Technician. It was my GP who first suggested the diagnosis, and she sent me to a consultant for confirmation. I was on the high rate of PIP for both aspects of it from quite early on. Guess I was lucky to avoid Wessely’s (people on ME forums call him The Weasel!) Graded Exercise Treatment. And was never tempted by Phil Parker’s Lightning Process and similar treatments. I am very lucky with my wonderful GP Practice!
Since getting Covid I now have Long Covid on top of ME, so am mostly bedbound. I count myself lucky that I can get from bed to bathroom and back. I mainly only go out for dentist and optician, as my GPs give me home visits.
Maggie
As you know, the most I can say is, go well.
Richard
Hadn’t appreciated much of that.
Parallels with house builders drip- feeding supply to control their prices seems quite strong. I guess living conditions are also key to health, as well?
It seems there is a massive role for the state (particularly in the UK where NHS data, and govt funding, is so important to facilitate research and trials). It seems crazy that pharma get (all) the IPR. I think pharma get extended patent terms compared to other “inventions” to reflect the time for development/trials. The industry is absolutely dependent on govt protection – why let pharma behave like a robber-baron?
As a minimum, it seems that the state should have critical infrastructure able to produce drugs/vaccines. Able to produce any drug out of patent and newer drugs where development has been supported. This can establish a baseline capacity to avoid being held to ransom. India does something similar, right? Pharma will complain that this will undermine their investments …. But they rely on the government and laws …. So we shouldn’t allow them to take the Mickey, with excess market control / profiteering.
As with housebuilding. Establish a nationalised capability/capacity to build. Penalise land banks that are not being used (incentivise build). Build high quality nationalised builder houses to establish threshold min quality, maximum prices. Stop builders controlling the market and producing poor or overpriced houses. The govt / local authorities hold all the cards on building, in reality. Why do we allow excess profiteering?
And excellent question.
Answers on the back of a £5 note please to a politician’s donation pot
I agree with most of what you say. Now I don’t need to write a review of “Sedated”, coverig the medicalisation and drug treatment of normal human variation.
However, you use aspirin as an example of a drug needlessly expensive and in limited supply. I can buy 16 x 300mg tablets at Tesco for 50p.
“Doctors thinking for themselves”. It’s always amazed me how medical students — hearty, loud, rugger playing philistines are the stereotype — turn into trusted, reliable family doctors.
It may be a disease, but things like high blood sugar, high blood pressure, high cholesterol have historically needed medics to measure these and tell you how bad your health is. There are now DIY kits to measure these at home, but on the whole you can’t tell how unhealthy you are by the way you feel. I think this is strange.
I believe that the reason for creating a ‘Department of Health and Social Security’ (AKA The Department of Stealth and Total Obscurity) was to give Crossland something that would keep him amused.
Having said that however as with the extra £20 pw on Universal Credit there are some very clear ‘trade offs’ between spending money in one place and saving it in another.
I suggest we need some sort of Department in Government whose job is to identify where spending can be redirected or where spending – or cuts in one Department can impact another
Isn’t awareness of and influence on inter-department issues the role of the Cabinet?
Assuming they are competent, shouldn’t “the board” be looking at things like that (informed by the civil service ….. But they should have an interest on the overall effectiveness of the govt agenda)?
Otherwise we just diminish their responsibility for an overall effective delivery of the govt?
Of course – they are hopeless in so many ways … But creating another hopeless layer instead of fixing the problem seems wrong?
This is so apparent with weight loss drugs. Big profits are made by the food industry from unhealthy foods which are heavily promoted, and are implicated in illness, addiction and obesity. Big Pharma then provides an expensive drug “solution” which some will take for life.
Agreed
I suspect for editorial reasons you didn’t mention mental health specifically but this is intimately tied in with the politics of care as a significant cause of GP visits. I am a director of a non profit that uses growing plants as a therapeutic tool and we connect with the social prescribing pathway for referrals. The building of community and shared experience to help provide basic needs is something that the politics of care would provide and significantly reduce the burden on the health service.
Thanks
Much to agree with
I grew up in a very deprived area of Liverpool. We had a family doctor, Dr Gibson (Scottish), who did everything. Surgeries, home visits, night calls, delivered babies in homes. I remember well going to the surgery in a large house not far from my home. It was during the 1950s. His wife would open the door and she wore Edwardian dress and admit me to the waiting room. My mother sent me alone, even though I was maybe 9 years old. It was intimidating but fine at the same time. This was not long after the NHS was created and my mother sometimes used to say that she got better service when she paid the doctor a penny! With the benefit of hindsight, I now understand that he was providing a safety net for the poor people of Toxteth. There was no way a penny would have covered the cost of his services. But, it did give people the belief that they had “paid their way” and it preserved their dignity. That was social care.
Over decades big pharma and medical professionals failed to cure my partner of painful, recurring and self esteem saping facial acne by prescribing various treatments and expensive drugs up to and including Roaccutane. After reading The Glucose Revolution by Jessie Inchauspe and applying her principles to reduce blood sugar spikes her acne disappeared in days never to return.
One can’t help feel that the food we eat and the way we are taught to eat and exercise (or not) has been specifically designed to cause us to be unwell.
That’s a cure for many complaints. And your conclusion is spot on.
As the junior I was signed up for the pharmacology journal membership in our farm vet practice (70s to 90s), so saw Big Pharma closeup. It wasn’t pretty.
The thing that depressed me most was reporting side effects via the yellow card system.
If you rang up the company to enquire about an adverse reaction, it was routine to be told that no one else had reported that problem, only to read a few months later of a major product advisory/withdrawal citing exactly the problems you had reported, affecting thousands of patients.
Organo-phosphate pesticides such as sheep dip and warble-fly pour-on for cattle, caused major chronic human health problems in those administering them (+ waterway pollution) for decades, but gov & industry covered it all up and still do.
On pricing, the thing I notice on human meds is paracetamol. The highly effective, simple cheap Paracetamol BP product is about 49p for 16x500mg tabs (controlled price – not v profitable) so the industry re-formulates it, advertises it heavily on TV, adding honey, lemon and a bit of phenylephrine to dry up a runny nose (Lemsip – 10x1000mg sachets) the equivalent of 20 paracetamol tabs, for £6.80, or just a bit of extra packaging and 65mg caffeine (Panadol 500mg/65mg) to get you to spend £6.25 for 32 tabs. (I’d rather take my caffeine via coffee grounds in a cafetiere). Whenever possible, on over the counter products get the simple BP formulation (British Pharmacopoeia, not Petroleum!) – avoid paying for all those TV adverts of sneezing actors). 49p to over £6, that’s a lot of extra profit for no extra efficacy.
Mind you, Holland & Barret and the “alt-pharma” corporations are in my opinion, often worse, with even less regulation and less reliable evidence of proven clinical efficacy.
Thanks
It is entirely legitimate to question the influence of pharmaceutical companies in healthcare. Medicines operate in unusual markets: demand is urgent, patents create temporary monopolies, and prevention is often underfunded. These tensions deserve scrutiny.
But describing the NHS as “captured” by pharma overstates the case and risks misidentifying the system’s real constraints.
Regulatory capture would imply weak purchasing discipline or policy subordination to industry interests. Yet the NHS is one of the most price-sensitive drug purchasers in the developed world. NICE frequently rejects or restricts medicines on cost-effectiveness grounds. The UK applies explicit health technology assessment thresholds. Under VPAG, companies return substantial rebates when medicines spend exceeds agreed limits. UK launch prices are often lower than in comparable countries. Access delays more often reflect cost containment than permissive pricing.
Medicines are also not the binding constraint in NHS delivery. Roughly 9–12% of NHS expenditure goes on medicines, while around half goes on staff. The principal bottlenecks are workforce capacity, infrastructure, diagnostics, and social care integration. Waiting lists are driven by shortages of clinicians and facilities, not by drug supply. In many cases, medicines reduce pressure elsewhere in the system by preventing admissions or avoiding surgery.
The invocation of the 1910 Flexner Report as a root cause of modern pharmaceutical dominance also stretches the historical link. Flexner professionalised medical education; it did not design the economics of the 21st-century global pharmaceutical industry. Modern drug pricing dynamics are shaped far more by post-war innovation, biotechnology, global patent regimes, and regulatory frameworks. Moreover, the NHS is a publicly funded, single-payer system with centralised price control — structurally very different from the US context in which Flexner operated.
None of this denies that pharma has influence or that prevention deserves greater investment. Patent systems require constant calibration, and public health funding in the UK has been squeezed. But the NHS’s core pressures arise from demographics, chronic disease burden, workforce shortages, and capital constraints — not pharmaceutical capture.
The real policy challenge is balancing innovation, affordability, prevention, and capacity within fiscal limits. Framing the issue as “capture” simplifies a far more complex system problem.
I think this comment misses almost every point I made.
If you assume the NHS is constrained by fiscal rules, then of course you start arguing about which line item is to blame, whether that be drugs, staff, buildings. But that is not how a currency-issuing state works. The UK can always fund the NHS it needs in financial terms. The real question is what resources we choose to deploy, and why.
And that takes us to the issue you sidestep. The pharmaceutical industry does not simply sell medicines into a neutral system. It exerts enormous influence over how illness is defined, which treatments are prioritised, and why prevention is neglected. A system built around treating chronic disease is profitable. One that asks why people are ill, whether that be beacuse of poor housing, pollution, processed food, insecure work, stress or more, challenges powerful business models across multiple sectors.
So yes, NICE bargains hard on prices. That does not mean the NHS is free of influence. It means we haggle within a model of healthcare that assumes endless treatment rather than tackling causes.
The real constraint is not fiscal limits. It is political choice. We could invest far more in prevention, public health, housing, food policy and environmental protection tomorrow. That would cut costs and improve lives.
But doing so would challenge big business, including pharma. You would clearly rather not do so. I would. That is the difference. I can only presume you are made comfortable by the status quo.
My question is:
Which would be more profitable for my investors, for my pharma company to invest in a new curative antibiotic, or a weight reducing drug designed for long term/lifelong use)?
At present the suggestion is that R&D is being focussed on the latter, along with the purchase of politicians to guarantee success.
That has clinical and social consequences.
Under the current system it is clearly the latter. The development of an antibiotic may not cost any less but the current system (in the UK) doesn’t pay for innvation, but really only for cost effectiveness. In other words, does this new medicine allow the system to save money over a current existing treatment. With an antibiotic that is difficult to show without limitaiton to a very narrow group of patients (for example, resistant to current infection strains), which then makes investing in that indication not economically viable. With weight loss drugs, or any chrinic disease then yes the value is higher over a longer period of time, and this drives decision R&D investment decision making.
I think this argument seriously understates the problem with weight-loss drugs.
You assume their “value” is higher because they can be used over long periods for chronic conditions. But that assumes the benefits are real, sustained, and cost-effective once all consequences are counted. We already know that many drugs in this class carry significant risks, from gastrointestinal damage to pancreatitis and potential vision loss. If millions take them for years, the downstream cost of managing side-effects could dwarf any short-term savings.
That is exactly the flaw in a system built around disease management rather than maintaining human capital. We create an obesogenic economy based on ultra-processed food, poverty diets, stress, sedentary work, and then sell lifelong medication to cope with the consequences. That is profitable, but it is not care.
Antibiotics, by contrast, cure. They reduce illness permanently and therefore generate less long-term revenue. The market undervalues them not because NICE is wrong, but because the pharmaceutical business model rewards chronic treatment.
So this is not just about NICE thresholds. It is about incentives. When an economy rewards treating symptoms rather than preventing causes, R&D follows the money. If we want different medicines, we need a different model of public health — one rooted in prevention, environmental change and the politics of care, not endless profitable disease management.
I think we probably share the same broad aim: fewer people becoming ill in the first place, and a society that takes the conditions of health more seriously.
Where I’d gently differ is in how we interpret what’s happening now.
R&D absolutely follows incentives. Antibiotics show how difficult it is to sustain investment in medicines that are short-course, used sparingly and deliberately conserved. That’s a genuine tension in the current model.
At the same time, NICE does attempt to account for side-effects and longer-term healthcare consequences when it assesses treatments. It may not capture everything perfectly, but the system isn’t blind to risk or downstream cost.
There is, though, a wider irony. The NHS is designed to allocate care within finite capacity. It asks: given the resources we have today, what produces reasonable value for the system (not the patients)? It is not really set up to maximise national wellbeing in the fullest sense — including productivity, social participation or long-term life chances. In that sense it’s managing pressures within the system, rather than redesigning the conditions that create those pressures.
I suspect part of the difficulty lies in time. Improving housing, food systems, work security and environmental standards would meaningfully improve health — but those changes take years, often decades, to show up in statistics. Politicians operate within short electoral cycles. People feel today’s waiting lists and today’s symptoms. That makes it harder to sustain investment in reforms whose benefits may not be visible for a generation.
So I don’t disagree with the aspiration for a more preventive, care-oriented society. I just think we have to hold two realities at once: people need treatment now, and structural reform takes time. The challenge is building a path that supports those who are ill today while steadily shifting the conditions that shape health tomorrow.
Terry
There is a maxim that says when in a hole stop digging. You are still digging.
You say “Antibiotics show how difficult it is to sustain investment in medicines that are short-course, used sparingly and deliberately conserved. That’s a genuine tension in the current model.”
So, as I have argued, you prefer the medical model that manages chronic illness and does not deliver cures, profit maximising on the way.
Thanks for agreeing with me.
As I said at the outset, you clearly have an interest in the status quo. The problem is it is a) failing us badly, b) letting ever more people become sick c) curing nothing d) profit mamximising. Give me a straight answer. Why are you so interested in that? You have cinfirmed you aree. Now, why?
I don’t feel like I’m digging a hole. I’m trying to diagnose one.
We seem to agree on something fundamental: the current system isn’t producing the level of health it should. In that sense, the system itself is unwell. Where we differ is on diagnosis — and in medicine, diagnosis shapes treatment.
Explaining how incentives operate isn’t the same as defending them. Recognising that certain therapies are economically favoured under current structures doesn’t mean preferring that outcome. It means being clear about the mechanics of the system we’re trying to change.
I agree that upstream factors — housing, food systems, environmental standards, work insecurity — are central to long-term health. If we want fewer people becoming chronically ill, those are critical levers. I don’t dispute that.
At the same time, millions of people are already ill and depend on treatment capacity now. A stronger preventive framework would take years, likely decades, to materially reshape disease prevalence. In the meantime, ageing, genetics and biology don’t pause. So any serious reform has to operate on two tracks: reduce upstream harm while maintaining downstream care.
Where I’m cautious is in collapsing this into a single causal story about pharmaceutical preference for chronic treatment. Incentives matter — absolutely. But so do political time horizons, institutional design and real-world capacity constraints. If we misidentify the dominant drivers, we risk prescribing solutions that feel morally satisfying but prove operationally fragile.
If we’re going to challenge the status quo, the challenge has to be precise. That’s all I’m attempting to do.
And as in football, it’s usually better to play the ball than the man.
I am playing the ball.
I do not think you are even on the field.
I do not think we are getting anywhere. All I get from you is excuses.
It may be that we’re not quite playing the same game.
I’ve tried to engage with the structure of the argument — incentives, capacity, political time horizons — agreeing where I agree and questioning where I think the diagnosis is incomplete. That isn’t a defence of the status quo; it’s an attempt to examine how change might realistically happen.
When the discussion shifts from those structural points to assumptions about motive, it becomes harder to keep it focused on substance.
If we’re not engaging the same questions, then we may simply be talking past each other. However I’ve appreciated the opportunity to test the ideas and to reflect on the responses.
Motive matters
Motive is what is driving us to ruin via neoliberalism
Motive is everything in political economy
I agree with you that prevention and the wider determinants of health deserve far greater priority. Poor housing, pollution, ultra-processed food, insecure work and chronic stress all shape disease patterns. When economic systems allow those costs to fall on the public while profits remain private, that is a serious structural problem. Those externalities are real.
Where I differ is on the nature of constraint and attribution.
Even if we accept that a currency-issuing government is not financially constrained in the same way as a household, healthcare is still limited by people, skills, time and physical capacity. Doctors, nurses, public health teams, scanners, operating theatres and community services cannot be expanded overnight. Training pipelines and infrastructure build-out take years. That is the operative limit on what the NHS can deliver at any moment.
Prevention also requires resources: environmental inspectors, housing upgrades, planning reform, school programmes, local authority capacity. Those are not abstract fiscal choices; they are competing claims on finite labour and institutional bandwidth.
It is also important to distinguish between upstream drivers of ill health and downstream treatment. Industries such as processed food, fossil fuels and certain labour practices demonstrably contribute to disease burdens that are not fully priced into their business models. That is a legitimate critique of modern capitalism.
Pharmaceutical companies operate largely at the treatment end of that chain. They may profit from managing chronic disease, but they do not typically create the housing, food or environmental conditions that give rise to it. Their commercial opportunity often arises because those wider externalities remain unaddressed.
That does not exempt pharma from scrutiny. Intellectual property frameworks and pricing arrangements should be continually assessed to ensure public value. But framing the system primarily as pharmaceutical dominance risks obscuring where many of the health-generating distortions originate.
If we want fewer chronic conditions, the harder political work lies in regulating the sectors that generate risk in the first place — not only in challenging those that develop therapies once illness has occurred.
I think there’s also a practical dimension to this that’s easy to overlook.
For an individual patient, properly investigating “root causes” is time-intensive. It can mean exploring housing, diet, work stress, sleep, trauma, social isolation, financial insecurity — all of which may be highly relevant. Done properly, that isn’t a 10-minute interaction. It can take multiple long consultations and input from different professionals.
GPs aren’t philosophically committed to symptom management. They’re operating within throughput reality. When you’re seeing 30–40 patients a day, you stabilise risk, follow evidence-based guidance, and manage what you can within the time available. That’s not ideological — it’s operational.
Scaling deep, individualised root-cause medicine across millions of people would require dramatically more clinicians, dietitians, psychologists, community workers and infrastructure. Even if the funding is available, the trained workforce and institutional capacity don’t materialise overnight. That’s the constraint I’m pointing to.
This is where prevention properly understood comes in. If we want to address root causes at scale, the leverage isn’t primarily longer GP consultations — it’s environmental and structural change: housing standards, food policy, urban design, air quality, education, labour conditions. Those reduce exposure upstream so fewer people need downstream management in the first place.
So I absolutely agree that prevention deserves more political weight. I just don’t think the dominance of symptom management is primarily a pharmaceutical story. It’s a systems design and capacity story. Pharmaceutical companies have largely optimised to the reality of the world as it is — treating disease within existing social and economic structures — because that is what the incentive framework rewards. That may be uncomfortable, but it is economically rational.
I think you are still assuming the medical model itself is right, and that is the problem.
You describe doctors managing throughput, and of course they do. But that only makes sense if we accept that medicine is about disease management rather than pathways to wellness based on care. That assumption is rarely questioned. We treat illness after it appears, rather than asking why it is so widespread in the first place.
Most modern ill-health is socially created: poor housing, bad food, pollution, insecure work, stress, loneliness. These are not random events. They are the by-products of the economic system we have built. If we ignore those causes, then of course we need armies of clinicians and endless prescriptions.
So yes, capacity matters. But capacity is not neutral. We choose to spend vast sums on downstream treatment and far less on upstream prevention. That reflects political priorities and the influence of industries that profit from chronic disease — including, but not limited to, pharma.
The issue is not that GPs lack time. It is that we refuse to design an economy that maintains human capital in the first place. A politics of care would ask different questions: why are people ill, how do we keep them well, and what social investment is required?
Until we change that frame, we will keep managing disease instead of creating health.
I agree that upstream reform — housing, food systems, urban design, labour conditions — would reduce a great deal of avoidable illness over time. That work matters, and it would likely reshape population health across a generation.
At the same time, a strong health system inevitably keeps more people alive for longer. When people survive heart attacks, cancers and infections that would once have been fatal, they age into periods of higher complexity. Multimorbidity becomes common. Lifetime utilisation rises. In purely economic terms, early mortality is cheaper than long-term survival — an uncomfortable point, but a real one.
So part of what we are experiencing is not simply systemic failure. It is also the combined effect of demographic ageing and medical success.
Even in a society that made major progress on housing, lifestyle, food quality and environmental standards, we would still face ageing, genetic disease, cancer and neurodegeneration. Upstream reform reduces preventable burden; it does not eliminate the need for care.
And the transition matters. Rebuilding social and economic structures takes decades. Meanwhile, millions of people require treatment now. If downstream capacity is weakened before upstream improvements have meaningfully reduced demand, the immediate human consequences would be significant.
That’s why I see this as layered rather than substitutive. We need to reduce avoidable harm upstream while sustaining the clinical capacity to treat illness downstream. Over time, better upstream conditions may ease the load. But they don’t remove the need for a functioning health system.