This lecture is the intellectual property of Professor S.W.Hawking. You may not reproduce, edit, translate, distribute, publish or host this document in any way with out the permission of The Stephen Hawking Estate. Note that there may be incorrect spellings, punctuation and/or grammar in this document. This is to allow correct pronunciation and timing by a speech synthesiser.
'Can you hear me.
I would like to thank Discourse for inviting me here today, and the Royal Society of Medicine, for hosting this important meeting on the National Health Service and its future. Like many people, I have both a personal experience of the NHS, and an interest in it, that goes beyond the personal, and is core to our view of a civilized society.
In 2009, I went to the United States to receive the Presidential Medal of Freedom from President Barack Obama. At the time of my visit, President Obama was campaigning for the Affordable Care Act, in the face of intense political opposition. While it is not the sort of free publicly funded and provided care we have in Britain, the Affordable Care Act means that insurance companies must offer an option of a basic level of health insurance, with lower premiums than before. At the time of my visit, an editorial was published in the US financial newspaper, Investors Business Daily. The editorial stated, ‘People such as scientist Stephen Hawking, wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.’
Unfortunately for Investors Business Daily, I got to hear about this. I refuted its claims saying that not only am I British, and very much alive, but in fact wouldn't be here today if it were not for the NHS. I have received a large amount of high quality NHS treatment, without which I would not have survived. I will tell the story of some of that treatment in my talk today.
The plan for my talk is to say something about my life and science. As you will hear, in my case, medical care, my personal life and scientific life are all intertwined. I will then share my thoughts about the NHS, about science and its role, and what needs to be done to protect the NHS.
As some of you may have seen from the film The Theory of Everything, in which Eddie Redmayne plays a particularly handsome version of me, in my third year as a student at Oxford I noticed that I seemed to be getting clumsier. I fell over once or twice, and couldn't understand why. I was somewhat disgruntled to be told by a doctor at the time, to lay off the beer but I suppose that is understandable when talking with a student. A year went by, and I had moved to Cambridge to undertake my PhD, but one Christmas, I went skating on the lake at St Albans, my home town, and I fell over again. But this time I couldn't get up, so my mother took me to the family doctor, who referred me to hospital for tests. I was just over 21 years of age.
It was 1962, and the tests then, were somewhat more primitive than they are now. I stayed in hospital for two weeks. A muscle sample was taken from my arm, I had electrodes stuck into me, radio-opaque fluid was injected into my spine, and the doctors watched it going up and down on X-rays, as the bed was tilted. After all that, I still wasn't told what I had, and gathered from the doctors’ conversations, that it, whatever ‘it’ was, would only get worse, and there was nothing they could do except give me vitamins. I could see that they didn't expect them to have much effect. I didn't want to ask more questions but I learnt, years later, that I had motor neurone disease. The realization that I had an incurable disease was a bit of a shock. I felt it was unfair, how could something like this happen to me.
I had no idea what my future would turn out to be, and was advised to return to Cambridge and carry on with my research into general relativity and cosmology. While struggling with my illness, I was still able to make important advances in our understanding of the universe; in particular I showed that the universe had to have had a beginning, in a singularity or Big Bang.
But it was a confusing time, and I discovered Wagner, who seemed to me to be as tragic a figure as I felt at the time. It was also around then, that I met Jane, my first wife, and at the same time was awarded a research fellowship at Gonville & Caius College, in Cambridge. Things were looking up. I had a job, and the fellowship meant that Jane and I could marry, which we did, in July 1965. The disease progressed rapidly at first. But it then slowed down, and I got through the rest of the 60s and then the 70s, with some increasing disability. But the birth of our three children, Robert, Lucy and Tim, helped enormously with the difficulties of the motor neurone disease symptoms. I felt lucky, I never imagined that we would be able to have three beautiful and accomplished children, and they are the best achievements in my life, if you can call children, achievements.
It was a few days after the birth of Lucy, in 1970, that I had a eureka moment. While getting into bed one evening, I realized that the area of a black hole's horizon could only increase, not decrease. This eventually led me to discover that black holes were not really black, they had a temperature and would glow red like hot coals. I had discovered a concept that is now named after me, Hawking Radiation. My discovery unified quantum theory, gravity and thermodynamics, and was actually very controversial at the time. It is now accepted and understood as being the key to unlocking the nature of quantum space-time. However, another thing it proved is that a disability need not stop people thinking, achieving, and getting on with life. We just have to find new ways of doing things.
By the early 80s, I continued to get worse, and had prolonged choking fits, because my larynx was weakening, and was letting food into my lungs as I ate. And in 1985, I caught pneumonia on a trip to CERN, the European Centre for Nuclear Research, in Switzerland. This was a life-altering moment. I was rushed to the Lucerne Cantonal Hospital, and put onto a ventilator. The doctors suggested to my wife, Jane, that things had progressed to the stage where nothing could be done, and suggested to her that they turn off my ventilator to end my life. But Jane refused, and had me flown back to Addenbrooke's hospital in Cambridge, by air ambulance.
As you may imagine this was a very difficult time, but thankfully the doctors at Addenbrooke's, tried hard to get me back to how I had been, before the visit to Switzerland. However, because my larynx was still allowing food and saliva into my lungs, they had to perform a tracheostomy. But, and as most of you will know, a tracheostomy takes away the ability to speak. For a while, the only way I could communicate was to spell out words, letter by letter, by raising my eyebrows when someone pointed to the right letter on a spelling card. It is pretty difficult to carry on a conversation this way, let alone write a scientific paper. Your voice is very important. If it is slurred, as mine was, people can think you don't understand things, and treat you accordingly. Before the tracheostomy, my speech was so indistinct, that only people who knew me well could understand me. But at least I could communicate. I wrote scientific papers by dictating to a secretary, and I gave seminars through an interpreter, who repeated my words more clearly. Life went on.
Luckily, and somewhat surprisingly, a computer expert in California, named Walt Woltosz, heard of my difficulties. He sent me a computer programme he had written called Equalizer. This allowed me to select whole words from a series of menus on the computer screen on my wheelchair, by pressing a switch in my hand. Today I use a program called ACAT, developed by Intel, which I control by a small sensor in my glasses via my cheek movements. When I have typed what I need to say, I then send it to a speech synthesizer, which relays it in the voice recognizable as belonging to me. I identify with this voice, and have no intention of changing it for a more naturally sounding one. When I controlled the programme with a hand switch, I could boast that I could talk with my mouth full. Now that I use a cheek switch, I can no longer say this, because chewing activates the switch, and what I would say would be nonsense.
But the situation with my larynx was not improving, and I was finding it increasingly difficult to eat and breathe. It was then a second life-altering coincidence occurred. In 1998, my second wife, Elaine, and I, were on a flight to Crete to attend a conference. A fellow passenger on that flight was David Howard, an Ear Nose and Throat surgeon. He introduced himself as he had been watching me struggle to eat and breathe, and he told us that he could probably solve the problem for me, as he was a surgeon in London specializing in reconstructive throat surgery. We exchanged contact details, and I began to consider David's offer.
The reason I needed to consider throat surgery was, because after the tracheostomy in 1985, I had a plastic tube in my trachea, which prevented food and saliva from getting into my lungs. Over time, the pressure in the cuff, which keeps the plastic tube in place, damaged my trachea, and made me increasingly cough and choke. Once back in Cambridge, we were also coping with my weight loss. By then I weighed a mere 6 stone, with almost continual chest infections, which were a drain on my general health. The most unpleasant thing for me was that I had to cough up a lot of the food that had slipped into my lungs during each meal. So, after a few more weeks, we decided to invite David Howard to our home, so he could explain what his surgery would involve.
David admitted that the odds of me surviving the reconstructive throat surgery were slim, but then we also knew that my odds of enjoying life, or surviving for much longer, were also minimal. I decided to have the operation. I was admitted to the old Victorian hospital, the Royal National Throat Nose and Ear Hospital, in Gray's Inn Road, London, on the 4th of May 1999, less than a year after that coincidental meeting on the flight to Greece. By then my larynx had no useful function remaining.
Contrary to popular belief, the most important function of the larynx is not the voice, which I had already lost, it is the protection of your lungs by closing off the airway each time you swallow. The tracheostomy that Roger Gray did in Cambridge, in 1985, had done a fine job, but years of having the plastic cuff blown up inside my trachea, meant that it had almost eroded through into my esophagus. The wall between the two tubes was paper thin, and this was now a life-threatening situation. In addition, I was at that time at risk of another life terminating condition, bronchopneumonia, especially as my weight was so low with malnutrition. I had no physical reserves. It was clear, the risks of the laryngectomy surgery were overwhelmingly outweighed by the risks of no surgery. I had the operation, and was sent home with Elaine and the team sixteen days later. That was 18 years ago.
Thanks to David and his team, my laryngectomy made my lungs safer, and my work of breathing easier, and I was able to breathe on my own for a further five years. However, in 2004, my levels of oxygen began to fall at night, and I was rushed into hospital, where I remained for four months. I was eventually discharged with night-time ventilation, and the doctors told my wife that I was coming home to die. I have since changed my doctor. For the last four years, I have been on full-time ventilation, using a Nippy 3+ ventilator on the back of my wheelchair.
I feel lucky, my disability has not been a serious handicap in my scientific work, and it has not prevented me from leading a full and active life. I celebrated my 75th birthday, with an international scientific conference in Cambridge, in June this year. I still have a full-time job as Director of Research, at the Centre for Theoretical Cosmology, at Cambridge, and am soon to publish another scientific paper on quantum black holes, with two colleagues. This is an exciting time to be a theoretical physicist. For example, the recent announcement of the direct detection of gravitational waves, ripples in the fabric of space-time, by the LIGO collaboration, verified a longstanding prediction of Einstein's general theory of relativity. The detection of gravitational waves was something I worked on at the very beginning of my career, so this advance in fundamental physics spans my whole scientific life.
So you see that I have had a lot of experience of the NHS, and the care I received, has enabled me to live my life as I want, and to contribute to major advances in our understanding of the universe.
Sometimes I have had to challenge medical opinion to get the care I need. But the important thing is, that the principles of the NHS mean that there is good care available, and that it is provided, at the point of need, to everyone, without regard for personal circumstance, or ability to pay. These are the principles of universal and comprehensive provision, on which the NHS was founded. It is important that care is available, without any of the added burdens for people that come with private health insurance. To be able to access that care from doctors and hospitals, without having to go through an intermediary in the form of an insurance company, or deal with massive amounts of paper work before and after, is crucial to good health. My team and I have had experience of dealing with health insurance companies in the US, and that experience shows that a health insurance company will try its best not to pay.
As well as my direct experiences, I have medically trained nursing staff in my care team, and so I hear about changes in the NHS through them. I am aware of the increase in private provision of care and the inefficiency that causes. The huge increase in the use of private agency staff, for example, inevitably means that money is extracted from the system as profit for the agency, and increases costs for the whole country. Personally, I have had an unhappy experience with an American owned profit driven nursing agency. They were eager for my custom but made a number of errors, and withdrew their service at short notice after eight months.
In September 2016, together with Professor Robert Winston, and Professor Neena Moedee, President of the Royal College of Paediatrics and Child Health, I co-signed a letter to The Guardian newspaper, calling for health care policy to be based on peer reviewed research and proper evidence. The specific issue on which the letter was based, was the so called weekend effect. Secretary of State for Health, Jeremy Hunt, had claimed that thousands of patients die unnecessarily because of poor hospital care at the weekend. He used this, as an argument that we need to implement a seven-day a week NHS.
I had mixed feelings about the issue. Having spent a lot of time in hospital, I would like there to be more services available in hospitals at weekends. It has been frustrating for me personally, when everything slows down at the weekend in hospital. Also, it seems possible that some patients spend more time in hospital than is necessary, because certain diagnostic tests can only be done on weekdays. So in principle, a seven-day service could be of benefit to patients, and to the NHS as a whole.
However, any change like this must be properly researched. Its benefits over the current system must be argued for, and evidence for them presented, and the implementation properly planned and costed, and the necessary resources provided. If there are no more doctors and nurses, for example, then a seven-day NHS will necessarily mean fewer staff, and a worse service on weekdays. There has been no proper due diligence done in the case of the so called seven-day NHS, and that was the whole point of our letter, and the reason I signed it.
Let me quote from the letter, as it illustrates a further point I want to make. We wrote, ‘The evidence for these claims is not supported by reliable research. Of the eight papers cited by Hunt, only four are peer-reviewed. Three use data from the same population, and are not independent, with just two from the last decade. The remainder are not peer-reviewed medical literature, and are only opinion pieces. Critically, when his claims began, at least 13 independent peer-reviewed papers were available to the secretary of state, that refute his definition of a weekend effect. Hunt has cherry picked research.’
Speaking as a scientist, cherry-picking evidence is unacceptable. When public figures abuse scientific argument, citing some studies but suppressing others, to justify policies that they want to implement for other reasons, it debases scientific culture. One consequence of this sort of behaviour is that it leads ordinary people to not trust science, at a time when scientific research and progress are more important than ever, given the challenges we face as a human race.
There are two ways to think about a national health care system. One is that the most humane and civilized system, is one in which all people are provided for equally, based only on their needs, no matter who they are, rich or poor, young or old. I believe this, and have made public statements that we must prevent the establishment of a two-tier system, with the best medicine for the wealthy, and an inferior service for the rest.
The other way to think is that a healthcare system needs to be organised in the most efficient way, so that there is as little waste of labour and resources, as possible. International comparisons indicate that the most efficient way to provide good health care, is for services to be publicly funded and publicly run. The more profit is extracted from the system, the more private monopolies grow, and the more expensive health care becomes. For that reason, I have also made public statements, that the NHS must be preserved from commercial interests, and protected from those who want to privatize it.
So, these two things coincide: the most humane system is the most efficient system. This means that when politicians and private healthcare industry lobbyists claim that we cannot afford the NHS, this is the exact inversion of the truth. We cannot afford not to have the NHS. A publicly provided, publicly run system is the most efficient, and therefore a more cost-effective way to provide good healthcare for all.
What is to be done? A physicist like me, analyses a system in terms of levels of approximation. The NHS, and the question of how to provide good quality health care to everyone, is hugely complex. That doesn't mean that we cannot understand it in broad terms. To a first approximation then, one can see the situation facing health care in this country in terms of forces with different interests. The future will be determined by the relative strength of those forces. On the one hand, there is the force of the multinational corporations, which are driven by their profit motive. In the US, where they are dominant in the health care system, the corporations make enormous profits, health care is not universal, and is hugely more expensive for the outcomes, than in the UK. We see that the direction in the UK is towards a US style insurance system run by the private companies, and that is because the balance of power right now is with the private companies.
On the other hand, there is the force of the public, and of democracy. Opinion polls consistently show that the majority of the public agrees with me, and is in favour of a publicly provided NHS, and opposes privatisation, and a two-tier system. So the public already supports the core principles of the NHS as the fairest system, and so what the public needs is the knowledge that this is also the most efficient and cost-effective system. As I understand many here today, including a group called Bring Back the NHS, are part of a growing movement to empower the public with exactly that knowledge, as the NHS reaches its 70th birthday next year.
Thank you for listening.'