The economic consequences of preventing illness are highly complex. Just comparing the costs of prevention with the direct treatment costs that should be avoided is far too simplistic. The true economic impact of preventative measures can often only be assessed sensibly with the aid of a sophisticated analysis. Any other approach can be very misleading.
Excessive consumption of alcohol is an example of a cause of illness that is in principle preventable. However, many economic arguments do not take the full picture into account. Attacking alcohol on the basis of the cost to the NHS, the police and the emergency services along with the links to illness, antisocial behaviour and crime is fashionable. However, the fact that spending on alcohol in the UK contributes around £15 bn of tax per year is often conveniently overlooked.
Tax revenue from tobacco products in the UK is around £10 bn per annum. For perspective this contribution to Government finances is about double the entire cost to the NHS of treating cancer (not just that linked to tobacco).
Seeking to avoid unnecessary deaths and avoidable suffering is an end in itself and reflects the values of a civilised society. This principle is embodied in the first provision in the Health and Social Care Act 2012, which states:
“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) In the physical and mental health of the people of England, and
(b) In the prevention, diagnosis and treatment of physical and mental illness.”
This wording leaves no doubt that the prevention of illness and not just the treatment is a major, intended objective of the NHS. However, we must not delude ourselves that the principal reason for this policy is economic or to save money.
Most programmes designed to reduce the risk of developing specific illnesses will have three phases from a financial standpoint.
- In the short term public expenditure is likely to rise because taking the initial, required action will cost money before benefits can be expected. In some cases such as cutting back on smoking and alcohol abuse there will also be a reduction in tax revenues.
- When the incidence of the targeted illness begins to be affected, money will be saved because people who avoid the illness will not need to be treated for it.
- A person who avoids the illness will have an increased life expectancy. Older people generally cost the NHS more. As a result of the person living longer, there will be an eventual increase in NHS spending. The general pattern in healthcare is that the more successful we are in extending longevity, the more healthcare costs will eventually rise.
How the above three phases will balance out varies greatly from project to project. The answers are relevant to what can be afforded. The commonest error is missing out the third stage or including it in too superficial a way.
Any financial analysis will be misleading if it does not give consideration to all three phases above. An example is provided by the treatment of very obese people. In their interests they should lose weight. Firemen may understandably not like being repeatedly called to help a very obese person to stand up. However, the morbidly obese person will have a short life expectancy. It is very possible that the total public expenditure on the overweight individual, over the rest of his life, may be lower than for a healthy slim person of the same age.
The most serious illnesses are those that are frequently terminal or lead to a marked long-term reduction in the quality of life. The commonest causes of death in all advanced countries including the UK are disorders affecting the circulation of blood (“cardiovascular“conditions) and cancer. They, together, account for around 60% of all deaths in the UK. Other important killers in the UK include respiratory diseases (14%), digestive disorders (5%) and accidents/injury (3%). The last of these is different from the others as the resulting deaths do not arise predominantly in the elderly. Accidents and injuries occur at all ages and so reduce each life by more years than causes of mortality occurring mainly in old age. In terms of lost life years accidents and mortality come among the top three killers in the UK.
The commonest major threats to the quality of life that do not account for a high proportion of deaths involve arthritis or the long-term deterioration of the nervous system, particularly the brain. These conditions are important to patients because they are generally incurable and take their toll over many years.
There is no widely accepted consensus about how to reduce the risk of getting arthritis or impaired nerve function. Further research will hopefully provide answers in these areas eventually. However, in the case of the leading causes of death, there are already definite, known ways of reducing the risks. The required changes in lifestyle are largely in the hands of the individual and range from common sense measures to regular medical check-ups and taking medicines as directed by the doctor.
I am not suggesting that the NHS ought to be responsible for all Government action to reduce mortality. Some of the work, for example in preventing accidents, is and should be done by other government agencies.
My view is that the main role of the NHS and Government in healthcare is to educate people (e.g. through public awareness campaigns and schools) and to make facilities available, rather than to compel anyone to live a healthy life. At the same time we hope that people taking high risks with their health will be encouraged to see the wisdom of change.
The moral case for compulsion is strongest where children are concerned. Just as children require special protection from tobacco and alcohol so they require help in avoiding an unhealthy diet. Jeremy Hunt (Secretary of State for Health) has rightly added Government support to the campaign to stop prepared children’s meals from containing too much sugar, fat and salt. If food companies cannot find a way of satisfying this requirement legislation will be introduced. Many other moves are possible including educational initiatives and making information available. Adults might, for example, benefit from estimates of calories being put on restaurant menus rather as they are on packaged food sold in shops.
The guiding principle in preventing illness as in treating patients must be to provide the best options for patients that we can afford, now and in the future. We must not lose sight of this goal and be misled by insensitive economic analysis. After all, the financial problems of the NHS could in theory be solved by increasing smoking and alcohol consumption five-fold. The combined tax take can then be calculated at around £125 bn per annum, enough to fund the entire NHS. The long-term problem of an ageing population would be eliminated as early death became more common. However, nobody of whom I am aware would be mad enough to advocate such an approach. We would be making the same error in a less overtly ridiculous way if cost saving rather than patient benefit became the main driver in preventing illness. The sensible opportunities are enormous and we must try to adopt as many as we can.