Image: Tax Credits
The reinstatement of a genuinely national and democratic health system will have to overcome the predictable accusations of being led by dinosaurs who are 'anti-change' and wish the NHS to remain crystallised in its 1948 form. With that in mind, OurNHS will be commissioning and publishing a number of pieces on the wider, long term future of the NHS, what improvements could be made, how the institution can grow and evolve organically while remaining firmly in line with its founding principles. We start with Anna Coote on 'prevention over cure'.
Public spending on the National Health Service has outstripped inflation every year of its life, with an average real growth rate of 4 per cent a year between 1949/50 and 2010/11, when total spending for health and social care reached £137.4 billion. For the first time now, the growth is halted. Unless the government has a change of heart, over the next four years the NHS faces the tightest spending regime in 50 years.
Yet everyone expects demand for health services to grow. There’s an ageing population and growing rates of obesity, depression and other chronic diseases. Following global trends, we live longer, but sicker. If the NHS can’t bridge the gap between funding and demand then services will deteriorate. To avoid that, says the Institute for Fiscal Studies (IFS), we must choose between ‘reconsidering the range of services available free of charge to the whole population’ and raising taxes to pay for more and better health care.
But is that really the only choice we have? There is another option, which is to reduce demand by preventing ill-health, so that we live longer and healthier, needing less health care, not more. Instead of spending all our political capital and personal energy on ‘saving the NHS’, we could be trying to tackle the causes of illness and keeping people well.
Experts have urged policy makers to do this for decades. Time and again, they have warned that social and economic disadvantages cause and entrench ill-health. The Black Report in 1980 calls for a broader understanding of the meaning of health and how to achieve it: ‘This will include improvement in incomes as well as better housing and environmental and working conditions’. The Acheson Report in 1998 repeats the message: ‘The weight of scientific evidence supports a socioeconomic explanation of health inequalities. This traces the roots of ill health to such determinants as income, education and employment as well as to the material environment and lifestyle.’ The Wanless Report in 2004 warns of the dangerously high costs of failing to prevent illness and urged the Department of Health to ‘re-orientate its role from caring for the sick to promoting good health’. The Marmot Review in 2010 points out that: ‘In England, people living in the poorest neighbourhoods will, on average, die seven years earlier than people living in the richest neighbourhoods’; these inequalities are caused by ‘inequalities in society - in the conditions in which people are born, grow, live, work and age.’
Mountains of evidence support the case for tackling the underlying causes of ill-health, which are social, economic and environmental. Rates of illness could be radically reduced over time if the balance of investment and action were shifted towards preventing illness instead of just treating it.
A new report from the National Audit Office (NAO) finds that five government departments - Health, Education, Home Office and Ministry of Justice - each devoted a mere six per cent of their budget to preventative programmes . Yet , as Amyas Morse, head of the NAO, confirms: ‘A concerted shift away from reactive spending towards early action has the potential to result in better outcomes, reduce public spending over the long term and achieve greater value for money.’
By restraining demand in this way, we could sensibly plan for a high-quality NHS, providing free care to those who need it (because not all illness is avoidable) and with a long, healthy future ahead of it, without being locked into an upward spiral of costs. Why, then, is so little done? Why, over the decades, has the NHS grown exponentially, gobbling up resources, with little more than four per cent of the health budget set aside for preventing illness? If we can’t answer this question and change direction, we’ll be stuck with the rotten choices set out by the IFS.
The New Economics Foundation (nef) has been exploring the reasons why preventing harm – in social, environmental and economic terms – is popular in theory but not in practice. First, it’s important to understand that there are different levels of prevention. In the health sector, these may be called ‘primary’, ‘secondary’ and ‘tertiary’. ‘Primary’ measures aim to prevent harm before it occurs and usually focus on whole populations. The ban on smoking is one example; taking a broader view, free universal education is another. ‘Secondary’ measures aim to mitigate the effects of harm that has already happened and focus on people considered ‘at risk’. These would include cancer screening, or programmes to give children in poor families a ‘good start in life’. ‘Tertiary’ measures try to cope with the consequences of harm and focus on specific cases, to stop things getting worse. Think of surgery to remove malignant tumours or steroid inhalers for people with asthma. Action at tertiary level should be a last resort. But it is entirely dominant in the health sector. Without tackling the underlying causes of illness, the same problems recur, turning people into ‘patients’ who keep coming back for more treatment and care.
There are several reasons why preventing harm – especially at primary level - takes a back seat. For one thing, the logic of prevention cuts against the grain of the ‘rescue principle’ that defines contemporary medicine, as well as philanthropy and charity. Doctors, nurses, social workers, charity workers, faith groups, philanthropic funders – with a few exceptions, they all prefer to help those who are already in need. The greater and more urgent the need, the stronger their commitment. As times get harder they increasingly target their help on the most acutely ill, the most’ at risk’. Yet people usually fall into these categories because there has been a failure to prevent harm.
Overcoming this kind of barrier means tackling professional culture and status, and changing attitudes, hierarchies, incentives and regulatory regimes. Crucially, it means challenging the ethical implications of clinging to the status quo. When does one cross the line between (a) practicing one’s profession to the best of one’s ability, and (b) securing one’s own employment, income, identity and status by failing to prevent the needs that one is trained to meet? The domain of healthcare and the pre-eminence of clinical treatment are strongly defended by rich, high-status, predominantly male and mightily established professional institutions. Outside the City of London, there are no cohorts with comparable powers. The point is not that these institutions actively oppose the prevention of illness. They instinctively employ what could be called ‘passive resistance’: agree that it is a good thing and do little or nothing about it.
At the same time, new pharmaceuticals and awe-inspiring clinical developments have changed expectations. We are encouraged to want more and better interventions, to repair previously unrepairable bits of our bodies, and to stave off death (it would seem) indefinitely. Supply drives up demand: it may work in open markets, but it can’t work for long in a publicly funded service with a finite budget.
Evidence presents another kind of barrier. If you give an arthritic patient a hip operation, you have an immediate, tangible result that you can measure. The same goes for most tertiary and secondary activities. Move upstream to prevent arthritis, for example by encouraging healthy eating and exercise, and you find that it takes much longer for interventions to have an effect. The causal pathways become more complex and indistinct, creating an evaluation bias against primary prevention.
It is much easier, especially in these days of ‘evidence-based policy making’, to make the case for investing public (or even charitable) funds in interventions where the outcomes are certain, and where measurable benefits can be reaped in the near future. Politicians want to show their voters that their policies deliver clear results about things that really matter to them, before the next election. The political cycle, leaning heavily towards short-term crowd-pleasing, puts a firm brake on the longer-term ambitions of preventing harm.
The voting public have an enduring love affair with the rescue and cure component of the NHS. White coats and stethoscopes, flashing blue lights, emergency rooms. Open heart surgery, MRI scanners, trolleys being rushed along corridors. We love it all and we want to save it. Yet in fact, what is eating up the healthcare budget is not all that telegenic heroism, but the unglamorous daily grind of processing people with largely avoidable chronic conditions – heart disease, diabetes, arthritis, asthma, hypertension and depression, to name but a few. Effective primary intervention would cost far less than coping with these conditions once they have set in. It would call upon other budgets – for education, housing, transport, work and benefits, for example.
But for the health budget, there are problems of overlap and timing. For political and humanitarian reasons, there would have to be increased investment in primary prevention without much noticeable decrease in secondary and tertiary measures. When we consider how rescue and cure tend to have immediate, tangible and measurable results, while primary measures are long-term, less concrete, less predictable and harder to measure, the odds seem stacked against shifting the balance of investment towards prevention.
When William Beveridge planned a free national health service, he saw it as an investment that would help prevent illness and therefore reduce expenditure on healthcare in future. He couldn’t foresee the complex ways in which, over time, new technologies, profit-driven pharmaceutical companies, powerful professional interests and changing demographics would fuel expectations and demands, driving up costs inexorably. Now the NHS is in mortal peril. Unlike us, it doesn’t have to die one day. But if we don’t tackle the underlying cause of its life-threatening illness – the avoidable growth in demand for services – we’ll have more than the neo-liberal ideologues to blame for its demise.