The Darzi Interim Report, published last week by the Institute for Public Policy Research, sets out to provide a reliable forecast of the financial gap between the health and care services the country will need by 2030 and what current financial policies will provide. In the most generous scenario it is estimated an additional £60 billion of funding must be allocated to health and social care by 2029/30.
But just how healthy is the statistical analysis that generates the £60bn?
Unfortunately it seems to be flawed in two main respects:
- No account is taken of managing demand;
- Acute hospitals, the most expensive sector of the NHS, are the basis for the projections – this despite the report itself saying provision will shift from acute to chronic conditions.
In 1948, the NHS was created with three core principles, to which was added, in 2011, a constitution of seven more principles and a set of values. With exceptions for teeth, specs and prescriptions, healthcare is unpaid for at the point of use for all who do not wish to, or cannot, pay for private treatment.
Strangely, there is no mention of what the NHS should actually provide. One cannot buy health or longevity so it cannot be either of those. The unstated offer seems to be that the state would pay for the time, facilities, technology and dedication of UK health care professionals. Does that include cosmetic surgery? Aromatherapists? Osteopathy? Treating gender dysphoria through psychiatry and/or surgical reassignment? No boundary has ever been set for what the NHS should provide, apart from medicines and devices quangos deem poor value for money. Instead we’re governed by convention. This has made restraining demand more than difficult.
This is not a big surprise. If ice cream had to be supplied at ever increasing levels of quality but free to all, ice cream factories would have long waiting times and reluctant financial backers. The reason other countries have more efficient and better suited health systems is their use of copayment to manage demand– as indeed we have done for teeth, specs and prescriptions and they do through insurance and low level charges.
Sadly the Darzi Report makes no mention of managing demand and it sets the definition of health very wide: “Health is much more than the absence of illness or disease. The World Health Organisation defines it is “a state of complete physical, mental and social wellbeing” (p.10).
The report claims, based solely on Grossman 1972: “Better health is an investment in ourselves and each other: this means an individual’s capabilities and assets, which in turn determine their economic potential” (p.9). One wonders if the Report’s authors actually read the article they cite. It was a purely theoretical model with no empirical validation.
And it leads to an opposite conclusion, one which the report contradictorily comes to as well inciting Licchetta and Stelmach: “Each generation expects more from their health and care system than their predecessors. Indeed, there is significant evidence that rising expectations has been one of the biggest drivers of health and care costs in the last century” (p.46). These two positions can’t be held together. We need to address demand as well as supply.
If we are to address demand, we need to understand the impact of the scale of demand is likely to be coming our way. Yet the report worryingly fails to do so. Beyond simply asserting that “social care which, if anything, is facing an even larger funding gap” and that “as a bare minimum the system will require an extra £10bn.; and that is just to maintain the existing level of provision” there is nothing to suggest the report’s authors have understood the problem they’re facing in the real world.
The projections grow demand pro rata to life expectancy, i.e. every year of life is assumed to have the same cost. But this is not true. As the report itself noted, the last years of life are far more expensive, for the NHS, than the previous ones. The last year is usually the most expensive of all.
Lord Darzi should be aware that each of us has only one last year of life no matter how long we live. Longer healthy life expectancy actually reduces NHS costs solely by deferring the expensive final years.
The Report subscribes to the current wisdom that bad habits, such as smoking and obesity, contribute massively to NHS costs even though the reverse is probably true for smoking and excessive drinking which feature high taxation followed by reduced calls on the pensions pot. Snowden and Tover calculated the smokers’ net contribution, after the additional health costs, to the public purse of £14.7bn a year. Mark Tovey showed that obesity accounts for less than 2% of the NHS budget for similar life-shortening reasons.
Treatment is increasingly shifting away from acute hospitals towards the more cost-effective care now possible in the community. The report itself says that medical care will switch to treating chronic rather than acute conditions: “This transformation – part of the shift from acute to chronic illness” (p.10) and “This shift [to chronic] will require us to get better at preventing these chronic conditions, shifting their onset as late as possible into life. Once people have them we will need to make sure care is community based and led by the patient rather than clinician led in the acute setting. It will also mean valuing care – not just formal social care but also the huge army of informal carers – more highly” (p.45).
Thus the central plank of the projected needs does not support the arithmetic. Instead the report relies emotively on the word “care” as can be seen in its concluding paragraph: “And, most important of all, it must build on the progress we have seen over the last decade in terms of the quality of care in health and care. This is after all, what people care about most.” (p.50). It is a political polemic designed to lobby for more NHS funding as distinct from reliable research into how the NHS books can best be balanced. “The model” we are told “has been peer-reviewed by experts” (p.46) which makes one wonder who these “experts” might be.