Can the NHS afford ever increasing life expectancy? Time for an honest debate.

A visit to hospital…

I found myself in hospital last week after my 83 year old, dementia sufferer dad had a fall. There was a significant amount of waiting around and down time which gave me the opportunity to observe the way the hospital worked which in turn started me thinking about the economics of the NHS.

…as the health service wrestles with resource allocation…

It was a good week to be trying to learn more about the NHS with a flurry of data and announcements. The most interesting was the publication of the NHS Plan by NHS England, setting out priorities for the next few years. This was striking in the way it acknowledged the resource challenges faced by the NHS and set out a proposed course of action to manage within these.

The Plan is explicit about trade-offs, particularly between routine and urgent treatments. The headline grabbing proposals were:

  • The abandonment of the target for 92% of all routine surgery to be done within 18 weeks of a GP referral;
  • Focus on cancer treatment and relieving the pressure on A&E departments; and
  • increased emphasis on integrating health and social care

All of this seems rational and in tune with an announcement in Scotland of a project to look at ways to manage rationing of healthcare. Professor Cam Donaldson, who is leading the team, said difficult decisions needed to be made about which services were of most benefit to most people. In any system that was free “the needs outstrip the amount of resources available” he said, and with the NHS and social care, “that has become an acute problem recently”.

…but more radical approaches may be needed…

I suspect the debate has only just started. It is clear that an ageing population will pace an increasing strain on the NHS. My experience last week showed me how difficult it is for the NHS to deal with dementia patients. It is incredibly hard to treat someone who can’t explain what is wrong with them and the need for supervision is much greater compared to other patients.

I was reminded of something a “C” suite executive of one of the world’s leading pharmaceutical companies once said to me:

“With hindsight, it was crazy for everyone to have devoted so many resources to tackling cancer without investing in treatments for dementia”.

Effectively, we have decided to allocate resources in such a way as to increase the burden on health services over time. We have been very successful in extending lifespans but this is almost certainly going to lead to more incidence of conditions such as dementia which are expensive and complex to deal with.

…starting with questioning the value of longevity…

It appears to be a given that extending average lifespans is a good thing and central to the mission of the NHS. This is pretty clear in the NHS Plan mentioned above with the focus on cancer over routine operations. In effect, quantity of life is being prioritised over short-term quality, something I suspect will be approved of by the majority of the population.

However, there are consequences. I was interested in the news that UK life expectancy has fallen in the last three years. This may be a statistical blip, but could it be a sign that we are stretching the human body too far and have reached our limits?

In particular, I wonder can we afford to keep people alive ever longer if we do not have the resources to invest in better old age treatment and the facilities needed to support older people such as care homes and carers. If we were able to capture some of the economic benefits of longevity in the form of higher contributions to funding healthcare then there would be a clear way forward. However, it is clear at the moment that we are unable to capture sufficient data on the benefits of longevity to fund the additional costs on the health service.

…and making the choices explicit.

Moving the discussion on resource allocation in the NHS into the public domain is very valuable. The debate about health care priorities has to reflect the economic challenges and not just the desire for treatment independent of the consequences. The funding challenge facing the NHS is clear from recent announcements and the objective in the current five year framework remains £22 billion of savings by 2020.  This will not be the end of the effort as the next framework will face the same challenge of delivering services while faced with an ageing population. (Indeed, it could easily be worse if Brexit reduces labour supply and so forces up costs as well as reducing the population, especially the active segment, and hence reduces the taxable base providing funding).

And this is not just about the NHS. I have just received the communications which tell me that my council tax is rising by 3.5% next year, 2% of which is to pay for social care, while my dad’s care home bill has risen by 3.99%. Costs of older care continue to rise and yet local authority budgets are being reduced in real terms. At some point, we will run out of road.

Questions we need to consider are:

  • Is the population willing to pay either more tax or spend more on insurance or pay at point of delivery, to fund the treatment and care costs that result from greater longevity?
  • Are we willing to accept a lower quality of life, delay in routine treatments, to live longer?
  • Should we allocate more resources to old age care and reduce the share allocated to saving and prolonging lives?

A trip to hospital quickly makes the challenges faced by the staff there and the efforts that they make to address these very clear. However, it is also clear that the system is at breaking point and tough choices have to be made. Continuing in denial is not the way forward, an open national dialogue is required as a matter of urgency.

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