Debating the future of health

Is the NHS in crisis? What about health systems globally? If so, how do we deal with this in a way that protects the fundamental goals of a health system? What role does innovation have in this?

These were some of the questions posed at the Astellas Innovation Debate, which I attended last week. You can watch the full debate online, and that’s well worth doing if you have any interest in this area. The panel - two Brits, one an NHS senior manager (former Chief Exec of NHS England), the other a Professor (in my department!) and GP; a Dutch health exec and an American health economist - were a good mix. They all brought a slightly different perspective to what health care in the 21st century looks like, but the level of expertise was very high, meaning the debate didn’t get bogged down in the basics, but progressed at a rapid pace. And it had to - 90 minutes to get through one of the biggest challenges we face, globally, is not a lot of time.

And they were matched, intellectually, by the audience. Invitation-only, there was a broad mix of academics, NHS staff, charities representing patients and carers, and a smattering of industry, for balance. God knows how I got an invite, but I was glad I did. Being in a room with that kind of brainpower was quite an experience, and confirmed my view that if you ever want to hire a really top-notch public speaker, get a GP.

As was expected when you talk about health policy in the UK, we ended up tracking down two big questions: how can health care in general adapt and innovate to handle the future; and how can we save the NHS?

What was nice was that the debate seemed to manage to handle both points without conflating them too much. Usually all debate about the future of health policy ends up being about the NHS and its current funding crisis. This is obviously hugely important, but is ultimately easily solved - 5 years of budget freezes and cuts (despite government rhetoric, there have been cuts) have left the system on its knees, and optimistically we’re about 18 months from total meltdown. The solution to that is more money. That’s it. You would fix 90% of the issues with overworked staff, low morale, long waiting times, and even bed blocking, just by adequately funding the NHS and social care services. It really isn’t hard.

But even once you’ve done that, challenges will remain; namely an ageing population, increased levels of obesity, and the availability of new and expensive medicines. The clear result is an increase in both the cost of and demand for health care. In recent decades health expenditure as a result of GDP has risen, and with the exception of brief recession blip in 2008, that trend is unlikely to abate. How to respond to this is the great health policy challenge.

The debate has two main strands, and last night’s discussion followed the same thread: where should we draw the line, in terms of costs; and how should we structure the system to respond?

The main takeaways from the debate were that you can’t put a figure on spending, but it should probably be higher than now, at least in the UK. In terms of restructuring, the evolution of health problems from infectious disease to non-communicable chronic, means that we can probably handle care more effectively by shifting our priorities to primary care, rather than centring the idea of treatment around hospitals. Preventative care is the great buzzword in health policy, despite the media’s obsession with the personalized.

However, there are a couple of points that didn’t really get made last night that I think are essential to actually making progress.

The question of need

One of the earliest questions asked of the panellists was “how much should we spend on health?” To me, and in fact, to any health economist, this is a pointless question. Although our profession is generally characterised as one of curmudgeonly penny-pinchers, the reason is simply that economics, in health and in everything, exists because of scarcity. Resources are not unlimited, and therefore we have to trade wants and needs off against each other. Economics at its most fundamental is simply the study of these trade-offs.

So it is frustrating to listen to a someone repeatedly ask how much we should spend, without knowing what we’re buying. You don’t go into a supermarket and decide how much you’re going to spend without knowing what that will buy you. You might set a budget, but that budget will generally be set with some idea of what your minimum grocery requirements are for that week. Setting a health budget without reference to what health actually costs is utterly futile.

Instead we need to address the question of need. How much health do we value? Not care, not treatment - but health. How long do we want to live? How do we think health should be distributed in society? Are we willing to pay that bit more to help everyone in society attain a similar life expectancy, which currently differs by 10 years and more between the poorest and richest, even just in the UK.

Once we know what we want from our health system, we can start to use the vast amounts of clinical data we have generated in the last 70 years to get a sense of what kind of health care we need to provide to achieve this. This is without doubt a huge question, but the good news is we’re not starting from scratch - we already have a health system, and it has a lot of strengths. It’s not about rebuilding from the ground up; it’s about looking at where we’re falling short of the ideal, and working out how much it would cost to achieve the ideal, and then assessing whether that falls within society’s willingness to pay. We need a much bigger political debate around how much we value health. There is some anecdotal evidence that people would be willing to pay more than the current £2000 per head per year, even through raised taxes. More evidence on this and a broader discussion would empower politicians to start to make the changes necessary to sustain the NHS for the future.

Disinvestment

Even if we achieve a clear view of how much people are willing to spend on health (and by extension how much health they care about), we will always need to make trade-offs - the NHS will always have a limited budget, and the fact is that there will always be treatments that aren’t affordable. This is where organisations like NICE come in.

In an ideal world, NICE’s decisions ensure that only cost-effective treatments are funded (ones that are worth the price we are being asked to pay). As time goes on, the NHS gradually becomes more and more efficient overall, as more cost-effective treatments replace lesser ones. However, for this to work we have to ensure that the treatments we are disinvesting from are the least cost-effective in the system. At the moment there is no mechanism to ensure that that is happening, and as a result some of our most cost-effective treatments are being cut.

The classic example is hip and knee replacements. We have extensive evidence that they are in general very cost effective - patients have significantly improved quality of life for a procedure that is straightforward and fairly inexpensive. That’s without accounting for the benefits of people being able to stay in work and remain active, contributing socially and reducing the risk of further illness associated with inactivity down the line.

However, they’re also a really easy one to cut when budgets get squeezed. They’re elective procedures, and the waiting lists can just get longer and longer. While investment decisions by NICE are taken at a national level, disinvestment ones happen on a regional, CCG-level basis. Without transparency and guidance, and ideally a recognition at the political level that disinvestment is both necessary and important, the services that get cut aren’t the least effective ones, they’re the ones that are least likely to cause problems for the decision makers.

The way forward

Since becoming a health economist, a large proportion of my pub chat has been given over to explaining NICE decision making to friends of friends. The fact is that people care about the NHS and health care, and very rarely do people not already understand the challenges its facing. Political fear and ideology is holding us back from making the reforms we desperately need.

Frankly it’s becoming common knowledge that the NHS needs a funding boost. With the right public engagement and a structured effort to identify the NHS that we want as a nation, including being transparent about what it will cost, we have a chance to really make a difference. But it will require a more nuanced conversation than “we have to spend less”. I think that this year’s debate was a step in the right direction.