Opinion: Towards a sustainable NHS

The NHS is one of Britain’s success stories and is the envy of the world. However, we are continually told that the NHS is in crisis and unless we have significant spending increases it will cease to exist as we know. With a growing and ageing population and a reluctance to fork out more money in tax it is clear that this problem will not go away without radical proposals.

It seems that finally we are getting somewhere. On Wednesday Simon Stevens, Chief Executive of the NHS, said that it was a ‘no brainer’ to try and prevent illness rather than simply treating the effects. He said that the NHS needs to ‘pull out all the stops on prevention, or face the music’.

For years it has been clear that the lifestyle choices made by millions of ordinary people in Britain is getting worse. It is estimated that binge drinking costs the NHS £5 billion a year and with obesity levels rising sharply, the cost of conditions such as diabetes and heart failure, to name a couple, are only going to rise with it.

It is therefore time for some radical solutions, which I believe the Liberal Democrats should aim to be at the forefront of. One potential idea would be limiting the number of fast food takeaway restaurants. In Worcester there are many such outlets but the problem is far worse in more deprived areas particularly in inner city areas. Legislation to put a cap on the number of fast food outlets within a certain distance of each other may help solve this issue.

A so called ‘sugar tax’ may also be a solution. It has been the case for a long time that it is cheaper to buy processed foods than fresh foods. Reversing this may provide the incentive for many people to use fresh produce once again.

However, I think the main way to tackle the issue of poor lifestyle choices is through public education campaigns. From teaching basic nutrition to young children at schools to television adverts it is vitally important that people understand what constitutes a healthy lifestyle. As a country we have been far too passive on this issue. Look at smoking for example where a long campaign has seen numbers taking up smoking fall and the idea of smoking itself become far more socially unacceptable.

I realise that restrictions and taxes are not very liberal policies but I believe that if we are ever going to save our NHS this is the only long term option. Throwing more and more money at it will provide only a short term fix. The time to act is now.

* Adam Warner is a Lib Dem activist in Worcester

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  • Adam,
    A couple of points on your interesting piece.
    You are correct to say that we are constantly being told that the NHS is in crisis and something must be done.

    The people who are saying this are large, corporate vested interests and the lobbyists, journaiists and politicians whom they fund. These vultures are circling the NHS in the hope that privatisation in one disguise or another will result in vast profits finding their way back to Chicago, or wherever they happen to be based.

    You are not quite so correct on your statement that —
    “…For years it has been clear that the lifestyle choices made by millions of ordinary people in Britain is getting worse…”

    In fact when it comes to smoking cigarettes (still the major cause of avoidable death in the UK) the choice made by ordinary people has been to either never take up smoking in the first place or to succeed in quitting the addiction.
    Of course this has come after fifty years of government intervention, which has always been welcomed by the majority of smokers, who are keen on anything that helps them escape the deadly addiction.

    I agree with you on the potential for a sugar tax and other government interventions that will be necessary to turn the tide on obesity.
    However, “lifestyle choice” is a convenient distraction for the large corporations who market sugar-filled, high fat and salt-filled products in their ruthless pursuit of profit.
    Whilst everyone deciding to lead a healthier life would be a wonderful thing the power of advertising and other promotionalmdevices by market giants has to be tackled head on.

    To say such things will bring howls of protest from free-market/Libertarian extremists.

  • Simon Gilbert 5th Jun '15 - 10:52am

    I’m afraid I have to disagree. Banning things is a distinctly illiberal approach that fails to understand the deprivation, learned behaviour and lack of social capital that contribute to people making poor lifestyle choices. Solving this involves empowering communities to improve their own wellbeing, aspiration and opportunities, rather than prohibition.
    No matter how healthy we are there will be a time when we all get ill, or develop multiple long term conditions.
    One of the main problems currently is that the benefits to individuals of access to services is completely funded by one central source, leading to a continual begging for health resources from government that will never realistically be resolved.
    If someone wants a non urgent, untriaged appointment after work why not allow them to top up their NHS entitlement by paying for this, thus capturing some of this benefit to empoloyees or employers if they pay, whilst bringing in more funding to cross subsidise safe, timely, effective NHS care? Currently the free at the point of use NHS, particularly with GPs, means that all but the most wealthy are stuck with the current strained system, with no way to improve this from their own means. Paying for private GPs isn’t an option as they don’t have the same access to ongoing NHS referrals, investigations and prescriptions.
    This isn’t a crazy right wing idea – many European countries, including Holland and France, have elements of up front patient payments, without hordes of dying ill people lining the streets of Paris and Amsterdam.

  • Glenn Andrews 5th Jun '15 - 11:57am

    I’d agree with the need to bring in radical solutions to improve health; like cheap secure social housing (free from damp and mould) being a reasonable expectation for most (especially if they are powered by sustainable means.) The legalisation of cannabis, which the state of Colorado has discovered reduces traffic fatalities as well as reducing binge drinking. On the subject of healthy lifestyles; a huge investment on cycle routes and opening up green spaces within metropolitan areas would at least give people the option of a healthier lifestyle.

  • I’m afraid the premise of the argument is flawed. The academic research show that on average smokers and obese people cost health services less over their lifetime than those with healthier lifestyles because they are much less likely to suffer the expensive, chronic conditions of old age. Of course adopting healthier lifestyles is a good in itself and should be encouraged. But it is the longevity which results from healthier lifestyles which is putting ever greater financial strains on our health services. The truth is we are either going to have re-prioritise current spending or raise more tax in order to sustain the NHS in its current form.

  • Obesity, cancer and dementia, the big three health issues facing us as a society right now. As crises go, one caused by living too long, too well is not the worst. But it is still a challenge. ‘Sin taxes’, where we discourage expensive behaviour by increasing costs when decisions are made, might help. Ideally, it maintains the NHS principle that it be free at the point of use, while bringing in revenue that will keep it funded and reducing its need for funding at the same time.

    The problem is of course that people generally eat fatty, high salt, high sugar processed foods for a very simple reason – that’s what can be afforded, in terms of money and time. Sugar and fat taxes could easily become a tax on working poverty, which would be a very bad thing. We need a combined approach, and finding a way to work with the big retailers to improve the quality of food at the budget end of the scale as well might help.

  • Joe Otten
    When it comes to medical matters I usually refer to people who are appropriately qualified rather than The Spectator magazine.
    Medics across the world would point you to peer reviewed evidence that clearly shows that you are mistaken in your belief that – “…it is not at all clear that the diseases of lifestyle choice are any more expensive to treat as we depart the mortal realm…”
    In fact it is very clear that treating people for various types of cancer or obesity-related diseases is very, very expensive and the NHS and NICE pulish a great deal of information on this subject.
    Cheap and effective interventions by government which prevent such diseases save £ Billions in NHS expenditure as well as giving people longer and better lives. This is not a pious hope. It is a matter of fact born out by worldwide research and evidence.

  • matt (Bristol) 5th Jun '15 - 12:49pm

    The NHS isn’t an ‘it’, even within, say, England. It is a coalition of local trusts with differing agendas (the main divisions are between community care, hospital care and mental health) staffed by mutuliple disciplinary groups who are often advocating for their own interests and agendas, all trying to work in tandem on at least one or other level with a variety of local authorities and consortia of local authorities with whom public health and social care (and other) responsibilities are shared and ‘managed’.

    I don’t believe there is one UK-wide or even England-wide headline-grabbing ‘solution’ to this mess, as there is not one problem, there is a complex of problems whose interactions are not fully understood even by those who understand they might exist.

    I’m more inclined towards a sugar tax than the other solutions you propose, as it puts pressure on to food producers to come up with alternatives, but it’s far from a magic bullet, and as Simon points out (although I’m not entirely 100% in agreement with everything he says) it is a conscious additional restriction of choice, which is maybe philosophically unattractive to many liberals.

  • @ JohnTilley 5th Jun ’15 – 10:51am
    Surely it’s not just “large, corporate vested interests and the lobbyists, journaiists and politicians whom they fund” who think the NHS is in crisis? Try an internet search for “NHS in crisis”, you may be surprised by the results.

  • Christopher Haigh 5th Jun '15 - 1:34pm

    I fully agree with the article. It is fine to believe that a market economy is the most efficient provision for our economic needs, however it does have its failings. Regulating boom and bust is a necessary government intervention as is preventing health hazards to providers and consumers within the market system.

  • @Adam
    The research is clear. If you look at the lifetime medical costs of smokers, obese people, and ‘healthy-living’ people then smokers cost the least, followed by the obese, and lastly the most expensive are those with healthy lifestyles. So encouraging healthy living, though good in itself, does not address rising health expenditure.
    Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure

  • Jenny Barnes 5th Jun '15 - 4:17pm

    Does the NHS consider the cost v benefit of major interventions late in life? Anecdotally they seem willing to undertake all sorts of expensive major interventions on people who are near the end of their lives. On top of which, it’s clearly more difficult to recover from things like major surgery or chemo/radio therapy in one’s 80s.
    On th e sugar tax. It sounds sensible to me. If it does bear disproportionately on poor people then reductions in tax in other ways could compensate. After all, we tax tobacco & alcohol.

  • matt (Bristol) 5th Jun '15 - 4:42pm

    Jenny Barnes – well, for a start, what rule does a clinician use to assess what ‘late in life’ means and for whom?

    At one point the NHS was using a definition of ‘older people’ that started at 55. I am aware of someone who works in a health and social care job who says they could work for a month when the ‘youngest’ person they work with is 78,80, and these people are often very independent, living their lives without major healthcare needs. There are 90 year olds with longer prognoses than 45 year olds. What reliable scientific crystal ball do we have to identify one from another to ensure our putative cost/benefit analysis is fully informed?

    For what its worth, I think there is such a tool for GPs, consultants and hospital managers (i suspect the University of York’s Centre for Health Economics had something to do with it), but I think it comes down to individual professional judgement by clinically trained staff at the end of it.

    I’m also not sure that a decision to withold treatment that appeared to be purely on the basis of age and economic efficiency, rather than underlying health benefits to the patient, would be human-rights compliant.

  • Peter Bancroft 5th Jun '15 - 5:32pm

    The NHS is still 30% cheaper than comparable health systems in France and Germany and so I would hope that as the Liberal Democrats we’ll accept that going up a bit before we become all authoritarian and order people how they should behave. The suggestions around a sugar tax (proven to not work in Denmark) and restricting fast food chains will inhibit the liberty of the poorest in a very real way, yet as Joe Otten notes above it won’t decrease NHS spend in any meaningful way.

    Even if you take the view that the situation justifies our party turning in an authoritarian direction (which I don’t), it doesn’t make sense to be that controlling for such little financial benefit.

  • matt (Bristol) 5th Jun ’15 – 4:42pm

    Matt, you are absolutely right to point to the wide variation in what is considered “elderly”.
    This is largely related to social class.

    Whilst many people (especially on one wing of the Liberal Democrats) like to pretend that class differences no longer has any relevance in politics or much else, when it comes to the expectation of a healthy life it is often the key determining factor.
    In most UK cities there are dramatic differences in life expectancy between wards depending on the social class of the local population.
    In the posh homes of Sheffield Hallam, for example , life expectancy is many years greater than in poorer parts of that city. It is not a coincidence that Hallam has fewer people employed in manual work than any other constituency in the country.

    I seem to recall that it is a team at Bristol University that do excellent mapping of the inequalities of health by social class by local authority ward.

  • Jenny Barnes 5th Jun '15 - 8:53pm

    NICE use a measure – Qalys- short for quality of life years as an outcome measure for potential treatments. And some potential treatments , particularly new an expensive cancer therapies, don’t provide enough Qalys to get funded. Presumably the money can get more Qalys. Another way. That looks like an economic and age related decision to me.

  • Matthew Huntbach 5th Jun '15 - 11:31pm

    Adam Warner

    For years it has been clear that the lifestyle choices made by millions of ordinary people in Britain is getting worse. It is estimated that binge drinking costs the NHS £5 billion a year and with obesity levels rising sharply, the cost of conditions such as diabetes and heart failure, to name a couple, are only going to rise with it.

    Sorry, but you really haven’t thought this through. If you want to cut NHS costs, and you say that’s what you’re writing about, you need to ENCOURAGE people to do things that will kill them off young. Then you won’t have all the costs of maintenance of people as they get all the conditions that are inevitable as one gets older. It is rapidly rising life expectancy that is the biggest factor in NHS costs going up.

    I’m not saying we should do this, just pointing out your argument is flawed.

  • Matt (Bristol) 6th Jun '15 - 1:17am

    Jenny, I meant ‘withhold an already in-use treatment from an individual patient’, but I see what you mean.

  • Philip Rolle 6th Jun '15 - 2:11am

    It does seem from the stats that we need to adopt stringent measures to deal with people with healthy lifestyles. They will bankrupt the NHS if allowed to continue with their wicked ways 😉

  • Matt (bristol) 6th Jun '15 - 8:39am

    Sara Scarlett makes a telling point about sugar subsidies (and can therefore collapse in shock, if she wants, as to be honest I have usually been hostile to the tone of her posts, sorry Sara, you just usually rub me up the wrong way) — I’m not aware how much the EU/UK is complicit in this, but its certainly a significant part of US agricultural policy. But if we were not significantly subsidising sugar (really don’t know this, sorry) and other countries were, we would have little option but a tax, if we wanted to pass on costs to manufacturers. But in the abstract/ideal, reducing subsidy on a harmful product is a more liberal option than increasing tax.

    Its significant that such subsidies are such an accepted part of our global economic system that none of us on this thread mentioned them until Sara did.

    All of this also exactly applies to tobacco, mind, and I find it hard to be tolerant of Liberal Vision’s links with FOREST and FOREST’s financial links with the tobacco companies who benefit from such subsidies.

    But anyway, now we’re linking local health policy to global economic policy, and moving away from nice, simple headlines like ‘save the NHS’, aren’t we?

  • Simon Gilbert 6th Jun '15 - 8:40am

    This piece illustrates the common misconception that universal healthcare must equal the NHS, and also that social policy and public health interventions must be influenced by the funding issues of the NHS. It is possible to improve healthcare with more funding, but this is separate from issues around health education and promotion. The more pertinent question raised by the title ‘towards a sustainable NHS’ is ‘is a fully government funded healthcare system the most sustainable way to provide universal healthcare?’

  • There is an argument that people refrain from taking better care of themselves precisely because there is a free at the point of use health service.

    The NHS is geared towards cure; prevention is surely the best way to go. A senior NHS exec told me recently that 10% of his trust’s budget – 10% – goes just on type 2 diabetes treatments. An entirely preventable condition.

  • I totally agree with TCO.

    Prevention is the best way to go.
    After more than 60 years of a Natonal Sickness Service it is time for proper priority to be given to prevention.

    An urgent preventative intervention by Government to regulate the corporate cartels that maximise their profits by pouring sugar down the throats of our children would be a good start.

  • @John Tilley I’ve just picked myself up off the floor 😉

  • “An entirely preventable condition.”

    You dont know what you are talking about. I have type II diabetes. When I suspected it, due to symptoms, I went to get assessed, and was told I was in the ‘very low’ risk category. My BMI had never been above 27 – ‘mildly overweight’. The actual test only went ahead because I insisted, and was found to have a blood glucose level of 28 and was told to contact my doctor ‘within 48 hours’.

    I personally attribute it to a bout of serious pancreatitis, in my early 20s, with probably several earlier undiagnosed episodes.

  • A Social Liberal 6th Jun '15 - 1:02pm

    Five or six years ago theTimes published an article which brought to light the unfortunate fact that Britains middle classes were costing the NHS far more as a result of their drinking habits than were the young binge drinkers. Unfortunately linking to this article is now pointless since the publication demands subscription. Given the premise of the article however, I would challenge Adams focusing on binge drinking.

  • TCO
    The causes of Type 2 diabetes are not fully understood so glib statements that it is preventable are not helpful. In fact it is not preventable, certain behaviours may increase the risk. Only in recent years have sugar free and low sugar products become widely avaiable.
    I wonder if everyone became non-smoking, teetotal vegetarians would help.

  • Simon Banks 6th Jun '15 - 4:14pm

    I understand Simon Gilbert’s Liberal objections. There is, though, an issue about behaviour people choose that hurts others, as John Stuart Mill pointed out, and if my behaviour leads to me needing expensive treatment paid for by you and you and you, the Liberal position is not necessarily to refuse to intervene. As any “classical” Liberal can point out, taking money from people reduces their freedom to choose.

    Joe Otten’s comments verge on the nit-picking. Treating for multiple health conditions sparked by obesity or smoking is expensive. The fatal heart attack or fall at 89 of the person who was still getting around and helping other people may not be so expensive. Besides, not all illness-preventing strategies involve banning things. Undoubtedly some people now do not smoke because they’ve been persuaded it might well kill them. Some people choose healthy foods and many more say they would if they had the information (or if the unhealthy foods weren’t cheaper). All kinds of non-coercive interventions, including more access to nature and to art, can reduce mental health problems. The NHS getting better at spotting problems early would catch many issues when they could be dealt with relatively cheaply. Reducing poverty, nearly all health experts say, would be the most cost-effective health intervention.

    The biggest problem faced by a preventative strategy has been around a long time. Stop ten people from developing cancer and you can’t prove any individual has benefited. It’s not news and no-one is grateful. If one desperately ill person dies because an expensive piece of equipment was not available fast enough, it can hit the headlines. Blame is apportioned.

  • Simon Gilbert 6th Jun '15 - 5:55pm

    @Simon B – does this not therefore demonstrate the problem with centralised health service? As almost anything impacts on health, and therefore any other NHS users, any government can use this to force people to do what they will. Could the elderly be punished for not spending enough on approved heating suppliers, for example, on the grounds that they may get ill and cost NHS resources?

  • sally haynes-preece 6th Jun '15 - 6:42pm

    I spent 40 years working in the NHS….and I know it is in a huge crisis. Retiring in 2009 was the best move I ever made. The thing is , it is not a national ‘health’ service….it is a national sickness service….and that needs to change. We must do more for prevention…..and as a pharmacist I know how important it is to get away from the idea that there is a ‘pill for every ill’

  • Matthew Huntbach 8th Jun '15 - 12:51pm

    Adam Warner

    Those people saying that the NHS costs more as people get older – are you factoring in the additional tax paid by those people? If people die they stop paying tax (obviously!) Just wondering if this has been considered.

    Yes, of course, that was at the centre of the point I was making. If one is cynical about costs, what one wants is an illness which kills people at about the age of retirement. That’s just what illnesses associated with poor lifestyle tend to do. If we wanted to save NHS money, for example, the one thing we really ought never to have done is to discourage people from smoking. Oh, what a wonderful money-saver smoking is, especially when it kills someone off with a sudden heart attack just after they retire – as it did my grandfather. Death through cancer is a bit more of a costly drag, sure, but if people don’t die through smoking-induced cancers early on, they live to get to die of more obscure cancers that eventually come along later.

    The big thing pushing up NHS costs now IS people living much longer. We need to accept that and rejoice in it, because I don’t really want people dying young from smoking induced diseases etc. But rejoicing in it means we need to be aware of the consequences – higher needs for NHS care, thus higher taxes.

    Or, if we balk at higher taxes and denounce them as “politics of envy”, “attack on aspiration” etc, well fine. If we won’t pay for it that way, we’ll have to pay for it some other way. See university tuition to demonstrate an example.

  • matt (Bristol) 8th Jun '15 - 1:17pm

    Matthew Huntbach – I guess the equivalent of a graduate tax for the NHS would be a post-operative health care tax? (ie we can give you a knee replacement or a heart transplant, but you pay x% more on income or savings tax) Egad. I’d never considered that, I hope no-one takes you seriously. Go away IEA, nothing to see here…

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