prevention – ultimately futile in broad economic terms as folk will likely live longer and get dementia….discuss….

I’m asked this a lot. 

Depressingly it’s also expressed with increasing regularity that prevention is ultimately futile in broad economic terms as folk will likely live longer and get dementia….
Sigh
This one crops up with depressing regularity.
Today’s iteration was as follows:-
“Some was telling me today that the more we prevent people stopping smoking then people stop dying of simple stuff. Heart disease / lung cancer etc. However, these people die of something and this new something is more likely to be more costly interventions such as more complex cancers, Alzheimer’s etc. which are much much more expensive conditions to treat through to death.
I found this fairly challenging though don’t have any evidence. My response is that these new diseases or causes of mortality would require us to transform our treatment of them surely…?”

Here’s my stock answer, I’d be interested to know if those with more expertise than me agree or not.

1)

It’s a pretty poor argument against investment in prevention

The truth is that investment in prevention MAY be a net save in some areas, may not in others.

Worst case in a macro sense is that preventive approach slows rate of growth compared to counterfactual of simply reacting when stuff happens (ie current model of NHS). Wanless made this case 20 years ago. Was accepted by Treasury then.

https://gregfellpublichealth.wordpress.com/2016/05/20/the-nhs-sustainability-and-transformation-plan-in-a-macro-economic-context/
 Precise estimates are largely impossible when talking about a programme of interventions. There are a lot of moving parts, all of which act with uncertainty. 

2)

Obviously the economics are complex (always is).

Depends on who is making what investments, whether policy based structural stuff (influencing behaviour of whole pops) or service based interventions (influencing behaviour one at a time) – former far more efficient and equitable. Depends on how you do time horizons, discounting (costs only or costs + benefits, what rate).

 

3)

The US are increasingly finding – with some data – see especially the Thorpe paper in this blog https://gregfellpublichealth.wordpress.com/2016/02/20/prevention-as-long-term-health-care-cost-control-13/#_edn1

That its not strictly cost per case it’s the number of cases that are driving cost growth (as well as the crazy system with perverse incentives to “do more” in the states.

 

4)

There are issues around asymmetric thinking re ROI everywhere – see here

We question the value of some investments (eg investments in prevention, primary care, many VCS stuff) whilst at the same time unquestioningly pour hundreds of billions into other areas without thinking of the value in either a short term or a long term way, or notion of value expressed in purely financial or health gain way…
asymmetric thinking re ROI http://www.nejm.org/doi/full/10.1056/NEJMp1512297 
poor understanding of concepts of value are pervasive
We need to ask same of NHS treatment! 

We don’t expect NHS to be perpetual motion machine, why public health? Goals same, health at best cost. 
one of my standard lines in this area is around this – ‘we question a VCS contract (or PH intervention) worth £4.78 and make them fill in a form that you weigh rather than read….and then performance manage to within an inch of it’s life questioning value for money all the while…..

But meanwhile pour tens of millions of xxxxxx care but don’t question value of keeping Mrs smith alive for another 3 weeks etc etc……’

 
 

5)

lastly on dementia per se

a third of dementia is vascular – standard CV risks and most likely CV risk reductions apply. Not all cases are preventable, some are

 

ive seen some recent evidence from states (?NEJM paper from memory) that the incident rate of dementia is falling. The prevalent rate may thus fall slowly (dependant on what happens with death rate), but the prevalent number will continue to increase with pop growth.

 

 

My learned and clever colleagues also expressed their view:-
6)

Well they’ve got one point right – death is the best disease prevention, admission reduction and money-saving option. It’s cheap as chips to do, and both prevalence and incidence go down … wots not to like.

 

7)

I suppose in every inane argument there’s some grain of truth – the holy grail of improved life expectancy + improved healthy life expectancy + reduced inequality represents the greatest challenge in this job.

 
8)

Even those who should know better better harp on about rising prevalence of x and y. 

Of course it bloody will – it’s a marker of successful treatments, but that’s also a marker of our reliance on medical intervention. 

What we really want to see is incidence falling … and that’s what policy focused approaches to prevention are all about

9)

Bonkers notion that treating CVD/lung cancer is simple compared to dementia. Lung cancer treatment? Simple?! Actually if everyone was dying of dementia it might be cheaper (at least until pharma catches up with the opportunity)

 

What people die of is always going to be slowly changing because of how we live our lives and treatment available (cancer not CVD, brain mets post Herceptin vs bony mets etc). Silly argument for not doing prevention.

 

it’s illness not age per se

 https://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP127_medical_spending_hospital_inpatient_England.pdf
And as I’ve said before – 

It’s not all about the ageing population, here’s my take on why

https://gregfellpublichealth.wordpress.com/2016/03/25/the-its-all-about-the-ageing-population-conundrum-where-next/

10)

Lastly there is a broader point about prevention of avoidable premature illness and death (and the misery that causes) and broader social & importantly the economic impact of that on productivity. Maybe I’ll come back to that in the future – what’s the point of the NHS as a social institution in economic terms etc.

So…. Long answer to short q….

But the short ansa is – the data to carry the argument doesn’t stack up on clinical, ethical or financial grounds

….Do you want to put me in touch with the protagonists of that one……. I’d be happy to have open discussion, it would be worth it.

 

 

I may be wrong and I’d be happy to defer to those with more experience and data.
I’ll come back to the caveats around this in the next blog.

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3 thoughts on “prevention – ultimately futile in broad economic terms as folk will likely live longer and get dementia….discuss….

  1. Interesting – for me its more to do with the framing of the question. In my view the ‘purpose’ of prevention is NOT to save health systems money but to support people have a good quality of life so that they can enjoy it to the full and contribute to society while they are around.

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