Monday 28 March 2016

Nick Triggle: BBC propagandist

Nick 'feels strongly about this' Triggle has been doing a bit of bank holiday propaganda for the BBC health website today (see here, here and here for some previous offences). Theoretically, Triggle's regular editorial pulpit offers analysis of health news. In practice, it allows him to portray value judgements as facts while slavishly taking the 'public health' line on every policy demand.

His latest article is headlined 'Dawn of the nanny state?' Dawn? Where have you been for the last ten years, Nick? It must be at least the afternoon of the nanny state by now.

After correctly noting that the Conservatives are now the nanny state party, Triggle mentions the sugar tax and asserts that 'the mounting evidence on sugar has played its part in convincing them to act.' What evidence would that be? Alas, he doesn't say - because it doesn't exist.

And then there is this...

The lifestyles we lead are costing the nation and, in particular, the NHS money. Some £11bn a year, to be precise.

The reference to precision is the punchline here, but the whole sentence is a joke. The £11 billion figure is made up of estimates of the cost of smoking, obesity and alcohol. The alcohol estimate is £3.5 billion, which is about three times higher than any realistic cost estimate, but the real problem with the figure is that it is gross, not net. Sin taxes on alcohol and tobacco amount to roughly £25 billion per year.

Any serious attempt to estimate costs to the state must include revenues received by the state. It we look at net costs, it is clear that the 'lifestyles we lead' provide a huge financial windfall to the government.

Triggle then brings up another dodgy figure...

Evidence suggests by 2020 there will be a black hole of £30bn. That is massive when you consider the NHS budget is currently just over £100bn... this is where, [the government] hopes, tackling unhealthy lifestyles come in.

If the NHS needs its budget to be increased by a third every ten years, it is difficult to see how it can be sustained. The £30 billion figure was conjured up by Simon Stevens, the NHS CEO, when he was trying to squeeze more money out of George Osborne, but whatever the real figure may be, there is no doubt that the health service needs budget rises that cannot be explained by either inflation or population growth. It is delusional to imagine that the core driver of NHS costs is 'unhealthy lifestyles'. It is, in fact, the opposite: old age.

Policies to encourage healthier lifestyles may be justified on their own terms, but it is a fantasy that they will cut costs. They are far more likely to increase costs - to the NHS, but especially to the pensions and welfare system - by increasing the size of the elderly population. This is well understood by health economists as I explained in Death and Taxes last year...

The old adage that ‘an ounce of prevention is worth a pound of cure’ may be true of health and wellbeing, but almost the exact opposite applies to financial costs. ‘Over the past four decades,’ writes Russell, ‘hundreds of studies have shown that prevention usually adds to medical spending.’

A study in the British Medical Journal concluded that the elimination of ‘coronary heart disease, cancer and chronic obstructive lung disease - the present targets of health promotion - would augment healthcare costs substantially’ because ‘lengthening life generally will increase healthcare needs, particularly long term nursing costs’. There are some exceptions to the rule that successful public health initiatives cost money, such as the prevention of accidents, childhood disease and lifelong disabilities, but most preventive measures to tackle diseases of old age merely lead to more chronic ailments and infirmity over a longer period of time and, ultimately, death from a substitute disease which is no cheaper - and often more expensive - to treat.

All of this runs contrary to the conventional wisdom. When the UK government cut the £3 billion public health budget by £200 million in 2015, the Faculty of Public Health claimed that it would cost the NHS ‘at least £1bn’ in the long run. This is most unlikely. As Jane Hall explains in the Oxford Handbook of Health Economics: ‘Although it is frequently argued (but not by economists) that prevention will save expenditure on future treatment, the current body of evidence demonstrates that it is more likely to generate additional health care costs.’

This cold economic fact seems to have passed many politicians and health campaigners by. Quoting Barack Obama, who claimed in 2008 that ‘Devoting more of our health-care funds to prevention will save tens of millions of dollars’, Rappange et al. (2010) replied that ‘although prevention may indeed increase the health of populations, these interventions, unfortunately, are, in general, unlikely to result in lower expenditures.’ They continued:

‘While preventive interventions may reduce illnesses and expenditures related to risk factors, especially when they successfully prolong life, they will increase illnesses and expenditures unrelated to those risk factors primarily in gained life years. The costs of these unrelated illnesses have been demonstrated to outweigh the savings on related illnesses for the important risk factors of smoking and obesity. In spite of this, the suggestion that prevention is cost saving remains persistent both in the academic field as well as in health-care policymaking. For many, it remains counterintuitive that a healthy lifestyle results in more rather than in less lifetime health-care expenditures. This is problematic as it may result in inefficient use of health-care resources based on overly optimistic assumptions regarding lower health-care expenditures due to prevention, and thus may cause disappointment (among policymakers) when prevention fails to meet these expectations.’ 

Bonneux et al (1998) put it still more bluntly, saying:

‘There is no evidence that healthcare costs are increasing because citizens live unhealthier lives. In fact, quite the contrary would seem to be the case.’ 

The tendency of preventive health measures to incur costs rather than save them is well documented, but the general public are not well aware of this because single-issue campaigners constantly assert the opposite.

A worthwhile article could be written by somebody at the BBC to explain this. It would have the merit of being interesting, important and true. Instead, we get a stream of misinformation from hacks like Nick Triggle masquerading as analysis.

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