Five uncomfortable truths about prevention
Research Manager and Head of Health
I came to health policy fresh faced two years ago. One thing that has consistently struck me is how stale the prevention debate has become – decades of maximum discussion with minimal delivery. I would read a report from 2004 saying much the same as one from 2023.
Put simply, promoting prevention has been the default mode in health policy for decades, and for just as long it has failed to materialise. Indeed, prevention has been the hammer for every nail – the answer to every policy question and challenge, often without serious consideration of the how, leaving its promise largely unfulfilled.
It’s also not clear there is a shared understanding of the what. For some, prevention means tackling the social determinants of health; for others, it refers to public health interventions or secondary prevention within the NHS. All are well-intentioned. But by meaning everything to everyone, prevention risks meaning nothing to anyone.
But the crucial point is this: even if we were clear on the how, a ‘prevention is the answer to all things’ approach would still fall short. Too many discussions on prevention are full of misconceptions, or even misrepresentations, about what truly drives costs up in the health system.
The difficult truth is that some problems simply cannot be prevented. These problems are expensive problems. And the absence of an honest conversation about these economic facts may in fact be undermining the shift towards prevention that, acknowledging its limitations, is indeed fundamental to the future sustainability of the NHS.
Below, I outline five essential but often overlooked issues that prevention advocates must confront as the NHS enters a critical period of survival.
- Proximity to death is one of the most expensive parts of healthcare, and prevention will not change that.
There are numerous reasons for the consistent growth in healthcare expenditure, notably an ageing population and technological progress. Behind these trends lies a quieter truth: one of the most resource intensive moments in any health system comes not from ageing itself, but from proximity to death. No matter how advanced medicine becomes, the final phase of life will always remain complex and costly.
Hospital utilisation is substantially higher in older age, as illustrated below. Inpatient utilisation rates in the 75+ age group increased by more than 50 per cent between 2000-01 and 2013-14.
Source: Office for Budget Responsibility, 2016
The final phase of life typically involves complex care needs – pain management, nutrition and hydration, support with breathlessness, delirium, and secretions – that require sustained professional input. Prevention can delay or compress morbidity, but it cannot eliminate the high costs associated with dying.
The key question is not whether these costs can be outright avoided – as is often the perceived benefit of prevention – but where and how those costs are incurred. How and where we deliver end of life care – whether in hospital, at home, or virtually – can make those costs more sustainable.
The evidence suggests that if resources are to be rebalanced to enhance the fiscal sustainability of the health system, greater investment should be directed toward adult social care, palliative care and virtual wards, where high quality, lower cost support can make end of life care both more sustainable and compassionate. This is crucially not prevention, but hospital level clinical care in the home.
- The problem is often the hospital not the demand.
The primary motivation for improving prevention is to reduce demand on the health system. And reducing demand will have some impact on easing the permacrisis in hospitals. But the scale of the demand increase on hospitals is commonly overstated, and therefore so too is the impact of demand diversion due to prevention.
And even so, no matter how much demand is reduced, this will not fix structural problems inside hospitals that consistently ensure low value for money and a poor patient experience.
Demand for emergency hospital care has grown quite slowly while the numbers of clinical staff in hospitals has increased substantially. The annual growth in A&E attendance has been around 2 per cent, which is consistent with long-term growth trends. And since December 2019, major A&E attendance has an annual growth rate of just under 1 per cent, which is considerably lower than long-term trends.
What’s more, Re:State analysis in 2023 found that there is not a strong relationship between changes in attendances and changes in performance, which suggests that the variable here is not demand (which is the primary motivation for improving prevention) but the hospital’s approach to demand. This is the result of patient flow and the internal inefficiencies of a hospital.
That is not to say that all patients turning up to A&E should be doing so, and there are indisputably more clinically effective and cost-efficient ways of delivering some of this care. However, while some demand may be mitigated through prevention, plenty can’t, and so the bigger win is alternative hospital operating models, as we outlined in Hospital as a service, not a building.
- Hospitals are expensive and prevention is cheap.
Lamenting the cost of hospitals, noting that a decent chunk is unnecessary and often avoidable, is a favourite health policy pastime. And this is true to an extent. But one fact that goes amiss in this discussion is that secondary care services are inherently more expensive to provide than most preventative interventions.
This means that even with reduced demand, many of the costs are actually unavoidable. Hospitals have a high fixed cost base – machines need to be maintained, specialist staff have to be available at all times, new technologies need to be funded and medical supplies paid for.
The average 9-minute face-to-face GP consultation costs £45 (adjusted for 2022-2023 prices). By contrast, the average cost of an MRI was 3.7 times the cost of this at £170 in 2022-23 prices. Treatment can cost considerably more. Treating a urinary tract infection in hospital, for example, can cost anything from £482 to £8,585. Complex procedures can cost over £40,000.
It is well established that prevention is comparatively cheap and the return on investment high. This logically means that the nominal sum of money apportioned to prevention and primary care can be smaller and still have an outsized impact. It is not possible, but nor is it necessary, to redirect tens of billions from hospitals to primary care, because the running costs and return on investment are completely different.
This does not mean that we should de-prioritise the public health grant or primary care funding, as has been the case for so long. We should be spending more on these. But ultimately, less overall money is needed to deliver high-quality public health and general practice.
Two things can be true at once: yes, there is money that is spent on hospitals that should be spent elsewhere. And yes, a large sum of money should always be spent on hospitals because they deliver the most expensive care in the health system for people at the most difficult time of their lives.
- Simply relocating services into the community is not universally good for prevention and is not cheaper.
One of the most misguided elements of the prevention debate is its insistence that everything is better delivered in the community. But while primary care is better delivered in (and often by) the community, secondary care is not. Relocating specialist care into the community is not more clinically effective or cost efficient than attending the hospital and this is consistently borne out in evidence, as we comprehensively outlined in Hospital as a service, not a building.
Providing care outside of the hospital has substantial workforce implications. This requires either splitting the hospital workforce between multiple smaller locations, in turn diluting the staff in the hospital and potentially undermining the efficiency of the hospital services, and/or significantly increasing the workforce in order to provide multiple services in multiple locations simultaneously.
Workforce is by far the most significant cost in the NHS, accounting for 49.2 per cent of the NHS budget. Delivering more specialist care in the community would likely mean increasing the overall size of the specialist workforce which – you guessed it – increases spending on secondary care at the expense of primary care. This counterintuitively undermines the shift towards prevention.
Of course, there is little dispute shifting care out of hospitals is the right objective – it’s that the means of achieving this are not physically moving the care out of the big hospital into a mini-hospital in the community. Rather, evidence strongly suggests virtual models of secondary care – virtual wards and remote outpatients – are both more patient centric and cost efficient. It should primarily focus on rethinking, not deprioritising, the hospital model.
- Prevention is ultimately about improving society not cost reduction.
One of the commonly cited benefits of prevention is, of course, reduced costs. Fewer sick people means less demand which means less spending. However, this is not always borne out in reality.
Prevention may not always actively reduce costs, but rather slow their rate of cost-growth. And in any case, the true value of prevention could more likely be felt beyond the NHS – in improved social outcomes – rather than through direct budgetary savings within the health system.
Across health economics, it is abundantly clear that NHS cost dynamics are non-linear: improving the treatment of one disease does not directly reduce overall expenditure, and can have unintended consequences elsewhere.
This cost conundrum is most evident in the advancements of medicine and technology. Even as prevention improves, new treatments are continually developed for conditions that were previously untreatable. As a result, more people receive often more expensive care, which inevitably increases costs.
The cost of treating heart attacks illustrates both the benefits of prevention, but the complexities of health funding. In 1984, $3 billion was spent on heart attack patients in the US. By 1998, this cost $4.8 billion despite the fact that the number of heart attacks declined by one per cent each year due to better prevention. This is because the method to prevent them was more expensive . It is certainly true that versus a counterfactual reality where no prevention took place, the cost would have been even higher.
But it is also false to assume that prevention will always lead directly to tangible, cashable savings. To see prevention as driving clear cost reductions would be to look at it in a vacuum independent from the rest of the system, when in reality, it’s entangled in a complex web of medical advancements and demographic changes.
Evidence suggests that for every $1 spent on heart attacks, the value to society was $7. It leads to higher value for money, but also higher costs. So like any other innovation in care, it is not a foregone conclusion that prevention will directly reduce healthcare costs. But it can slow cost growth, takes away costs in other parts of society and deliver substantial wider benefits, such as improved productivity from longer, healthier lives.
To conclude…
Despite all of these hard truths about prevention, the core fact remains: prevention is indeed the foundation of a modern health system. But effective and efficient institutions are also the foundation of a modern health system. It is no use preventing disease while the litany of structural problems across the NHS are allowed to flourish, because of a misguided assumption that merely reducing demand on those institutions will fix them.
The NHS should both be a system of prevention and a system of care. And delivering the former does not deliver the latter. Prevention alone cannot save the NHS – but prevention and reform can.