Health Disservice:

We Spend More on Health Care. Where Has it All Gone?
Listener: 12 April, 1997.

The great twentieth philosopher, Karl Popper advised scientists to be aware of how the scientific problem with which they are concerned changes over time. The same applies to policy advisers. Policy problems change, so the unaware adviser or politician may be trying to resolve an outdated issue.

Why, for instance, do we keep spending more on health? There are some standard truisms, which give partial answers. The population is aging, and an older population requires more health care. New diseases – spectacularly AIDS – have appeared. We also spend to cover inferior life styles. The effects of the big increases in tobacco consumption of half a century ago are still working their way through the medical system. New technologies are more expensive.

We are also getting more health gain from the extra spending. Fifty years ago life expectation was 69 years, today it is nearer 76 years. We could justify the additional expenditure in terms of the 9 additional years of life (although medicine is not the only factor in the prolongation). But that would miss the point. Today much of medical care is not concerned with saving (or prolonging) life. It is concerned with making life more comfortable, of enhancing life.

Put this way, the point is obvious, but I am not sure that we have incorporated it into our health care policy thinking. The standard image of what the medical system provides is – say – treatment for an inflamed appendix. If the treatment is not provided the complications can cause death. On the whole the system deals with emergencies reasonably well. But an increasing proportion of spending on health care – on the elderly, the disabled, the mentally unwell, even physician’s and surgical care in hospitals – is more about improving the quality of life than extending its quantity. Of course a better quality of life will often prolong life, but there is health care which would not make that claim. Hospice care for someone dying of, say, cancer, may not actually prolong life. The aim is to make the patient as comfortable as possible, and to enable friends and family to adjust to the death. But even if hospice care does not prolong life, most people would still consider it an appropriate activity for the medical system.

Other examples are less clear cut, but the principle is clear. Medicine does not just save lives. Often it makes living more tolerable. This change has crept upon us, without careful thought about its implications. Fifty years ago, when we were fashioning the public health system as we know it today, the expression “elective surgery” did not even appear in the Shorter Oxford Dictionary. Today the term is so familiar it appears in the much smaller Concise Oxford Dictionary. But if in principle we distinguish between emergency surgery which saves lives, from treatments which improve lives, we still tend to treat all waiting lists for surgery as of equal importance. This is not to say that early elective surgery is valueless. Sometimes great pain is relieved by it. But conceptually it raises different issues from our traditional notions of surgery which underpin our accounts of proper health policy.

Our society tolerates quite wide differences in life comfort. Some people eat well, live in luxurious houses, experience varied and entertaining lives in interesting and socially respected jobs, while others have only access to poor diets, inferior housing, limited recreation, and a series of low quality jobs interspersed by depressing bouts of employment. It would be easy to extrapolate from here and ask why the state should provide the elderly poor with a hip replacement surgery? It did not provide much support when the person was younger.

I have not the space here to discuss whether all such social inequalities are unacceptable (although I insist they have increased in the last decade). Addressing only the health area, I want to suggest we are faced with a policy issue which is not a matter of whether we provide life saving treatment to all those in need, but to what extent we provide life enhancing care. Obviously we cannot provide all the care to make everyone as comfortable as possible (any more than we do that for their food, housing, and recreation). So we might have a public policy strategy which aims to keep everyone to a minimum degree of attainable comfort.

This is not as radical as it as first sounds. The 1991 health system reforms included a proposal that there would be a defined core of health care to which we would all be entitled from the public system. Despite the then minister, Simon Upton, saying this core was crucial for the reforms he was implementing, there is still no defined set of such entitlements. The committee charged with identifying it found the task too hard. (Instead of admitting their incompetence and resigning, they redefined their purpose. No wonder the health reforms have collapsed.) Yet the issue remains. What are we entitled to from the public health system, not just in terms of life saving treatments. but life enhancing ones?