When I connected to the Forum annual lecture of the Academy of Medical Sciences yesterday I heard the president make two statements that you hear all the time—and might be called “conventional wisdom” —but are mostly wrong. He said that the costs of healthcare are rising because of aging of the population and that the aging of the population is the result of success. He’s right that the population of the UK (and, indeed, most countries) is aging, but he’s wrong that that is the main cause of rising health costs, and I dispute that the aging of the population is a success. (Ironically, the members of the Academy are probably a more important cause of rising costs than the aging of the population, as I’ll explain.)
Aging of the population is a cause of the rising costs of healthcare but a minor one compared with the main driver that much more can be done and that most of what can be done costs more than what used to be possible. This is what economists call “supply-drive demand.” You build hospitals, intensive care units, roads, prisons, and medical schools and they promptly fill up. You develop new, highly-expensive treatments, and people want to use them. As a healthcare leader once said to me, “The main cause of the increase in healthcare costs is the National Institutes of Health.”
A study published in JAMA found that aging of the population led to about a 12% increase in healthcare costs between 1996 and 2013 in the US while increases in price and service intensity—that is, the variety and complexity of services—led to a 50% increase in spending. Changes in disease prevalence or incidence resulted in reduced spending reductions of 2.4%.
Many of the consumers of these expensive and complex services are, of course, older people, but the Congressional Budget Office of the US looked in 2007 at the long term outlook for healthcare spending until 2082 and unpicked how much of the increase would be due to aging and how much to increase in the cost of healthcare. They saw the federal spend on health care increasing from 4% to 18% of Gross Domestic Product with aging accounting for less than 2% of the 14% increase and new treatments and rising costs accounting for the rest.
Perhaps all this would be acceptable if it led to good health until death, but it doesn’t. I think of this first in very personal terms. My father, who smoked all his life and was in the infantry advancing through the desert at the battle of El Alamein (which carried a 50% mortality), died quickly of renal cancer aged 81. He had no curative treatment and little treatment of any kind. He never seemed old to us and died well at home. My mother, who is about to be 91, in contrast, has had no short-term memory for 12 years and has lived in a nursing home for eight years. She no longer recognises us but is physically well. She is not unusual: dementia is now the commonest cause of death in women—and soon will be in men. My mother’s predicament doesn’t feel like success.
Although life expectancy has increased, healthy life expectancy has not increased so fast, meaning that people spend longer unwell at the end of life. In 2013 to 2015 in England the period lived in poor health was 16.1 years for males and 19.0 years for females. And the length of time in poor health is much longer for the disadvantaged than the advantaged. Is this success?
And many of these elderly people are lonely. The number of over-50s experiencing loneliness is set to reach two million by 2025/6, a 49% increase in 10 years. Half a million older people go at least five or six days a week without seeing or speaking to anyone. Those like me who have not experienced loneliness do not tend to recognise how painful it is, but it has been described by a psychologist who has long studied it says “acute loneliness is a terrorising pain, an agonising and frightening experience that leaves a person vulnerable, shaken, and often wounded.” Is so many people remaining alive to experience something so awful success?
Death is not the worst things we can experience. “I want to die while I am still alive,” said Paulo Coelho. Modern, medicalised death is often horrible and expensive. “An even more horrible death,” said Luis Buñuel. “is one that’s kept at bay by the miracles of modern medicine, a death that never ends. In the name of Hippocrates, doctors have invented the most exquisite form of torture ever known to man: survival.”
Medicine deserves some radical rethinking, and perhaps the Academy of Medical Sciences might take the lead.
Richard Smith was the editor of The BMJ until 2004.
Conflict interest: RS is a fellow of the Academy of Medical Sciences.