“Personal responsibility” is a strange phrase: while not as slippery as some, it can mean any number of things, and be put to use in any number of political contexts. It was the title of the speech that the Health Secretary, Jeremy Hunt, gave yesterday. In that, he spoke of three aspects to the concept.
First up, he talked about the need for personal responsibility for health – that while the NHS tops the leagues in a lot of respects, the UK as a whole is bad when it comes to “lifestyle illnesses”, particularly things derived from obesity and smoking. I guess that telling us that that’s bad and we could look after ourselves better is something of a bromide; but slightly more jarring was the statement that
[t]hankfully people are starting to take more responsibility. Doctors report dramatic increases in the number of expert patients who Google their conditions and this can be challenging for doctors not used to being second-guessed. But it is to be warmly welcomed: the best person to manage a long-term condition is the person who has that long term condition. The best person to prevent a long term condition developing is not the doctor – it’s you.
This is worth noting for a few reasons: first, it’ll be interesting in the context of what I’m going to say in a couple of paragraphs’ time; but there’s a couple of other things worth noting. While the final sentence may be fairly unobjectionable at first glance, the penultimate and antepenultimate ones seem much less obvious. Management of long-term conditions may be best left to the patient in some cases; but in all? That’s not nearly so obvious. It’s particularly unlikely when Dr Google is the purported source of information. Dr Google, after all, may send you to NHS Choices – but it may also send you to What Doctors Don’t Tell You*, or sites that are even more obviously written by and for what we may politely call aluminium milliners. Sometimes, patients doing a bit of homework is a good thing. But sometimes, they’ll just end up asking for colloidal silver therapy. (What could possibly go wrong?)
I’ll come to the second theme in a moment; the third thing he talked about was taking responsibility for our families. Again, on the surface, this looks fine; but I guess there might be worries here about shifting things that could or should be provided by the community into the private sphere, behind suburban front doors. But that’s for another day.
It’s the second thing on the list that has drawn more attention: the proposal that labels on prescription medicines should specify how much they have cost the UK taxpayer. “Today,” Hunt said,
I can announce that we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes. I will start the processes to make this happen this year, with an aim to implement it next year.
In one sense, this is straightforward “nudge” thinking. Make people realise what a sacrifice has been made on their behalf, and they’ll be more likely to want to make good the social debt/ expiate the guilt of having been unwell. (One does get the feeling sometimes that ministers may have been reading Erewhon and mistaking it for a how-to guide.) More sympathetically, though, not completing courses of treatment – particularly antibiotics – is a problem; so if people can be nudged to go the whole course, then there could be a public health justification for that.
On the other hand, some have raised a concern that being made aware of the cost to the taxpayer wouldn’t incentivise completion of a course of treatment, but actually disincentivise getting any treatment at all. Thus a spokesperson for Pharmacy Voice has suggested that
some patients, particularly older people, could be deterred from taking the medicines they need because they are worried about the impact on the public purse.
But there’s another problem with the idea, which is this: it’s doomed to be misleading.
Drugs do have an up-front cost, but they aren’t given away in a spirit of altruism. And the upfront cost to the taxpayer may disguise other costs that would be avoided without the drug.
Notably, if completing a course of treatment for something like blood pressure costs £x, its true cost can only be assessed in terms of the counterfactuals. High blood pressure increases the risk of heart disease and stroke, each of which is likely to cost rather a lot more to treat. So a box of pills that costs £x might very well be much cheaper than the £y it’d take to provide emergency treatment and rehabilitation to someone who’s had a stroke (assuming, of course, that treatment would be forthcoming; maybe the families of people who’ve had a stroke would be expected to “take responsibility” for them…).
And, of course, providing drugs to people that stand a chance of reducing morbidity and mortality is also likely to maintain economic activity. Someone who is chronically ill but receiving treatment might well be able to work to earn, and hence to spend, money; cumulatively, owing to the magic of the multiplier effect, that could quite possibly generate quite a decent amount for the Exchequer. So not only is it the case that fifty quid for a box of pills could count as a reasonable premium to pay to avoid the higher counterfactual costs – it might also more than pay for itself in much more concrete terms.
The point is that the “cost to the taxpayer” label is not all that reliable – except, perhaps, as a way of stoking political ire about lazy fat people who just sit around all day chewing pills paid for by decenthardworkingfamilies (which sequence of syllables, I think, must be one word, given the way they get trotted out by politicians of all stripes).
I wonder, too, whether we might also find people who have had their consultation with Dr Google, and decided that the drug is not only over-expensive, but is harming them after all. In other words, all this emphasis on personal responsibility might end up making some people more likely to stop treatment prematurely, and not to worry about it just because it’s the taxpayer that’s picking up the tab.
The nudge aspect might work, and it might be defensible. But its defensibility must depend – mustn’t it? – on accurate figures being used. And in this case, the only way a label could be accurate would be if it read “COST: IT’S COMPLICATED”.
*What: you thought I’d link to the actual site?