Select Committee on Science and Technology Written Evidence

Supplementary evidence from Professor Sir John Grimley Evans

  1.  The Committee asked Sir John Grimley Evans whether he could provide any figures on the proportion of NHS expenditure spent:

    (a)  on those in the last six months of their lives (at whatever age);

    (b)  on the 16 per cent over 65, other than the last six months of their lives; and

    (c)  on those over 85 (again other than the last six months).

  2.  He replied that, with the caveat "other things being equal", the position was:

    "In terms of healthcare costs the two significantly expensive things that happen to us are being born and dying. The increase in costs associated with final illness can be detected statistically as long as 15 years before the point of death but the main excess expenditure occurs in the last five years of life. The costs in the last five years of life do not derive from predictably futile treatment but from treatments doctors hope will be curative or palliative. With present levels of life expectancy most people experiencing what will prove to be their final illness are aged over 75. This can give the impression that high costs of health care are due to age rather than to being ill, and that any increase in numbers of older people due to lengthening of lifespan will increase NHS expenditure disproportionately. This is not so.

    With present patterns of age-associated frailty, healthcare costs in the last five years of life rise at around 1 to 2 per cent per annum from the age of 65 to 80 and then fall. (There are no comparable data for younger ages available in the UK.) The increase from 65 to 80 represents the longer hospital stays and greater intensity of care necessary for frailer people. The fall after 80 is partly attributable to the withholding or withdrawing of treatment where a patient does not want it or doctors consider it not in the patient's best interest. It will also reflect the fact that the older people are when struck by severe illness, the shorter, on average, their survival.

    But the 1 to 2 per cent per annum increase in costs with age from 65 to 80 is minute compared with a tenfold increase in costs over the last five years of life, an increase that will occur whatever the age of death. For this reason, further increase in lifespan in the UK will have negligible effect on overall healthcare costs. Indeed, if increase in longevity is associated with postponement of illness, and therefore shorter survival, costs might fall."

  3.  In reply to a further question on the comparative merits, and cost, of prevention as against cure, he replied:

    "The relative merits of prevention and treatment were churned over in the heady days of coronary heart disease epidemiology 40 years ago, and no general solution emerged. While for a single specific condition (falls or stroke for example) prevention may be better in allowing individuals to avoid an unpleasant experience altogether, or, through the age-fatality effect to shorten its duration. But it does not follow that prevention is necessarily cheaper than treatment for two main reasons:

      (1)  The cumulative lifetime costs of prevention may exceed the cost of treatment in terms both of economics and fiscal accountancy.

      (2)  There is the problem of competing morbidity. As far as healthcare costs are concerned one might avoid sudden death from a heart attack in one's 50s (cheap) only to survive a stroke in one's 60s (pretty expensive) or suffer Alzheimer's disease in one's 70s (very expensive).

    These arguments will be familiar to some people unsympathetic to the Committee's work, and, according to newspaper reports, have recently been taken out of the attic by health economists employed by an American tobacco company. Since the whole issue is both complex and unresolvable I would advise that to raise it at all would be to offer a hostage to Fortune and Distraction. There are good humanitarian reasons for improving the experience of ageing; there is no need to bring money into it!"

May 2005

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