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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