In which we are reminded that the NHS management don't understand economics

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It starts with this:

‘Collectively and cumulatively [these actions] and others like them will help shift power to patients and citizens, strengthen communities, improve health and wellbeing, and – as a by-product – help moderate rising demands on the NHS’

This is the rather ghastly sounding 'Health as a Social Movement' line in the NHS's vain attempts to pretend that preventative medicine will 'moderate rising demands'. What is most striking here is that, yet again, the basic economics of all this are overlooked (although given they've appointed the risible joke of a think tank, New Economics Foundation, it's pretty clear they're not remotely interested in actual real economics).

Unless the project is about improving productivity through these community-focused actions then the only impact - assuming they do improve health and wellbeing - will be to increase the long-term demands (and hence costs) on the NHS.

The report ...projected that people with Type 2 diabetes who participated in a disease management program to prevent serious complications would cost the federal government slightly more money over 25 years than they would have without any intervention.

If you stop and think about this for a second, the reason for a healthy community being more expensive is pretty obvious - most of the costs in the health system (and the care system too) are directed towards older people so if more people live to a ripe old age there are more of those 'end of life' costs.

To use a big example, we've seen a massive decline in the numbers of and in survival rates from heart attacks - since 2002 the mortality rate has more than halved. In simple terms this means there are double the number of long-term heart 'patients' compared to the old days when they all died of a heart attack. This absolutely brilliant and a credit to doctors, pharmacists and the health benefits of a bigger, richer economy. But it's costing the NHS a fortune.

And it's not just heart attacks but every sort of disease, from childhood infectious diseases through to cancers, that has seen declining mortality rates. And this means it's pretty normal to live into your 80s, not unusual to make it to 90 and increasingly common for folk to make it to 100. So when we act - quite rightly - to prevent disease and reduce mortality rates the result is more and more old people and more and more demand for the NHS services that are under so much strain.

The challenge for healthcare is to improve productivity - to reduce unit costs for operations, for providing care, for dispensing medicines, for all the vast array of stuff health care does. And spending money on "health as a social movement" only does this if it means that the allocation of NHS resources to these communities is thereby reduced. So long as we focus on simple prevention as a demand management tool, we will find no benefit in higher productivity and a pile more demand-led costs for the system.

This is, of course, what you get if you believe that NESTA, the RSA and New Economics Foundation are the sorts of organisations that are able to guide the NHS towards greater efficiency and higher productivity. A load of left-wing cant and absolutely no moderation of rising demand.

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The case against modern public health

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Public health is not healthcare. It is the authoritarian encapsulation of a nebulous concept usually called "wellbeing". Public health assumes that we, as humans, seek wellbeing and that our understanding of the concept is the same as they have determined.

...it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Occasionally invoking the force of law (immunizations, seat belts), it prescribes and proscribes for both individual patients and the general citizenry of every age and stage. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.

Worse still this idea of 'preventive medicine' offers a further false prospectus by suggesting to the purseholders of health care systems that by embracing interventionist public health those systems will reduce their costs.

...the report also makes an economic argument for preventive care, highlighting the possibility of reducing healthcare spending -- which in 2011 reached $2.7 trillion, just shy of 18 percent of gross domestic product -- by billions of dollars. And that has health economists shaking their heads.

"Preventive care is more about the right thing to do" because it spares people the misery of illness, said economist Austin Frakt of Boston University. "But it's not plausible to think you can cut healthcare spending through preventive care. This is widely misunderstood."

As that quote indicates this argument is entirely false:

Despite the costs associated with the ageing population, it is sometimes claimed that people who are at risk of premature mortality due to lifestyle factors are a 'drain on the taxpayer'. Smokers, drinkers and the obese, in particular, are blamed for rising costs to the general taxpayer.

These claims do not stand up against evidence. If one looks at the lifetime costs to all public services, it is clear that the 'longevity-related' costs of healthier people are considerably higher than the 'lifestyle-related' costs of less healthy people. Acute healthcare costs are usually higher, long-term healthcare costs are invariably higher, and welfare costs (eg. pensions) are vastly higher.

And this, of course, assumes that the public health or preventative health measures are effective. The sad truth is that many of them - smoking cessation programmes being a good example - are expensive and largely ineffective. Local authorities are funding weight loss clinics - in direct competition with a huge private sector - when, again, the evidence of their effectiveness is pretty limited.

However the main objection to public health programmes isn't their cost or that they don't work, it is rather that their advocates seek to direct your choice - to urge you to eschew pleasure - in the expectation that you will see the benefits in a possibly longer, healthier life. Although the proponents of public health have laid claim to the idea of wellbeing, their approach to its promotion is to remove pleasure and happiness in order to impose an approved and safe form of wellbeing, a sort of dull, dreary '70s Sunday afternoon contentment.

Public health is an ideology of control not a healthcare programme. It dulls the senses of health management by suggesting their inevitable cost pressures will be relieved by patients embracing an approved lifestyle that eliminates the risks contributing to the growing number of people living with chronic conditions like type-2 diabetes. Above all public health represents a crusade to promote a moral and righteous life to the populace - don't smoke, don't drink, don't stay up late, do the right amount of exercise, eat the right diet, avoid salt and sugar. This lifestyle is promoted through the use of public funds to appeal, on one hand, to our fear of mortality through talk of cancer, heart attacks and dementia, while simultaneously suggesting that beautiful, successful people adhere to this stultifying, dull set of consumption behaviours. Across all this runs the argument that, if we want our children to be one or those beautiful, successful people - or even to live - then they mustn't be exposed to these sins of diet or pleasure.

It is hard to think of a section of government that so completely (and for its practitioners unconsciously) embraces the warnings about soft totalitarianism set out by Orwell and Huxley - and especially the latter with his observation that totalitarianism would be a matter of acceptance not something violently imposed by a powerful, all-seeing state. Restrictions on our lives - repeat the mantra of don't smoke, don't drink, eat the right food - are accepted because the experts with their evidence tell us that embracing these restrictions is the right thing. Just as as self-appointed stasi helped enforce the smoking ban, we will see similar as new fussbuckets arise to challenge those who drink openly, who eat sugary or salted foods.

The truth about public health spending is that nearly all of it is wasted, is money spent on promoting an ideology of control. No lives are saved by public health's actions. No money is saved for the wider health system by the interventions of public health. No-one's wellbeing is improve by public health. Indeed for many thousands the actions of these ideologues result in a worse life. Yet in my city of Bradford over £30 million is spend on public health programmes, money that could fix the roads, could provide care for the elderly, could smarten up parks. Instead we'll spend it on nannying the hell out of the population, on promoting an unpleasant controlling ideology founded on a myth of wellbeing that has no basis in fact or substantive value to the poor masses it is being imposed upon.

It's time to stop all this. There is no case for public health as practiced today.

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