Feature / Unhealthy growth

Gordon Greenshields looks at the cost to the NHS of  growing but avoidable problems – smoking, obesity and alcohol consumption

As the NHS grapples with financial sustainability, the public needs to be much more aware of the issues and choices that must be faced and be realistic about the consequences of not taking bold, decisive and effective action. 

This is particularly true in their attitudes to their own health. There are enormous costs for the NHS in treating ill health where poor lifestyle behaviour in diet, exercise, smoking and alcohol consumption are key risk factors.  This is a large, growing, avoidable financial burden on the NHS that needs to be drastically reduced as part of its transformation agenda.

The statistics make for grim reading. According to Health and Social Care Information Centre (HSCIC) statistics for 2011, 65% of men and 58% of women in England are overweight. The same statistics show that a quarter of men and women are obese – broadly a 10 percentage point increase since 1993.

The figures are also worrying for children (aged two to 15) – 31% of boys and 28% of girls are overweight and 17% of boys and 16% of girls are obese. The obese percentage is significantly higher for boys in the 11-15 age group.

For medical conditions relating to obesity, there were 11,736 hospital admissions with obesity as a primary diagnosis and 266,666 with it as a primary or secondary diagnosis – representing a trebling of hospital admissions since 2006/07.

The rest of the UK shows similar figures, but obesity is in fact a global issue. According to the Organisation for Economic Cooperation and Development, Canada, Chile, Luxembourg and Ireland are all in the same range as the UK, while the US (36%), Mexico (32%), Australia (28%) and New Zealand (28%) all have higher levels of obesity.

NHS England’s A call to action reminded us that some estimates suggest 46% of men in the UK and 40% of women could be obese by 2035, resulting in a likely 550,000 additional cases of diabetes and 400,000 additional cases of stroke and heart disease.

Alcohol and smoking

Statistics around alcohol consumption are also worrying. Some 23% of men and 18% of women drank more than the recommended maximum weekly intake of alcohol units, again according to HSCIC statistics for 2011. Some studies suggest these figures represent significant under-reporting and could be as high as 44% of men and 31% of women exceeding these guidelines.

The 2011 statistics for England show there were 200,900 hospital admissions with a primary diagnosis and 1.22 million with a primary or secondary diagnosis attributable to alcohol related conditions – increases of 42% and 51% since 2002/03.

The Cabinet Office Strategy Unit has also estimated that up to 35% of all A&E attendances and ambulance journeys are alcohol-related.

Smoking prevalence has fallen from 27% in 1999 to 20% in 2010, although this level has been fairly constant from 2007 onwards. However, those aged 20-34 had a much higher prevalence at 27%, which is concerning for the future. According to HSCIC figures, an estimated 1.5 million hospital admissions had a primary diagnosis of a smoking-related disease and in 2011 there were around 79,100 deaths in adults aged 35 and over attributable to smoking (18% of all deaths for the age group).

Smoking was more common in Wales, Northern Ireland and Scotland, with all the countries having a 23%-25% prevalence compared with 20% for England.

These statistics show that the UK has a serious problem with lifestyle self-abuse behaviour, despite having some of the highest tax levels in the world on alcohol and tobacco.  That seems to indicate that fiscal policy alone will not solve this expensive and growing problem in relation to its impact on NHS resources. 

The trends on increasing levels of hospital admissions are particularly concerning, considering care may also be given before and/or after the admission in A&E,

 outpatients, GPs’ surgeries and possibly by

the ambulance service.

Costs to the NHS

Varying costs of the risk factors inherent in lifestyle self-abuse behaviour can be found in government and other publications, but they use different methodologies. This makes it difficult to compare the risk factors and cumulative costs inaccurate.

However, a study published in 2011 did use a common methodology, albeit using 2006/07 information. I have recently used a similar methodology to the 2011 study to update the figures for 2011/12 with information drawn from NHS England programme budgeting data and Treasury public spending statistics (see box overleaf).

The table overleaf sets out the 2006/07 and 2011/12 consequential costs of obesity/overweight, smoking, and alcohol consumption and the results of the sensitivity analysis of those figures. Using the methodology with the updated figures suggests costs have risen by £3.3bn to £15.1bn in 2011/12, a rise of 28% from 2006/07 and consuming around 12.5% of the total NHS UK budget, which is similar to 2006/07.

The fact that spending as a proportion of total NHS budget has not increased should not give us any comfort. This proportional spend level is likely to rise, as total funding will be severely constrained over the next decade.

Arguably, these costs may be underestimated for two reasons. First, there is increasing evidence that excess bodyweight contributes to other conditions, such as benign prostate hypertrophy, asthma, sleep apnoea and infertility, none of which have been included in the costs of obesity.

Second, the programme budget methodology was changed in 2010/11. There was a 5% increase (£4.3bn) in total primary care trust expenditure in that year. However, there were unprecedented cost reductions in half the relevant disease categories, but a £3bn (25%) increase in miscellaneous. This suggests that the new methodology adversely affected the costs in the past two years of the time series. No allowance was made in the sensitivity analysis for these points. 

There are a number of assumptions in the calculations, which need to be considered  when looking at the findings. For example, the methodology uses the England programme budget figures representing estimated expenditure for each category and sub-category. These figures are then used to estimate NHS spending across the whole UK, assuming each country has the same proportional category spend. So these costs must be seen as indicative rather than absolute.

The more detailed analysis suggests the consequential costs of obesity/overweight have risen by £1.6bn (30.4%) to £6.8bn and smoking by £0.6bn (18.3%) to £3.9bn.  But those relating to alcohol consumption have risen by £1.1bn (34.7%) to £4.4bn, highlighting this as an area of growing impact that has now substantially overtaken the costs for smoking. 

Payment by results tariffs were raised by 7.2% over the same period, so there is a real increase in costs of lifestyle self-abuse behaviour, which is supported by the statistics.

The sensitivity analysis shows that the costs for obesity/overweight could be £0.1bn higher (+1.5%) and alcohol consumption lower by £0.1bn (-2.4%) and these are considered reasonable. But in the case of smoking, the costs could be lower by £1.5bn (37.5%), which is very significant. If the minimum and maximum range of the sensitivity analysis were applied, this would give a cost range of £13.5bn-£15.2bn which represents 11.2% and 12.6% respectively, of the total NHS UK budget.

Serious implications

The consequential costs of treating diseases where the key risk factors are obesity/ overweight, smoking and alcohol consumption are enormous – about 12% of the NHS budget – and this is likely to grow given the trends apparent in the statistical analysis. The question is whether these escalating costs – current and future – are sustainable given the difficult financial situation the NHS faces.

If the NHS is going to be financially sustainable over time, changing the ‘habits of a lifetime’ for a major part of the population and substantially reducing the consequential financially damaging cost trend will be fundamental to its financial survival.

The NHS will need to develop and provide a portfolio of strategies and approaches to substantially change these trends. This will not be a cheap, quick-fix scenario and is unlikely to provide a quick return on investment as it is a complex, multi-faceted, long-term journey of behavioural change. Given its horrendously difficult financial environment, how can the NHS invest sufficient funds in the next decade to change these lifestyle self-abuse behaviour trends and their spiralling consequential costs? It reminds me of the Chinese curse: ‘May you live in interesting times!’

Gordon Greenshields is a visiting professor at University of Chester Business School and was director of finance and corporate information at the NHS Executive 1991-94