Think healthy

The journalist AA Gill died at the weekend after a short battle with cancer. His final article was published posthumously in the most recent issue of The Sunday Times, describing how he coped with his fatal illness. What was particularly striking about the article (the gist of which you can get from the BBC here or The Guardian here) is the description of how cancer survival rates in the UK are the lowest in western Europe. The doctor who treated him noted that the reasons for such a poor performance are due to “the nature of the health service” which imposes such a huge administrative burden that it hampers early diagnosis of the disease which is so vital to successful treatment.

Many foreign people of my acquaintance do not share the same reverence which the Brits show for the National Health Service. This is in no way to denigrate the professionalism of those who work in it. The doctors, nurses and all other medical staff do a wonderful job saving lives and healing the sick – but they work in a system which is dysfunctional, as many NHS employees readily admit. As Gill himself noted, the Brits lie to themselves about the quality of the service they receive. “We say it’s the envy of the world. It isn’t. We say there’s nothing else like it. There is. We say it’s the best in the West. It’s not. We think it’s the cheapest. It isn’t … You will live longer in France and Germany, get treated faster and more comfortably in Scandinavia.”

When it was founded in 1948, it offered a genuinely revolutionary approach to health provision in the west. But precisely because it is free at the point of consumption, it has always struggled with questions of “how best to organise and manage the service, how to fund it adequately, how to balance the often conflicting demands and expectations of patients, staff and taxpayer [and] how to ensure finite resources are targeted where they are most needed.” (source: Geoffrey Rivett, here). As treatment becomes more expensive and the population gets older the pressure on resources becomes more intense. The current government has opted to ring-fence NHS spending (but not welfare spending – we’ll do that another day) but continues to struggle to reform the system. No politician has yet had the courage to impose charges as a means of regulating near-infinite demand, such is the totemic importance of the NHS to the British electorate.

Precisely because resources are finite, Gill was denied treatment on the NHS which may well have prolonged his life because it was deemed too expensive. The cost of providing him with a drug called Nivomulab would have amounted to between £60k and £100k per year – four times the cost of traditional chemotherapy. And this is where economics comes in. Health economists are employed in the NHS to ensure that best use is made of the resources available. It is a job which needs to be done. After all, if economics is (at least partially) about the study of the allocation of scarce resources, then health issues would appear to be highly amenable to the scrutiny of economists.

But Johannes Bircher at the University of Bern argues that we do not actually know what health is (here) and therefore it is not a commodity which can be priced: After all, we cannot produce, obtain, exchange, sell or store it. Such an approach rather undermines the assumptions underlying Kenneth Arrow’s classic 1963 paper (here) which treats health as a commodity – albeit one with different characteristics to normal consumer goods.

My own issue with the field of health economics stems back to my undergraduate days and questions of cost-benefit analysis, because I have always struggled with the question of how you put a price on life. No matter what form of valuation you use, no amount of money can ever compensate for the very essence of being. This is not a question for economists – it is one for the philosophers. 

All that aside, Gill showed a remarkable degree of stoicism in facing up to his fate and wrote that he was happy for the last 30 years of life, having broken his alcohol dependency cycle in the mid-1980s. For a man who wrote so wittily and so scathingly on a range of subjects, it is only fitting that we leave the last word to him on a subject we all know and love so well – Brexit. “We all know what ‘getting our country back’ means. It’s snorting a line of the most pernicious and debilitating Little English drug, nostalgia. The warm, crumbly, honey-coloured, collective “yesterday” with its fond belief that everything was better back then, that Britain (England, really) is a worse place now than it was at some foggy point in the past where we achieved peak Blighty.”