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The cost of healthcare: assessing the evidence

In this edition, the concept of ‘acting on the evidence’ is explored in depth (1,2). In clinical practice, we have adjusted, in general, to the philosophy and practicality of evidence-based medicine (EBM). What we have not adjusted to is the absence of evidencebased politics with regard to medicine, though in truth its absence has affected many aspects of life, including the Iraq war. Why politicians cannot base their decisions concerning many issues, including medicine, on a sound evidence base is a never ending puzzle, as is their apparent inability to learn from experience. It is as if the sound bite ‘lessons to be learned’ is never acted on, or at least audited. In the cardiological arena, the evidence base for a preventative strategy is overwhelmingly strong and leads on to the logical development of community cardiologists whose remit would be to target risk reduction as a means of ensuring better health. As a consequence, invasive intervention and surgery would decrease even further than currently being observed. The cost saving would be substantial and not complained about because the end result would be ‘cut-free’. In response to the evidence, the opposite has occurred with expensive cardiac angiogram suites built here, there and everywhere involving staffing issues, high running costs, low volumes and training interventional cardiologist who are active after the event rather than before. The National Health Service (NHS) is treated politically like a revolving door with ministers pausing briefly as they use it as a stepping stone to allegedly more important portfolios – there is in reality nothing more important than good health. (A wise man ought to realise that health is his most valuable possession – Hippocrates). Changes are proposed without due consideration and certainly without an evidence base because there is no trial process. If the medical profession behaved in a similar manner, there would be justifiably public condemnation. The reasoning appears to be a mixture of cost-saving combined with improving organisation, and from that hope for better overall care. The problem is, that is what was supposed to happen with all the previous reorganisations which were not fully evaluated before being compulsorily introduced. There is no evidence that any aspect of the current process will tackle the fundamental issues of providing efficient cost and health effective care. An example of illogical thinking is the use of appraisals, brought in to avoid another Shipman episode. First, appraisals would not have detected Shipman’s behaviour and secondly, for general practitioners why is it necessary for them to be annually appraised at a cost of 100 million pounds each year? By making it less frequent, the savings are not only obvious but also avoid any reduction in clinical services. Drugs prescribed in the NHS in England cost £7.40 each course unless you have an exempt condition such as diabetes. If you are hypertensive on three drugs, this amounts to £22.20 per 2 months. Controlling hypertension prevents a substantial number of strokes, which as well as being individually disabling are expensive to manage – but hypertension is not an exclusion and for some the medicine will be too expensive to purchase. In Scotland and Wales, NHS prescriptions are all free – prevention is therefore encouraged, whereas in England this is discouraged. Some political minds need to be closed for repairs. Prevention of disease must be the objective of every medical practitioner – this is where reorganisation is needed. Investing in prevention will reduce overall NHS costs without cuts to services – the ideal medical objective is to reduce the need for a doctor in general, while increasing availability when specifically needed.