Forget the dementia tax. The NHS could easily prevent it andThe NHS could easily save at least £5 billion just by tackling the true causes of disease and focussing on their prevention.
The UK National Health Service was founded on the basis that making medical treatment for all disease free, would result in a healthier nation and then medical costs would come down. That could have worked if the focus had truly been on disease prevention. But changes in diet and lifestyle in the 21st century have fuelled endemic diseases of diabetes, dementia, cancer and cardiovascular disease and medicine has skewed towards prescribing drugs rather than encouraging prevention. When you consider that there have been more sugar-related deaths (from diabetes and obesity) at a rate of 100 a day, in the last decade in the UK than total UK casualties in World War 2 it puts the disastrous effect of these diet-related diseases into perspective.
Consequently, the NHS has become the fastest growing failing business in Britain and the 20th largest employee in the world, with 1.3 million employees, primarily because we have too many sick people. The way to reduce the cost of the NHS is to have less sick people, which means focussing on disease prevention. Prevention is better, and much cheaper, than cure and the only way to significantly reduce the burden on the NHS going forward.
The assumption that a population with a higher percentage of older people will further increase costs assumes that old people must be sick. This may be currently true, with the average woman being disabled, meaning unable to climb ten stairs, for the last decade of their life, but it does not need to be the case if we prevented the diseases, that affect older people, from developing. One in six over 40 have diabetes, one in three over 50 are obese and one in four over 80 have Alzheimer’s. We spend next to nothing on effectively preventing these diseases.
For example, 0.11% of the government’s dementia research budget is spent on prevention research. The total spend, from 2006 to 2013, was a mere £156,000 out of £140 million. Unlike other countries the UK does not ring-fence any research funding for prevention. Australia, for example, has ring-fenced $38 million for prevention research.
The NHS annual drug bill keeps going up. Big pharma agreed to cap it at £12 billion, but that doesn’t include generics – drugs off patent – so the current cost is around £15 billion. This was a two-year deal and it also means that any comprehensive effort to reduce the medical professions’ current dependency on prescribing drugs would come under big pharma pressure.
Yet the causes of the costly diseases are poor diet and lifestyle choices, stress and pollution, not a lack of drugs. The NHS costs £113 billion a year, or £1,765 per person. It is funded from our tax, accounting for roughly 18% of the average person’s tax. It is far from ‘free’.
The King’s Fund estimates, in the current scenario, that the NHS will need a further £8 billion a year by 2018, and the current government intends to put in a further £3 billion in the next year if they get back into power.
By tackling the causes of disease, and focussing much more on prevention, the NHS could easily save in excess of £5 billion a year* – more than enough to fund the estimated increase in cost due to an ageing population.
*Please note that these figures are based on expert groups’ analyses, not my own. I do not have the means to independently verify them. There will be some crossover effects, eg dementia prevention strategy will also target diabetes prevention, so the figures are very rough estimates of possible costs and impact. Also, as people consume less sweet foods and drinks the sugar tax revenue will decrease.
Here are five suggested changes for a healthier nation, more in line with the original intent for a National Health Service, rather than one focussed almost exclusively on disease treatment.
Tax sugar. The WHO set a maximum intake of sugar at 5% of calories. If any product containing 10% or more of calories from sugar were taxed at 20%, the same as VAT, that would generate an estimated £2 billion. Also, a compulsory ‘warning’ saying ‘excess sugar is bad for your health. Keep your intake below 5% of calories.’ The tax would provide the means to further educate and discourage the eating of sugary foods, working with councils and community groups for a consistent anti-sugar message, and encouraging eating a low sugar, low glycaemic load (GL) diet, in much the same way that smoking has been discouraged. A low GL diet based on whole, not refined foods, is strongly associated with reducing risk for diabetes, cardiovascular disease, breast and prostate cancer.
According to the Faculty of Public Health adding 20p per litre to the cost of sugar-sweetened drinks would generate £1 billion. However, also adding a 20% tax to sweets and sweet foods would generate a further £1 billion. This is predicted to cut the rate of obesity by 1%, thus saving a further £500 million a year by reducing the costs of obesity-related healthcare, which is currently £5 billion a year. Combined, this would generate £2.5 billion. Even if sweet treat consumption reduced by a third that’s still £1.66 billon generated – a healthy sum to fund health education and prevention strategies.
Encourage fish eating. Fish eating is associated with lower risk for dementia, depression, cardiovascular disease and cancer. One weekly serving of oily fish is associated with halving dementia risk. Having two servings of fish a week, one being oily fish, has consistently been shown to significantly reduce risk for cardiovascular disease, metabolic syndrome and depression. Omega-3 fish oils should be prescribed alongside psychotherapy in preference to anti-depressant drugs as a first resort given their bad safety profile in increasing suicide risk. Fish is rich in omega-3 fats, also found in some nuts and seeds, as well as vitamin B12. Fish is also anti-inflammatory. Omega 3 fish oils are also natural anti-inflammatory agents and would therefore be likely to reduce the NHS’s £535 million drug bill for analgesics. This would be funded from the sugar tax at a budget of £50 million a year.
Promote dementia prevention. Half the risk for dementia is due to factors we can change. That’s what a group of 112 dementia experts say. Three of the most important risk factors are an overall improvement in diet, B vitamins and intake of omega-3s. A study published in April showed that those people in the top third for a healthy Mediterranean style diet have half the risk of dementia of those in the bottom third. Having a high homocysteine level, an indicator of insufficient B vitamins, which is found in approximately half the older population, accounts for 22% of Alzheimer’s cases. So does having a low fish and/or omega-3 intake, according to a study by the US National Institutes of Health. Since these factors overlap approximately one third of all Alzheimer’s could reasonably be prevented simply by dealing with these two factors – getting enough B vitamins and omega-3 fats. The impact of improving overall diet would add on additional risk reduction.
Giving extra B vitamins to those with high blood homocysteine levels has already been shown to reduce the Alzheimer’s associated rate of brain shrinkage by nine times. By encouraging early screening for subtle cognitive changes from the age of 50, for example with the free online www.cognitivefunctiontest.com, then measuring blood homocysteine in those who test poorly and prescribing inexpensive B vitamins (B6, B12, folic acid) at a cost of 10p a day to those with raised homocysteine (above 10 mcmol/l), and ensuring sufficient omega-3s would result in cutting the current annual state cost of dementia of £11billion by a third, namely £3.5 billion. If only a third of those at risk are identified and treated this would still be expected to produce more than £1billion in cost savings. The immediate annual saving from measuring homocysteine and giving B vitamins only would save the UK approximately £66 million a year, according to Oxford University’s health economist. Another estimate calculates a saving of 88 billion euro of costs related to dementia over 5 years by improving low omega-3 FA and raised tHcy levels through nutritional interventions across the EU.
Sweden is already implementing early screening, homocysteine testing and B vitamin treatment, so it is practically doable. Doctors are currently paid £50 to screen a person for dementia but people would much rather do this privately, online. The £50 would be better spent on a homocysteine blood test for those at risk. Targeting 50+ year olds is key because that is when the first signs of brain shrinkage and memory loss occur. Such a strategy is estimated to reduce the number of Alzheimer’s cases by circa 70,000 a year, at a saving for the state of at least £1 billion. However, the same saving again would be made by carers and families of dementia patients, who bear the biggest brunt of the burden.
Tackling other risk factors by encouraging a modest and achievable reduction of diabetes, hypertension, obesity, depression, physical activity and smoking is estimated by the International Longevity Centre – UK to save in the region of £1.5 billion a year by further reducing the number of people developing dementia.
By tackling all known and preventable risk factors the estimated saving is around £2.5 billion. If £300 million were allocated to achieve this, £100 million being allocated to prevention research and £200 million to a prevention campaign, the net saving is £2.2 billion.
Reverse diabetes by encouraging a low sugar, glycaemic load (GL) diet. Over three million people in the UK have diabetes (type 2) which is a preventable and reversible disease. Diabetes costs the NHS over £10 billion a year. Diabetes medication alone accounts for 47 million prescriptions at a cost of £848 million. However the London School of Economics estimates that the cost of prescribing medication for complications of diabetes is around 3 to 4 times the cost of prescribing diabetes medication and therefore in excess of £2.5 billion.
If all people with diabetes or prediabetes were referred by their GPs to attend a progressive half day seminar taught by nutritional therapists, with food demos and exemplary cases shared by previous diabetics, learning how to follow a lower carb, low glycaemic load diet using whole foods and healthy alternatives to sugar this would both reduce current diabetes treatment costs, and prevent those at risk from developing diabetes, and cut existing cost of medication and future cost of amputations and hospitalisation. A ten-year diet/lifestyle intervention in the US reported a saving of £300 per diabetic person per year. If applied to the 3 million diabetics in the UK that equates to a saving of £900 million.
The average cost of a diabetic, according to diabetes.co.uk is around £2,000 per year. Currently 700 a day are diagnosed with diabetes, or a quarter of a million a year. Reducing this by 20%, which means 50,000 less cases a year, would save over £100 million. That’s a combined saving of £1 billion a year. The campaign to prevent diabetes would be funded from the sugar tax with a budget of £150 million a year.
Discourage polypharmacy. Half of people over 65 are on five or more different drugs – often for diabetes, cholesterol, high blood pressure, indigestion, arthritis and depression. Many of these drugs promote further diseases. For example, last year 57 million antacid drugs were prescribed, at a cost of £128 million, which are known to increase dementia risk by preventing B12 absorption. (So does the diabetes drug metformin). Very few doctors encourage diet changes, for example digestive enzymes or probiotics for indigestion or trial avoidance of common food intolerances despite evidence of efficacy. Also, 57 million prescriptions were issued for anti-depressant drugs at a cost of £265 million. Recommending oily fish and/or fish oil supplements would reduce the need for anti-depressants. Improving the nation’s diet would cut the need for these drugs. The current annual drug bill is £15 billion. A targeted 15% reduction would save £1.5 billion. If £100 million from the sugar tax were spent educating doctors in nutrition (£25 million) and employing the existing 2,500 nutritional therapists in the UK (£75 million based on a salary of £30,000p.a) across GP practices and hospitals to effect non-drug approaches this could be achieved.
Net result: £5 billion a year less NHS costs; £1.6 billion revenue from a sugar tax; a budget of £600 million for prevention education Net effect: £6 billion a year saved.
Reduced drug costs
Encourage fish eating
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Of course. Doctors can prescribe B vitamins and omega-3 fish oils already but rarely do. This needs to be actively encouraged for those who need them. Encouraging more fish consumption for all of us is an important first step. I do, however, recommend first testing homocysteine before giving high dose B vitamins. The research shows that you need circa 500mcg of B12 to bring down homocysteine. You'll never achieve this from diet, or even a basic B complex. On the other hand, it is debatable that a person could ensure sufficient omegas just from food. However, if a person's plasma levels are low, or if eg they are depressed or suffering with memory problems, a few months adding in supplemental omega-3 fish oils would be wise. The NHS allow omega-3 supplementation after a heart attack, but only for up to 6 months.
Matthew M, 6 May 2015
How about product warnings on meat and dairy Patrick.
Matthew M, 6 May 2015
Such as "Dairy products cause acne and oily skin which may mark your skin" and maybe "Daily consumption of meat will cause daily stomachaches and brutally immovable constipation.
Matthew M, 6 May 2015
My father has an H score of 19 is that enough to get a written prescription for B vitamins of the standard of solgar highernature and biocare and easy to get to level recommended in H factor.
Patrick Holford, 6 May 2015
They may not prescribe those particular supplements but that level of homocysteine certainly warrants supplementing high doses of B6, B12 and folic acid. Doctors can prescribe these.
Matthew M, 6 May 2015
I stopped believing in pharmaceuticals and surgeons and doctors and agree diet prevention is where money should be spent.
More money is spent in the school meal system in a day than is spent in a week in our hospitals. Why have nutritionists not been consulted to sort out the terrible state of hospital food for patients. Why are obese TV presenter chefs involved in creating menus of our hospitals why are there no BBC programmes with nutritionists being approached if its so dire.
Informed consent is a joke judging from my own experience.Patients are duped into poor treatments. I want to be informed of the benefits and risks and alternatives to the therapies being given currently. If I had a chest pain like my father because of blocked arteries, I'm told that the solution is heart surgery but not told that nine out of ten studies show that angioplasty (where they stick the tube up into your heart) does not save lives.
When I was 16, the night before my dad had bypass surgery I watched the procedure on telly (very bad timing) and I was shocked at what he'd have to go through, not knowing anything about alternatives back then, were we told that he would have 100% risk of brain damage from the heart/lung machine. It damages the blood cells, introduces gas, debris is dumped back into the patient and they have diffuse embolisation and these emboli go into the blood vessels of the brain and they kill pieces of the brain.
100% of patients looked at after surgery show evidence either in the blood or in the spinal fluid of damage to the brain and about 90% are severely or significantly demented right after surgery.
24/7 Emergency/Accident care surely needs adequate funding not sure what that should be could easily met but we are bamboozled into beliving we can't afford a welfare state when there's plenty for nuclear weapons
Matthew M, 4 May 2015
Scrapping Trident and taking the drug industry into public ownership would have saved you all that maths Patrick.
It'll help pay the sick pensioners a decent retirement income to help with all the rising living costs. Nobody to vote for that round my way unfortunately
Matthew M, 4 May 2015
Flagged my own comment. Way to radical that ain't it.
Matthew M, 4 May 2015
Would you use some of the 5 billion savings and make those vitamins and Fish oils supplements free at the point of need Patrick.