Commentary: Look after the penniesBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1380 (Published 01 April 2009) Cite this as: BMJ 2009;338:b1380
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There can be little doubt that in a World with reduced financial
resources spending on healthcare will decrease.
In the UK the total annual expenditure on healthcare in the NHS in
2009 will be £ 109 billion, 7.5% of GDP. Present Treasury estimates imply
that this will effectively have to be cut back by probably 10-20% in the
future. Savings, in part, might come from better use of existing
The bulk of NHS expenditure relates to treatment, reparative &
curative procedures. 70% of the total is spent on hospitals; whilst
general practice, which deals with 95% of illness, only accounts for 10%
Preventive procedures receive only a small part of this expenditure.
In the USA total healthcare expenditure is $ 2 trillion (£1.4
trillion) of which 2% relates to prevention.
What part will preventive medicine play in the future?
Arguably, considerable savings, in both financial terms and in terms
of morbidity and mortality, could be made by preventing disease, rather
than managing established disease. However, certain caveats and provisos
must be applied in analysing the actual benefits this might bring.
On the face of it, “prevention must be better than cure”. The reality
however shows that paradoxically in practice this is not always so.
For example, opponents of preventive medicine argue plausibly,
tobacco smoking increases the likelyhood of developing ischaemic heart
disease and thus reducing smoking should reduce heart attacks. However,
the reality is that the onset of the attack is merely delayed to a later
age. Thus, over an individual’s life time the cost of healthcare will not
necessarily be reduced, by ceasing to smoke.
Similarly, screening men for cancer of the prostate not only
increases the number of men undergoing often unnecessary investigations
and treatment, but does not reduce the numbers dying from prostate cancer.
The overall cost is probably thus increased.
Further, it has been postulated that preventing illness and thus
prolonging an individual’s life permits the development of more age-
related illness and increased lifetime healthcare costs.
Proponents of preventive medicine tend to consider both financial
costs and the quality of life. They recognise that pre-retirement there is
economic gain from reduced disability and improved work capacity; however,
post-retirement although independence may be enhanced initially, longer
term there is increased requirement for medical & social support. At
about the age of 50, it has been calculated, the economic benefits of a
few more productive years equals the added costs of old age.
Even if this be so, there can be little question that for the
individual and for society the benefits of increased years of healthy life
are enormous, although unquantifiable.
Numerous studies show that some preventive measures are clinically-
effective, some of these are also cost-effective and some are neither
clinically nor cost-effective. Certainly immunisation against infectious
diseases is of proven clinical value and almost certainly it is cost-
effective. Similarly this is true for routine screening for diabetes and
raised blood pressure. However routine screening for breast cancer and
cervical cancer although clinically valuable are probably not cost-
effective. Genetic screening, at its present state of development, is
clinically valuable only in a limited number of conditions and thus not
The reliability of routine screening and its clinical value is
considerably enhanced if targeted at groups of the population who are at
greater than average risk.
Modifying lifestyle by reducing tobacco & alcohol intake,
improving diet and increasing physical activity should significantly
reduce heart disease, lung cancer and several other diseases. To be
maximally effective associated legislative measures, amongst others,
restricting smoking in public places & increasing duty on alcohol
& tobacco, must be implemented and observed. The cost of public
education and of introducing such measures is not great, other than in
loss of revenue from tax, and the benefits could be immeasurable.
Turning briefly to treatment costs, the cost of adding one year to an
individual’s life has been calculated for several illnesses. £14,000
for cancers, £8,400 for circulation disorders, £7,400 for respiratory
diseases. Would this money have been saved if these diseases could have
Several questions remain, as yet, unanswered. Should a larger share
of healthcare expenditure be spent on preventive measures? Should evidence
-based procedures, both in prevention and treatment, be analysed to assess
their clinical and economic values and then incorporated into the
Wanless concluded his 2002 report by proposing that the NHS should
shift from being a service which treats disease to one which focuses on
preventing it. The reality is, as with all aspects of life, the answer
lies at neither extreme, but is somewhere in between.
On balance, it seems reasonable to conclude that the proportion of
spending on proven preventive medical measures, relative to total
healthcare expenditure, should be increased to obtain economic, social and
individual benefits. This expenditure could be offset by concentrating
spending on treatment and “curative” medicine on proven procedures.
The Strategy of Preventive Medicine Geoffrey Rose 1992
Does Preventive Care Save Money? Cohen J et al 2008
Further evidence on the links between healthcare spending &
health outcomes in England Martin S 2008
A closer look at the argument for disease prevention Woolf S H 2009
Securing our future health: Taking a long term view Wanless D 2002
Securing good health for the whole population Wanless D 2004
Dr Harald M Lipman
Executive Director International Cardiac Healthcare & RiskFactor
Formerly Senior Medical Adviser Foreign & Commonwealth Office
Competing interests: No competing interests