Intended for healthcare professionals


A dream about value, the NHS, and end of life care

BMJ 2022; 378 doi: (Published 11 August 2022) Cite this as: BMJ 2022;378:o2004
  1. Richard Smith, chair
  1. UK Health Alliance on Climate Change

Dreams have content but no meaning, much like life. We have responded by creating myriad religions, and millions of theologians have spent lifetimes squeezing meaning from those religions. I can do the same with a recent dream I had.

My dream seemed to happen within a royal college, which is not surprising as because I’m the chair of the UK Health Alliance on Climate Change, an alliance of royal colleges and others, I spend much time thinking about colleges.

In this composite college I met Gordon Brown, the former UK prime minister. With a wide grin, he slapped me on the back and said “I call you Britain’s chief value officer.”

“We do,” I responded, “need less attention to cost and more to value.”

I was a student in Edinburgh at the same time as Brown and knew him slightly. I bumped into him over the years and met him last year at COP26 in Glasgow. Somebody took our photo, and the picture shows us both with wide smiles. We don’t have chief value officers in Britain, but I have a friend in the US who was the chief value officer of a large health system.

Value, you remember, is benefit divided by cost. You can increase value by producing more benefit for a unit of cost or by producing the same amount of benefit for a lower cost.

I have been thinking about value in healthcare, particularly about value at the end of life. As the Lancet Commission on the Value of Death (which I co-chaired) found, something like 10% of annual health expenditure goes on the 1% of people who die in that year.1 Most of the money is spent in the last few days and weeks of people’s lives, much of it on hospital care including intensive care. Is that value for money?

For the dying people it might be. Perhaps the treatment extends their lives, and we know that people will pay a great deal for extra weeks of life. As Shakespeare writes in Measure for Measure:

“The weariest and most loathed worldly life

That age, ache, penury, and imprisonment

Can lay on nature is a paradise

To what we fear of death.”

Perhaps this treatment keeps people comfortable at the end of life, allowing them to die with dignity, but we also know that families, friends, and morphine can keep people comfortable at minimal cost. The treatment must include a lot of active treatment, including surgery and time in intensive care. We know that there is much overtreatment at the end of life, and that treatment probably increases suffering, although suffering is hard to measure—as are love, freedom, and most of what makes life worthwhile.

If I were Britain’s chief value officer, I would have to advise the prime minister that it’s hard to reach a confident conclusion on the value to the individual of the high expenditure at the end of life. But if asked to use my judgment, I would say that despite Shakespeare, it’s of poor value for the individual.

But when it comes to society that huge expenditure is poor value, particularly when healthcare is crowding out expenditure on education, housing, benefits, the environment, transport, the justice system, and the arts, most of which are more important for health than healthcare. To deny a child good food so that a dying person, who is often very old (over 80), can die in intensive care is not good value for society.

I would advise the prime minister that high expenditure at the end of life is poor value for society. “How,” he would ask me, “can I balance the value to the individual against the value for society?”

“That,” I would answer, “is the job of politicians.” “But,” I might add, “you could ask people’s opinion with some sophisticated questions. You could also say that all NHS treatment will continue to be free at the point of delivery until a particular age, perhaps 75, and that palliative care will be free at all ages, but if people want intensive treatment after 75 they will have to take out an insurance policy before the age of, say, 40. My guess is that few people will. I recognise that this would break fundamental NHS principles, and there would have to be a means test for the insurance premium. I wouldn’t, however, advise making it free for the people who are poorest because my judgment is that we would be giving them the opportunity to suffer more.”

Back to my dream. The other part of my dream was murky, but it revolved around the discovery that unbeknownst to the senior leaders of the college the staff were having to live off either horsemeat that was past its sell by date or food intended for animals.

What might this mean? I passed yesterday in Sainsbury’s the box of food intended for the food bank. It was fuller than ever. Many people in Britain, including children, are going to bed hungry—as are about a billion people in the world. Was my dream telling me that it makes no sense to spend so much on healthcare, particularly on intensive treatments for people who are dying, when children are going hungry? Was the dream also telling me that the country’s leaders simply don’t know—in a deep sense of know—that so many are hungry?

Or could this be a message about NHS staff being fed horsemeat, as in, being exploited? Bearing in mind that expenditure means activity and that about three quarters of the spend on healthcare is on staff, the high spend at the end of life means that staff are spending lots of time treating—and probably overtreating—people at the end of life. Their time and energy could be better spent. As it is, NHS staff are like hamsters in a wheel, having to run faster and faster to keep the show on the road. It’s not sustainable.


  • Competing interests: none declared

  • Provenance and peer review: not commissioned, not peer reviewed.