ASSESSING THE PREVENTIVE HEALTH PROGRAMMES VALUE
Evidence over many years shows that whatever financial and other resources are put at the disposal of western medicine will be swallowed up. In fact one researcher has calculated that by doubling the current expenditure longevity would not be altered significantly. Half of the increased expenditure since the 1950s has gone in higher prices. The other half has gone largely on more hospital beds, more technology, more hospital admissions, more health employees and more in-patient days in hospital. But in spite of all of this the major killers-heart disease, strokes and cancer-have declined little. The exception to this is the decline in heart disease deaths in the US that has occurred over the last fifteen years. This has almost certainly come about as the result of lifestyle changes and not increased expenditure on curative medicine. Although it is difficult to make
accurate estimates it is generally agreed that about 2 per cent of healthcare expenditure goes on preventive medicine in most western countries, yet we are told from the cradle that prevention pays and that a stitch in time saves nine. Just how true are these claims?
Trying to assess the value of a preventive programme is a complex task. It is not too difficult to work out the cost-effectiveness of a simple curative procedure because the end-point is often fairly clear and you know what the starting point (an ill person) is. But when it comes to spending money on prevention there are many problems, some of which arise because the person involved is healthy and the benefit conferred on him or her, or on society, may not be easily quantifiable in terms of money and may occur many years after the original expenditure on the preventive measure.
When trying to work out how financially worth while a preventive health programme is we have to consider four main points: (1) The positive and negative effects of the programme; (2) how many of these effects can be clearly related to a preventive programme; (3) what value can be put on the results and (4) the balance of the advantages and disadvantages of the programme.
As an example let’s look at screening for breast cancer. The effects of the programme will include: the cost of convincing women they should be screened; the cost of their time off work or other duties to go to be screened; the cost of actually getting there; the cost of the screening itself (both in people and equipment); the cost of following up the abnormal findings; the cost of treating those who have abnormalities but who would have otherwise gone untreated; the cost of any doctor-induced problems (i.e. other problems which the screening programme itself brings into being) and their follow-up treatment; and the savings resulting from the reduced use of medical and other facilities by the women who have a cancer detected early and so do not need more expensive treatment.
The next step involves putting values on the programme. There are several questions that need to be answered. Obviously the cost of convincing women to be screened has to be related to the numbers who actually come forward. If it costs 100 pounds per woman simply to persuade her to be screened this alters the whole balance of worth of such a screening to the community. What about the increase in doctor-induced diseases? Is it possible that by having too many false negatives we give women false confidence, causing them to ignore lumps in the future? Or that by giving too many false positives we worry people so that they end up having unnecessary and worrying operations?
The last thing we really have to be sure about is what good the screening actually does and which part of it is most worth while. Obviously doing a total physical examination and an X-ray every six months would be a way of detecting breast cancer early but the side-effects of the X-rays, and the costs, would be enormous.
Lastly, a price has to be put on the whole thing and this can be difficult. The actual cost of delivering the medical side of such a programme is, of course, easily worked out but the benefits (peace of mind, improvement in life expectancy and so on) are much more difficult to evaluate financially.
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