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Journal round-up: The Lancet 397(10288)

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What is a general medical journal doing on an academic health economics journal round-up? The Lancet only publishes HEOR papers very occasionally, but this issue has a particular focus on economic issues in the Health Policy section. A set of three wide-ranging papers discuss changing health needs of the UK population, the future healthcare workforce, and the level of funding the NHS will require over the coming years. These papers are part review, part recommendation, and were written to accompany the LSE-Lancet Commission Report on the future of the NHS. The commission included 20 authors encompassing the great and the good of UK health policy research.

These papers would make an excellent introduction for students, or those new to the topic, on current issues and key statistics for UK health and the NHS. Commonly discussed aspects of UK health policy were all given consideration and included in a coherent overall picture. Relevant past policy initiatives (which always seem important at the time but are easily forgotten) were reviewed along the way.

Health needs. This review covered familiar territory in describing the transition from infectious to non-communicable diseases, and from acute hospital care to community and long-term care needs. Both international and intertemporal comparisons were drawn on to demonstrate areas of potentially high and increasing need. Among these comparisons, it was most surprising to me that not only has the rise in UK life expectancy stalled but there have even been increases in deaths rates in several age groups. Also worrying was the reported infant mortality increase between 2014 and 2017 in some regions of the UK after nearly a century of declines.

One difficulty, when thinking about what to take away from this piece, is understanding the concept of ‘health needs’. The usage in this paper seems to conflate the burden of ill-health, as measured by disease statistics, and the need for healthcare, which depends not only on the presence of disease but also whether there are (cost-)effective healthcare technologies to ameliorate it. As a result, a very sensible conclusion that investment in disease prevention may offer good value is framed rather strangely as a “preventative focus” to “reduce needs”. As if it is necessary for a good preventive policy or intervention to actually produce a net decrease in total healthcare use, taking account of second-order effects of life extension. Assessing disease prevention policies based mainly on their impact on the overall demand for healthcare or the NHS budget is unlikely to produce optimal health policy. This is because potentially highly cost-effective options that do not unambiguously reduce budgets may be rejected. Prevention may indeed be better than cure but it need not be cost-saving.

Future workforce. This paper wasted no time in dropping one of my favourite statistics. The NHS is the fifth largest employer in the world, with just under 2 million employees across the UK. The future of this enormous workforce is, naturally, a cause for concern in any plan for the future of the NHS. A major concern is the issue of staff and skill shortages. Specific shortages in nursing and mental health nursing, in particular, are noted. Other important features are the persistently low pay for carers and those in clinical support roles, the sometimes perverse use of temporary staff (who may have left permanent NHS contracts due to worse pay and conditions), and the reliance on a steady flow of skilled foreign staff coming to the UK. Recommendations include all the things most people would surely agree with: integrated planning, enhanced career development opportunities, promotion of staff wellbeing, tackling discrimination in the NHS, and providing better pay and conditions. Of course, whether or not any of this is likely will depend on the topic of the final paper of the series.

Spending commitment. The most persuasively written of the three papers, the text included a review of the historical spending trajectory, the international context, and a strong case for increasing spending above the recent trend. The authors proposed a 4% annual increase in public spending on healthcare, meaning an increase from 7.3% of GDP in 2018 to 9.9% by 2033. If we include non-publicly funded healthcare in this projection then total health spending would be around 12.1% of GDP over the same timeframe. This would be somewhat above the current level of spending as a percentage of GDP of France and Germany. How the 4% annual increase recommendation was arrived at is multifaceted. Projections of the resources required were combined with high-level costing assumptions for desired areas of investment. Is a 4% annual increase really the right number? The case for greater increases in spending on health in the UK was persuasive to me. The utility of a precise target, perhaps less so.


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