Wednesday, 30 December 2015

How to live longer and save the NHS a large pile of money

We are all getting older, and as we do so we hope that the NHS will be there to put us right if we get ill. But increasingly it is starting to look as if perhaps they will not, or at least they may no longer be able to afford to put us right for long.  New drug treatments often cost many thousands of pounds a year and the expectations of improved life are often marginal.

The National institute for Care and Health Excellence (NICE) have a formula for determining if a particular intervention should be recommended. If it will cost less than £20-£30K per year to add one full year of life then the treatment can be recommended. This cost level is known as a QALY (Quality Adjusted Life Year).  

This is all very good in theory (in practice it’s actually a right mess!) but it leaves me wondering why other non-drug interventions are prescribed so very infrequently.  For example, the cost of enrolling with an expert Personal Trainer, having two hour-long sessions a week and receiving expert advice on diet and health is somewhere between £5K and £10K per year, depending on the experience of the trainer. If the treatment worked then the ongoing costs per year of maintaining the results is likely to be less as time goes by. Not many people would doubt the effectiveness of this intervention. So long as the patient were to commit to the programme of treatment I don’t think anyone would doubt that doing so would increase the chance of them living a longer and happier life.

Using the guidelines from NICE you might expect that this intervention would cost significantly less per QALY then many common drug interventions. So why are we not using health and fitness programmes as a medical intervention in order to increase lifespans, improve patient well-being and save the NHS a huge amount of money?

Yes, in some cases doctors are referring patients to weight management programmes like Slimming World or Weight Watchers, but the attrition rate for these programmes is high and the benefits if they happen at all are often short-lived. According to Slimming World the average weight loss from their 5 million clients has been 12 pounds, and yet on their sign-up page they estimate you will lose 10 pounds in your first 8 weeks; so it must all go a bit pear-shaped after that! The reason for this is often that they are only addressing one side of a multi-sided problem. They do not address personal fitness, and many nutritionists might argue that they barely address the problem of diet as they simply provide a regime for eating less, using the out-dated formula “calories in=calories out”.  These programmes are cheap, but the cost per QALY is is still high as they are not effective in the long term and so life expectancy is not improved by very much.

And so I have tried to estimate the cost of a Personal Training QALY, using my wife’s fitness business as an example.

Of 20 PT clients training for the past year, all have lost over 10% of their body weight, some have lost lots more. All have lost several inches from their waistlines (a key marker for improved health and life expectancy), all report feeling more energised, happier and healthier. My problem lies in estimating what this has done to their longevity; but I suspect that none of them would argue if I suggested that the intervention of personal training had improved their chances of living least 3 or 4 years longer. In fact, given the choice of training or not training and the state of their health a year ago I would estimate that most of them are likely to live on average at least 5 years longer than they would have done without the intervention. As with drugs there is an ongoing cost in order to maintain the benefit but it reduces over time as healthy living becomes a way of life, with drugs the cost remains, forever.

So, the cost of a Personal Training QALY would appear to be somewhere between £1,000 and £2,000 and reducing year by year. According to NICE that’s quite cheap actually, and very much cheaper than the cost of the conventional treatment of type 2 diabetes, the effects of which (including dependency on drugs) can be seen to be reversed by targeted programmes of diet and exercise.

Does anyone have a better solution for saving the NHS a large pile of  money?