1 November 2017

The price of public health puritanism

By Duncan Simpson

Public health authorities in the UK have seen a vast expansion in their remit in the last few years, with English local authorities, in particular, moving into a plethora of finger-wagging programmes.

But the nannying has gone too far. Being a healthier person is actually rather simple: you eat less and you walk more. We all know that. Yet this truism seems to have escaped public health bureaucrats in the UK. Our analysis, at the TaxPayers’ Alliance, of smoking, physical activity, obesity and alcohol programmes shows that vast outlays of taxpayers’ cash are being made with limited gain.

Take smoking. Among those authorities who responded to our Freedom of Information request for 2015/16, the average spending on each person who stopped smoking (usually after a four week period) was £568. Yet the City of London managed to spend almost £2,500 a piece on the 182 people who managed to quit. Those who live in the City are unlikely to be five times more addicted to cigarettes than the average Briton; the disparity most likely indicates that the efficacy of the service is particularly poor.

There were some particularly egregious instances of misspending on obesity programmes. A sum of £1,300,000 was lavished on 180 overweight Liverpudlians – that’s a whacking great £7,000 per person. In Wiltshire, Bromley and the Isle of Wight, taxpayers’ money went on subsidies for Weight Watchers and Slimming World. Perhaps dieters should be persuaded to take responsibility for their weight-loss and pay for these services themselves.

It didn’t stop at Weight Watchers. Knowsley Council gave £75 to the Knowsley Flower Show as part of its physical activity programme. Bury in Greater Manchester used £7,500 from their public health budget for a pirate adventure game “that’s perfect for families to have fun together”. NHS Greater Glasgow and Clyde even used some of their £158,000 Healthier Inverclyde Project on alcohol education and awareness sessions for primary school children.

It’s not all wasteful spending, though. The outlay on alcohol-related problems (some London councils spent almost £10,000 for each person who drank less), did include structured treatment, such as medically assisted detoxification, and group therapy with Alcoholics Anonymous. It is important that genuine health needs are addressed in this fashion – but that’s clearly not what taxpayers’ money is being spent on.

Indeed, there’s a worrying absence of any measurement to determine whether programmes are an effective use of money. The National Institute for Health and Care Excellence (NICE) sets out guidelines for local authorities and public health authorities to determine whether a programme is worth setting up: what are the costs of the intervention relative to the expected health benefits to the individual? Across the UK, one in five of these interventions did not use cost effectiveness or a similar metric. Poor oversight of these programmes leads to significant wastage and a continuation of bad decision making by the public health puritans.

Our research revealed a pattern of consistent abasement of public health’s original functions. Previously, public health meant health protection. This entailed emergency preparedness, stopping the spread of infections, and reducing environmental hazards. Unexplained diseases were wreaking havoc in cities, which led to the construction of infrastructure and vaccination programmes to stop this. Sir Joseph Bazalgette’s sewer system in London is a fine example of this. But today public health means something quite different.

The meaning is reflected in government fondness for lifestyle taxes. The escalation of indirect taxes on alcohol, tobacco and, from next year, sugar, is forecast to generate more than £21 billion for the Treasury. The extension of these taxes is ostensibly to alter behaviour, but the money serves as a cash cow to an already bloated exchequer and is another example of the freedom-eroding priorities of this government – and previous ones.

In response to any criticism, the public health puritans claim that by altering individuals’ lifestyles now, we, as taxpayers, can benefit from spending less on ailments such as diabetes and lung cancer further down the road. But these arguments fall down on two counts.

First, the costs to the taxpayer of treatment are too readily conflated with “societal costs”. It’s an amorphous term, with one team of health economists incorporating noise pollution by nuisance drunks as part of their “societal costs” calculations. They deemed the cost to society from alcohol to be $1.4 trillion. Any subsequent calculations of savings that can be made by interventions are invariably misleading.

Second, the logical extension of their argument is that smokers, drinkers and those who eat too well should eventually be denied treatment. Yet the whole premise of the NHS is that treatment should be available at the point of need. Clinicians should stick to treating people, not pontificating about what we spend our money on.

Time and again, we hear stories of the NHS on the brink of imploding, with various flu, bed or MRSA crises around the corner. Rather than delivering patronising lectures on our behaviour, clinicians and the public health brigade should focus on treating people who are actually ill.

If public health authorities in this country are to insist on the continuation of these programmes, then, at the very least, a cost effectiveness exercise (or near equivalent) must be undertaken. More to the point, such programmes entirely miss how market innovations are responding to shifting consumer tastes, such as the growing popularity of high strength craft beer or popularity of vaping. It is time for the public health puritans to get off their high horses.

The Efficacy of Public Health Spending by Duncan Simpson is published by the TaxPayers’ Alliance

Duncan Simpson is a policy analyst at the TaxPayers' Alliance