In launching the Spending Review the chancellor has promised to deploy “an iron fist against waste”, including in the NHS. But an even greater prize could be on offer if the government rethinks the way decisions on health-care spending are made with a shift towards prevention.
A perfect illustration of the UK’s broken system came last week. Just hours before the prime minister made his pledge to reduce waiting times, the National Institute for Health and Care Excellence (NICE) and NHS England said they would be limiting access to new weight-loss drugs that could help him deliver on that promise.
The choice was short-sighted, underlining why the success of the prevention agenda will depend on system-wide reform. It is also absurd. Fewer than 30,000 people have so far accessed these drugs on the NHS while those who can afford to already buy them privately, with more than 400,000 people purchasing out of pocket.
NICE does a commendable job within its own narrow framework. It cannot be blamed for staying within the remit set by the Department for Health & Social Care. NICE is set up to make decisions, such as the one on the injectable weight-loss drug Mounjaro, by evaluating the cost of rollout against immediate health outcomes and cost savings to the health-care system. Yet, in June this year the Scottish Medicines Consortium – NICE’s Scottish equivalent – approved the same drug to be rolled out to a much wider category of people in Scotland.
NICE appears to be neglecting the wider benefits that these drugs can bring, and it is the latest demonstration of a system-wide issue. Macroeconomic considerations play a limited role in the allocation of health spending, so preventative interventions struggle for funding. The potential benefits of a healthy population are not routinely measured (which is why we have previously argued for an OBR-type independent watchdog for health, treating good health as an economic asset and measuring it appropriately).
Together with the Ellison Institute of Technology, we have sought to fill the gap in understanding. In a joint paper published by TBI earlier this year, Professor Andrew Scott modelled the macroeconomic consequences of a 20 per cent reduction in six long-term conditions. This was estimated to lead to a 0.74 per cent uplift in GDP within five years, and a 0.98 per cent uplift within ten – through people living longer, healthier, more productive working lives. This amounts to an annual boost of £19.8 billion within five years and £26.3 billion within ten.
Modelled specifically for a weight-loss drug that reduced the prevalence of obesity, thereby lowering the risk of cardiovascular events (CVD) or associated complications and the incidence of musculoskeletal disorders (MSK), it was estimated that it would lead to a joint 20 per cent reduction in the incidence of both CVD and MSK and lead to a 0.3 per cent improvement in annual GDP (£8.1 billion) within five years. Notably, the analysis demonstrated that the reduction in musculoskeletal disorders accounts for a larger share of this improvement compared to the reduction in CVD.
This would be a huge return on investment in making weight-loss drugs more widely available.
The UK is in a spiral of high taxes, low growth and decaying public services. Economic growth is desperately needed. But we cannot succeed if nearly 3 million people are out of work due to ill health while overweight and obesity cost the economy nearly £100 billion per year.
NICE needs to be equipped and directed to incorporate broader economic impacts into its decisions, such as reductions in the rate of people dropping out of work, increases in productivity, fewer people receiving welfare payments and the long-term financial benefits of reducing chronic conditions like obesity.
The Spending Review and the implementation of the NHS’s 10-Year Health Plan provide a huge opportunity for the government to drive the change the UK is crying out for.
The chancellor and the health secretary have the chance to completely rethink the way that the system makes decisions on investment in preventative measures.
Urgent change is required to break the cycle of declining health, weak economic growth and constrained health budgets. Instead, the government must enable a new, virtuous cycle that prioritises prevention in health-care spending, keeps people healthier and supports longer working lives.
The NHS also needs to rethink the way that preventative measures such as weight-loss drugs are delivered, which is currently constrained by an outdated approach that treats obesity in highly specialised weight-management clinics in the most expensive part of the health system. Other countries, such as the United States, are leading the way, significantly expanding coverage of weight-loss drugs through Medicare and Medicaid to more than 7 million people, with a predicted 30 million expected to be on GLP-1s by 2030.
One of the primary reasons NICE limited the availability of Mounjaro is that primary care would not have been able to cope with the demand. But we don’t need to rely solely on GPs to roll these drugs out at scale. There are around 400,000 people on these drugs already in the UK for weight loss – most of them self-funded and prescribed through online pharmacies. Some people will require sustained wraparound support to improve the likelihood of success of the medications, others will require intermittent check-ups from their GP, while some will be able to manage just fine without either. If we don’t broaden NHS access to these drugs through new models of care like online pharmacies and digital companions, then we risk widening health inequalities further.
The government is to be commended for putting prevention at the heart of their agenda for health care. But without system-wide reform these efforts will be doomed to fail.
In 2025 TBI will be carrying out macroeconomic analysis of the impact of weight-loss drugs and setting out exactly how we can design a system to deliver them at scale.