Part 4 of: What would make life better?
In 1865, life expectancy in Britain was about 40 years. Today, it is more than 80. If you doubt that growth has made our lives better, that fact is worth dwelling on. Since 1865, we have got around 7 times richer, and our life expectancy has doubled. The story of economic growth is intertwined with the story of modern healthcare; as we have got richer, our lives have got longer and healthier. My aim in this series is to link economic growth to making life better, and the links don’t come much stronger than that.
But the long, steady rise in life expectancy seems to have slowed down recently. In the UK and in the USA, life expectancy has begun to plateau at around age 80 over the last decade. This slowdown gets starker if we take a more rounded look at our health. In the UK, healthy life expectancy — the number of years we can expect to live in good health — is around 63 and has also been flatlining over the last decade.
Is it a coincidence that the slowdown in UK life expectancy has happened alongside the slowdown in economic growth since 2008? I’m not sure — health and economics are both complex topics, and there are surely many factors behind each slowdown. But what I can say more confidently is that if you want to make life better, if you want the economy to grow, improving people’s health is a very good way to do it. If the average person in the UK can only expect to live in good health for 63 years, there is clearly ample scope for improvement. After all, what more do we want, what else would we pay for, than longer, healthier lives?
The increase in life expectancy over the last 150 years or so has been remarkable. Before the 1870s, life expectancy in the UK had always been around or below 40 years. It increased gradually at the end of the Victorian period, to around 47 years in 1901. By 1948, the year the NHS was born, life expectancy had increased to 68 years. That’s a 21-year improvement in 47 years, a remarkable shift. With the NHS in place, life expectancy continued to grow steadily, albeit more slowly, to reach a little over 80 today.
What prompted these changes? There are many, many factors and breakthroughs, far too many to list here. Most of them are rooted scientific progress — new discoveries, greater understanding of diseases, better treatments — but also rely on economic development and social and policy changes to make them possible.
While there were some earlier breakthroughs — such as Jenner’s smallpox vaccine in the late 18th century — it wasn’t until the mid-19th century that the development of modern medicine began to gather pace. Scientists like Louis Pasteur discovered that many illnesses were caused by microbes, which enabled medics to prevent the spread of disease and reduce infant mortality. John Snow’s identification of the source of cholera and Joseph Bazalgette’s groundbreaking London sewer network laid a template for sanitation and public health improvements in cities. Figures like Florence Nightingale and Mary Seacole helped to lay the foundations of modern hospitals, in which nursing and caring play such a central role.
It was in the early 20th century, though, that life expectancy really began to rise, with breakthroughs like Alexander Fleming’s penicillin and X-rays making a wider range of diagnoses and treatments possible. The development of electricity and other technologies would have further increased possibilities, and hospitals and modern healthcare became more widespread in the years before the NHS was created. Once the NHS was in place, every person in the UK could access at least some level of health care, from cradle to grave.
Life expectancy continued to grow in the post-war years, albeit slightly more slowly. The growth of R&D in the pharmaceutical industry led to a range of news drugs being developed, while many more vaccines have been developed and rolled out. Many global diseases have been gradually eradicated or mitigated, with vital consequences for people around the world. Healthcare has become continuously more sophisticated over time. If you want to sense-check this, compare the world’s response to Covid-19 (flawed as it has been) to the far more deadly Influenza Epidemic of 1918 or the Black Death of the 14th century.
As these changes have progressed, we have begun to spend a greater share of our income on health. Spending on the NHS has increased from around 3% of the UK’s GDP in 1950 to around 7% now. Given that GDP per capita has roughly tripled in that time, that represents a very big increase, around seven times more real spending per head. Some of this increase in spending has gone towards better, more expensive treatments. Some of it is down to one of the consequences of better healthcare: an ageing population.
Increased health spending and an ageing population are both, in my view, good things; it is wrong to see them as a burden. We all want longer, healthier lives. We want to pay for them. It makes perfect sense to spend our vastly increased income on health — frankly, it would be odd if we didn’t. Of course, the question of who pays for additional healthcare spending is contentious, but the fact that we do it is one of society’s biggest success stories. If we have an option to spend even more of our income on health in return for longer, healthier lives, I think we should do it.
This blog is mainly about the future, not celebrating the miracles of the past. There is no doubt that our progress on health — in the UK and USA at least — has slowed in recent years, even before Covid plunged it into crisis. Why? Here are a few reasons worth considering.
Are we hitting natural limits in life expectancy? Do illnesses like dementia and heart failure, and the wider realities of the ageing process, make it impossible to extend life much further?
Are new treatments getting more expensive and harder to develop? The comparison between previous blockbuster drugs, like statins, with the search for cancer treatments might point in this direction. Where once pharmaceutical companies could develop one drug for millions of users, now treatments seem to be more specialised and focus on smaller groups. There is an argument that research activities across the whole economy are getting less productive over time which fits with this view.
Is it more to do with policy failure? Are we spending money in the wrong areas? The vast majority of the UK’s health care spend goes on treating illnesses and long term care; less than 5% was spent on preventative care in 2019. Are we failing to invest in preventing long term conditions, like diabetes, and instead spending more on treating the effects of these conditions? This could be particularly influential on healthy life expectancy, which is affected by the millions of chronic health conditions in the UK population.
Or do the problems lie in our behaviour? As important as health is to us, we don’t always act rationally around our own health. Factors like obesity have a huge impact on our health, and they are often driven by the choices we make (or are pushed into making).
I suspect there is something of all of these issues going on. It seems plausible that increasing life expectancy gets harder as it rises, both because the illnesses you’re tackling get tougher and treatments get harder to develop. It is also undeniable that, in the UK at least, we have many preventable conditions that worsen our health and probably our life expectancy.
But I don’t see a case for fatalism, for accepting that we have become as healthy and long-lived as we ever can. Other countries have continued to increase their life expectancy and extend some way beyond the average Briton’s lifespan. Whenever scientists have proposed maximum limits on life expectancy, their claims have always quickly been disproven. Just because it is harder to keep improving our health doesn’t mean it can’t or shouldn’t be done. Policy failures can be corrected, behaviour can be influenced, and more challenging innovations are often still worth pursuing.
It seems to me that there are two key factors which might be holding us back.
The first is a set of ethical considerations: are we really open to the types of changes that would continue to extend our lives? Many of the big frontiers in health now are in areas that feel existentially uncomfortable. Overcoming or amending the ageing process seems like quite an important next step, but it is fraught with ethical challenges. Can it be right to extend human life beyond its natural limits? Would postponing death in this way somehow undermine what it means to be human? Other areas of major potential — like gene editing — are also likely to run into similar questions. I have assumed that a longer life is a better life, but we as a society need to ask ourselves whether there’s a point where that ceases to be true.
The second is a question about who pays, and who is allowed to pay. Pushing the limits of healthy lives — pausing the ageing process, for example — is likely to be seriously expensive. There are plenty of bio-tech start-ups with potentially ground-breaking technologies but very few willing customers, in the UK at least.
The state cannot pay for advanced treatments for everyone, unless it massively increases its willingness or ability to raise taxes. Private customers may be more willing to pay, but for the most expensive treatments they will tend to be a small market. And what are the implications of a society where those who can pay get to fight biological processes, while those who cannot are left with shorter lives? Is that a politically sustainable situation?
There are clear downsides to an “everyone can have it or no one can” approach though. Private customers can help fund the development of new treatments and markets, potentially bringing their costs down over time and eventually opening them up to everyone. To suppress private spending too much may be to hurt everyone’s health in the long term. Government might even want to consider helping more people fund new treatments privately, perhaps by providing means-tested match so that people on all incomes have an opportunity to access this.
Aside from the looming barriers of ethics and funding, there are other ways we could improve our health which should be far less controversial. Tackling chronic conditions, like diabetes and respiratory conditions, and their underlying causes, like obesity and dirty air, should be an obvious priority. So should reducing the inequalities between different places and different parts of society. The gap in healthy life expectancy between the UK’s most and least deprived areas is almost 20 years.
Some of this would require a more interventionist approach from government. This may seem politically challenging, but there are successful precedents from sugar taxes to public smoking bans. Crucially, it also requires a willingness to follow evidence carefully, and invest proactively in public health measures which can make a meaningful, sustained difference.
So, a healthier life is a better life, good for people and good for the economy. But what should we do differently? First, we should see healthcare more as an opportunity than a burden, as a worthy place to spend more of our collective income. We should be deliberate and actively aim to make lives longer and healthier, rather than just reacting. Second, we should spend more of our collective income on health care. That means increasing state funding — by raising taxes if necessary, because health is what people want and it’s good for the economy — and directing a greater share of the funding towards preventive work, or whatever the evidence shows to work. Third, we should be more open to private spending on healthcare, especially if it can help to bring down the costs of ground-breaking treatments and make them more widely accessible. There may even be a case for government to help people, in a means-tested way, to fund healthcare over and above the universal offer.
When I started this series, my hypothesis was that most of the things that could make our lives better were collective action problems, or demanded more of public policy. There are few areas where the state has a bigger role than in healthcare. But our health is not just a thing to be managed and contained — we can and should actively improve our health and extend our lives. If health is one of the things we value most highly, and if we will only let the state look after our health, then we need to start demanding far, far more from our governments. And we should prepare to pay for it.