‘If we had a drug in our therapeutic armamentarium that conferred all the benefits of regular exercise it would be the single best treatment for preventing disease and improving overall health and life expectancy’. from ‘Run for your life . . .’
Maintaining good health and fighting disease and other health problems are enormously expensive. The NHS annual budget is set to be more than £150 billion in 2022/23, which is about 9 per cent of GDP and 30 per cent of spending on public services. The social-care budget is even higher. NHS spending is planned to increase by 4 per cent per annum for the foreseeable future, but the demands are set to rise even more steeply. Currently about 18 per cent of the population is over 65 and this will have risen to 25 per cent by 2046. None of this takes in the astronomical costs of managing the Covid pandemic.
Increasing age brings increasing debility and this is compounded by medical advances which, while helping with the treatment of individual diseases, also results in longer survival and ultimately more cost to the NHS. Any effective treatment for the management of disease increases costs in the long term, because more people live longer with all the chronic diseases and dependency which old age brings. Exercise is the only treatment that does not increase NHS and social expense. By improving health overall and reducing old-age dependency, it actually reduces the bill.
The cost of sedentary behaviour
Inactivity, or sedentary behaviour, is associated with poor health at all ages. The social and economic costs of this are impossible to calculate accurately. Plenty of people have had a stab at it but the various estimates made, using assorted methods, differ wildly – but they are all very large! One example calculated some of the associated costs in five common conditions which are in part caused by inactivity –cardiovascular disease, type 2 diabetes, cancer of the colon, cancer of the breast and cancer of the uterus. The investigators chose these conditions because they had well-validated measures of the ‘population attributable fractions’ for physical inactivity – i.e. what proportion of the cause of each disease could be blamed on sloth. For this small number of diseases – out of 20 possible conditions – their conclusion was that the cost to NHS-funding bodies was £800 million per annum. That sounds like a gross underestimate to me.
The medical costs of disease are only a very small part of the overall cost to the nation. For instance, the British Heart Foundation and Oxford University used the same diseases to calculate the direct cost to the NHS. They reckoned that in 2003–4, over 35,000 deaths could have been avoided if the population were physically active at the levels recommended by the UK government – and that physical inactivity was responsible for 3.1 per cent of morbidity and mortality in the UK, contributing over £1 billion to the direct health-cost burden to the NHS.
Again, this estimate vastly understates the overall costs to all those involved – the NHS, the national economy, the individual’s finances and their employers’ productivity and expenses. Some idea of the extent of these costs was given by another British Heart Foundation publication, ‘Economic costs of physical inactivity’, based on 2010/11 figures. The table below illustrates the overall costs and the costs to the NHS of those conditions to which inactivity is a substantial contributor.
|Condition||Cost to NHS||Percentage contribution of inactivity||Cost of inactivity|
|Coronary heart disease||£5 billion||10.5 per cent||£543 Million|
|Type 2 diabetes||£1.2 billion||13 per cent||£158 million|
|Breast cancer||£0.3 billion||17.9 per cent||£54 million|
|Colon cancer||£3.5 billion||18.7 per cent||£65 million|
For cardiovascular disease, there were almost 180,000 deaths and over 1.6 million inpatients (including consultant visits, ordinary admissions and day cases). The direct healthcare cost of all cardiovascular disease was £8.7 billion and the total economic cost (including healthcare cost, informal care and loss of productivity) was £18.9 billion. The average cost of a hospital admission for a CVD event is estimated to be £4,614.
For colorectal cancer, annual treatment costs were approximately £1.1 billion, 18 per cent of which could be prevented by regular exercise. The figures for breast cancer were a cost of £300 million, of which 18 per cent could be prevented.
For diabetes, the cost of direct NHS patient care (which includes treatment, intervention and complications) for those living with type 2 diabetes was estimated at £8.8 billion, and the indirect costs (such as loss of productivity) were estimated to be £13 billion, 13 per cent of which is preventable.
For obesity, the total annual cost to the NHS (including treatment and its consequences) was estimated to be £2 billion, with a total economic impact to the nation of around £10 billion.
The cost of low fitness levels
A number of studies have examined the relationship between cardiorespiratory fitness and costs to society. In the US, a sample of nearly 10,000 subjects from The Veterans Exercising Testing Study (Myers et al, 2019) showed a relationship between CRF and healthcare costs. The least fit quartile had higher costs by $14,662 per annum compared with the fittest quartile. There was a dose relationship with each MET increment in fitness being associated with a reduced cost per patient per annum of $1,592.
There has been an inverse relationship between CRF and likelihood of being admitted to hospital for those infected by Covid-19. The Mayo group (Brawner et al, 2021) identified 246 patients with Covid-19 who had received a recent exercise test. Among these, 89 (36%) were hospitalised. CRF was significantly lower among patients who were hospitalised (mean 6.7) compared with those not hospitalized (mean 8.0). Each unit higher of peak METs was independently associated with a 13% lower odds of hospitalization. If these figures were generalised, the implication for the costs of the pandemic to the NHS would be huge.
Simple community initiatives to increase exercise levels have been shown to reduce healthcare costs. One practice which has organised a walking programme for ten years analysed its hospital costs and compared them with those of a comparable local practice. The “walking” practice had hospital costs of c £8,000 per 1,000 patients p.a. compared to £12,000 to £13,000 for the other practice
A European perspective
A 2015 report from the Centre for Economic and Business Research calculated that physical inactivity was the fourth leading risk factor for global deaths and the cause of 500,000 deaths in the EU, with a cost of £84 billion a year to the European economy. They reckoned that physical inactivity was a bigger risk to public health than smoking. The study also showed that being physically inactive goes beyond physical disorders. One in four Europeans (or 83 million people) is affected by mental ill health. The research estimates the indirect cost of inactivity-related mood and anxiety disorders to be over 23 billion euros a year.
The costs of care for the elderly
A new report from the All-Party Commission on Physical Activity estimates that inactivity is costing the UK £20 billion per year and causing 37,000 premature deaths. This financial estimate includes the costs of treating all those conditions that are caused by a sedentary lifestyle – obesity, high blood pressure, diabetes and all the others discussed above. It also includes lost working days due to sickness and lack of productivity of unfit workers. It must be a vast underestimate, since it does not take account of the huge costs of caring for elderly dependent people. A current estimate of the cost to the public purse of care of the elderly is about £22 billion – and the notional cost of informal care is an incredible £68 billion. Despite this, in the past five years £900 million has been cut from the UK Public Health grants given to local councils, who bear the brunt of the social-care expenses.
Inactivity also brings all the social costs discussed in previous chapters. The most important of these is the progressive loss of physical ability in later life – the difficulty in carrying out the activities of daily living, the loss of well-being, the loss of independence and the consequent financial burden of needing care. The overall benefits of good health are incalculable, but these benefits are there for the picking.
Political action is urgently needed to prioritise the promotion and encouragement of physical activity for the whole population, particularly in later life.