LAUSR

Reading the debate between Brouwer and McCabe about whether spillover costs and outcomes should be included in economic evaluation [1, 2], it strikes me that what is never discussed is the ‘opportunity cost’ of ‘not’ addressing demand side factors in health economics. The estimates of the cost of mental health problems among the UK workforce range from £74 billion to £99 billion per year to the economy, which is equivalent to four-fifths of the whole annual budget of the National Health Service (NHS) in England [3]. It costs one and a half times more to treat the chronic health problems of a person who also has untreated depression than a patient without depression [4]. Sometimes it is helpful to go back to basics. Many students of health economics will recognise the Williams plumbing diagram [5] reproduced in Fig. 1. The debate between Brouwer and McCabe is taking place in boxes D (supply of healthcare) and E (micro-economic evaluation at treatment level). As a Public Health Economist, I am interested in demand-side management through prevention, i.e. boxes A, B and C of the Williams diagram. Most interventions to prevent ill health and disability take place through legislation and in our workplaces, schools and the natural environment, and many interventions recommended by the National Institue for Health and Care Excellence (NICE) have a cost per quality-adjusted life-year (QALY) well below the £20,000 per QALY threshold [6]. I welcome the debate between Brouwer and McCabe and see each of these contributors focusing on different parts of the health economics plumbing diagram [5]. McCabe is clearly interested in cautioning against the inclusion of spillover costs and outcomes in a supply-side world of boxes D and E. Brouwer, like me, is more interested, I believe, in box C and also box G of the diagram (evaluation at whole system level) in a welfare economics context. Not only is it, I believe, necessary to take a societal perspective but also an economy-wide perspective. In 2001, I published a paper in Health Economics arguing that we need a paradigm shift from ‘health care economics’ towards ‘health economics’ [7] and I welcome the growing number of publications relating to boxes A, B, C and G. This direction of travel is marked by the Second Panel on Cost-Effectiveness in Health and Medical Economics in the US that argues we should at least produce an inventory of the wider costs and outcomes of new treatments [8]. Health economists working in box G at a whole system level, local or national, could make a valuable contribution by meeting the evidence needs of budget holders and commissioners on the ground. I would like to see health economists contributing to research on the relationship of improving health and well-being across the economy, and measuring economic growth not only through gross domestic product (GDP) but also through other measures of social and economic welfare (box G of Williams’ diagram [5]). Although potentially problematic for health economists and requiring stepping out of boxes D and E, the reality is that the direction for policy travel is for joined-up health and social care budgets. Examples of joined-up working include the NHS England integrated care development programme [9]; local government and third sector housing associations increasingly fulfilling wider social welfare roles; and NHS primary care experimenting with social prescribing to prevent ill health and promote well-being. There is a real move on the ground to capture social value across sectors, and this includes spillover costs and effects. This inevitably leads us to growing dissatisfaction with GDP as a measure of economic growth to represent the health of an economy for which important markets such as health and education This comment refers to the articles available at https ://link.sprin ger. com/artic le/10.1007%2Fs40 273-018-0730-6 and https ://link.sprin ger.com/artic le/10.1007/s4027 3-018-0729-z.