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Health and education expenditure in the United Kingdom: What priority?
Health Policy and Education 2 (1981) II-84 Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands
77
HEALTH AND EDUCATION EXPENDITURE IN THE UNITED KINGDOM: WHAT PRIORITY?
DONALD P. FORSTER* Department of Family & Community Medicine, Universityof Newcastle upon Tyne, Newcastle upon Tvne, NE1 7R U England BRIAN J. FRANCIS Centre for Applied Statistics, Universityof Lancaster, Bailrigg, Lancaster, LA1 4YL England C.E. BRIAN FROST Divisionof Economic Studies and Medical Care Research Unit, Universityof Sheffield, Sheffield, SI 0 2TN England PAUL J. HEATH Barnsley Area Health Authority, Bamsley, S75 2PY England
ABSTRACT Public expenditure on goods and services per head of population on the National Health Service (NHS) in the United Kingdom has risen less rapidly than some other forms of public expenditure such as education. Revenue expenditure at 1970 market prices on goods and services in the NHS per head of population rose by 38% during the period 1951 to 1968. During the same time interval, expenditure at 1970 market prices on goods and services in education per head of population rose by 84%. Health, as measured by standardised mortality ratios (SMRs), improved over a similar period. This paper argues that, in the long term, the priority given to education expenditure may not necessarily be detrimental to further improvements in community health.
Introduction Doctors within health services are familiar with the techniques for evaluating the effectiveness of medical treatments within limited spheres. For example, different medical treatments or services may be compared in a randomised controlled trial and evidence obtained as to which treatment or service is better in terms of reducing unwanted and unhealthy outcomes, one of which may be death. A much wider issue, however, is whether a given amount of money spent on direct health care improves health more than the *To whom correspondence
should be sent.
01652281/81/0000-0000/$02.50
0 1981 Elsevier Scientific Publishing Company
78 same amount devoted to other fields such as housing, nutrition or education. This is a complex problem depending not only on how health is defined but also on the efficiency with which each programme is put into effect. Some commentators have suggested that health services have a relatively small impact on health in economically developed countries (Anderson, 1972; McKeown, 1976). In the United Kingdom, the Education Act of 1944 and the National Health Service (NHS) Act of 1946 (implemented in 1948) placed these services firmly in the public sector such that only small proportions of expenditure lie within the private sphere. The structure of the NHS was extensively reorganised in 1974 and this paper proposes to examine, where relevant data are available, the period between the inception and reorganisation of the NHS in the U.K. The concept of community health can be simplified by referring to an improvement in age-adjusted death rates or standardised mortality ratios (SMRs). This restricts the definition of health markedly but is legitimate in the sense that these measures are officially used as indicators of the need for health care. Working parties on the allocation of health service funds in England, Scotland and Wales have each used mortality as a proxy indicator of health care needs (DHSS, 1976; Report of the Steering Committee on Resource Allocation in Wales, 1977; SHARE, 1977). In practice, equity in funding between regions has been sought by partially basing the level of health funds allocated to each region on its SMR. Mortality, however, may act not only as an indicator for health care but also as a measure of the outcome of health care and hence as a success indicator. The Report of the Resource Allocation Working Party (RAWP) in England was itself sceptical that a redistribution of funds between curative services would have a significant impact on mortality patterns (DHSS, 1976). The terms of reference of RAWP, however, were restricted to making recommendations for equity of funding relative to need. There are many gaps in our knowledge of what is achieved by public expenditure. For example, it would be important to know the effects of certain categories of public expenditure on health in terms of the outcome of mortality. One approach to this type of problem is that of Planning, Programming and Budgeting (PPB). In theory, PPB consists of specifying an objective and comparing the costs and effectiveness of various programs in achieving the objective and therefore it should be able to encompass inputs from a number of government departments. In practice, however, most PPB in the United Kingdom is restricted to a single department (Pole, 1974); hence, spillover effects between different public programs are overlooked. In this paper we develop the argument that there are possible benefits to health from another department, namely education, which should also be considered.
79 Trends in Expenditure Figure 1 shows the expenditure on the NHS per head of population in the United Kingdom at 1970 market prices for the period 195 1 to 1974. The data are derived from National Income and Expenditure publications for various years. Capital expenditure in the NHS at 1970 market prices has been estimated by applying the deflator of costs for Gross Domestic Capital Formation to the current expenditure on NHS capital formation in each year. It should be noted that, due to a change in definition, recording of expenditure on certain services such as child care and local welfare was transferred from the NHS to social services during 1969. Conversely, recording of expenditure on school health was transferred from education to the NHS in 1974. For these reasons, greater emphasis will be given to the percentage rise in real expenditure in the period 1951 to 1968.
20 t I
'?950 52
I1
54
56
I
I
I
I
I
I
I
58
1960
62
64
66
68
1970
I 72
I 74
Year Fig. 1. NHS expenditure per head of population at 1970 market prices (U.K.).
NHS revenue expenditure per capita (that is real expenditure on goods and services in the NHS per head of population) rose by 38% during the period 1951 to 1968. NHS capital expenditure rose at a higher rate than revenue (though starting from a small base value); hence the graph of revenue plus capital expenditure per head of population shows a greater increase than revenue alone, namely of 47% from 195 1 to 1968. On a semi-logarithmic scale, Fig. 2 shows the real increases in NHS revenue expenditure on goods and services per head of population compared to education and other kinds of public expenditure (excluding defence). Real expenditure on goods and services in education per head of the all-ages population shows an increase of 84% in the period 1951 to 1968. It can be
80 _..-•-=
f
l. . . . . ..-• ..*+ OTHER P”BL,C EXP!3JD,T”RE
100 90 90
......****
t
...........--
#.....*-*---"
70 60 I
5Ot
EDUCATION
40 -
_/NM
REVENUE REVENUE
30 -
20 -
lOl 1950
I 52
I
I
I
I1
54
56
66
1960
I 62
64
I 66
I 66
I 1970
I, 72
74
Year Fig. 2. Expenditure per head of population at 1970 market prices (U.K.).
argued that only a relatively small proportion of the all-ages population receives the benefits of education. However, even if the increase in real education expenditure is expressed per head of the principal recipients of education, namely the population aged 5-14 or 5-19, then the increases are 68% and 67% respectively from 195 1 to 1968. Similarly, the percentage increases in real education expenditure for the period 1969 to 1974 are considerably in excess of the increases in health spending. Figure 2 shows also that the increase in expenditure per head of population on goods and services for other public services, excluding defence, rose by 47% between 195 1 and 1968. Trends in Mortality Figure 3 shows the all causes SMRs for the United Kingdom, 1962 being the base year. The fall in SMR from 118 in 195 1 to 9 1 in 1974 represents a decrease of about 23%. This decrease could be considered to be a reduction in the need for health care as reflected by SMRs. Alternatively, the fall in SMR might suggest an improvement in outcome consequent upon a variety of inputs affecting health, some of which would involve health care itself whereas others would lie outside this field. Figure 4 shows restricted SMRs for the same period in the age groups O-64 and 65 and over. These age groups were selected on the grounds that mortality may reflect morbidity more adequately in persons under 65 (SHARE, 1977) and that if inputs, particularly health care inputs, have any effects, then these are more likely to occur in the younger age groups. Regression lines were fitted separately to the periods 195 1 to 1962 and 1963 to 1974 using the data in Figs. 3 and 4. These periods were chosen
81 SMR
130 125 F 120t 1151101051009590-
1:: 1950 52
54
56
58
1960
62
66
64
66
1970
72
74
Year
Fig. 3. Standardised mortality ratios for U.K. (1962 = 100) persons.
SMR
UNDER65 65ANDOVER
1950 52
54
56
56
1960
62
64
66
66
1970
72
74
76
78
1960
Year
Fig. 4. Restricted standardised mortality ratios for U.K. (1962 = 100) persons.
arbitrarily to divide our data at approximately the mid-point. No significant differences were observed between the trends in the two periods for persons aged 65 and over or when all ages together were considered. However, the SMR for the under 65s fell more rapidly in the early rather than the later period @ < 0.05). (The detailed method and tables are described in a statistical document which may be obtained from the authors upon request.)
82 Discussion It is clear that there has been an improvement in health in terms of the fall in the all causes SMRs in the period 1951 to 1974. Our results suggest that, in the time period 1963 to 1974 for the under 65s, the rate of fall in mortality was lower than in the period up to 1962. This can be viewed as less rapid reduction in need or a slowing down in the beneficial effects for the under 65s in terms of mortality in the latter time period. The position is complex, however, since in a consideration of all causes mortality both cross-sectional and birth cohort factors may be at work (MacMahon and Pugh, 1970). In addition, the time interval between the inputs to health, including health care, and the improvement in health may be variable. Our data suggests that, in the period considered, priority has been given in public expenditure to education rather than health care. We have emphasised education expenditure rather than spending on housing or environmental improvements, since, in an age when chronic diseases predominate and infectious diseases have in the main been controlled, the important influences will be in the fields likely to modify people’s life-styles. The question which arises is whether there are reduced gains in health because of this division of expenditure in favour of education. In a longitudinal analysis it is difficult to assess the effects of direct NHS expenditure on mortality relative to the effects of other kinds of expenditure such as education. What other evidence throws light on this problem? Auster et al. (1972) in a cross-sectional study between the states in the United States estimated that a ten per cent increase in health expenditure per head of population would reduce mortality by two-thirds of a per cent in the white population, whereas a ten per cent increase in education would reduce mortality by over two per cent. An important point here is the amount of health expenditure devoted to reducing mortality relative to the amount allocated to activities such as alleviating pain, reducing disability and caring for patients. It may be that as health expenditure rises, medical inputs will be increasingly direct to ‘care’ problems such as geriatrics, psychogeriatrics and community care rather than to ‘cure’ problems. Again in the American context, Grossman (1972) has suggested that the most important variable in the production of health is the level of education of a person. He has argued that the more educated demand more health but less medical care in that they would have an incentive to offset part of the increase in health caused by an increase in education by reducing their use of medical services. In Great Britain, the higher the educational qualification gained, the less likely a person is to be a current smoker (OPCS, 1977). Similarly, the older a person is when he leaves school, the more likely he is to take part in active sports and games during leisure time (OPCS, 1976). However, there is also
83
some evidence that physical activity at work may confer protection against coronary heart disease, one of the major causes of morbidity and mortality (Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society, 1976). Although the better educated appear to reduce the risks of earlier death by certain forms of behaviour, such as avoiding cigarette smoking, it cannot be assumed that this occurs across the whole spectrum of health risks. For example, little is known about the relationship of education to alcoholism or risk-taking while car driving. From many studies it is also often difficult to separate out the effects of education from those of related variables such as social class or income. It should be stressed that reference is being made to the possible effects of general education and not solely to specific health education in the school curricula, though this may have additional benefits. If education does effect health for the better, by what mechanism is this achieved? There is some evidence that children model their behaviour on that of adults (Bandura and McDonald, 1963). Bewley et al. (1979), for example, have shown that there is a significant relationship between boys’ smoking and that of their male teachers. The precise nature of the relationship between education and health needs to be explored in detail but it does appear that there is a positive association between length of schooling and the adoption of a healthy lifestyle. In this paper, we have considered the difficulties of assessing the effects of various kinds of expenditure on health. Overall, however, the balance of evidence suggests that those whose concern is the health of the community should not be too dismayed at the more rapid rise in real education expenditure during the period considered in the United Kingdom, since there may be important spinoffs for health, although there is likely to be a lag period between the expenditure and the improvements. The RAWP exercise in England can only be considered as a first step since it links the distribution of funds solely in the health care field to mortality and avoids the issue of using a reduction in SMRs as a success indicator. We conclude that in the long term, health or mortality cannot be considered in isolation from expenditure on programs outside the health care field. Acknowledgements The Medical Care Research Unit, Sheffield University, is supported by the Department of Health and Social Security and Trent Regional Health Authority. We are grateful to Professors J. Knowelden and J.H. Walker and Dr. J.G. Leece for helpful comments on an earlier version of this paper and to Mrs. Dawn Robinson for secretarial assistance.
84 Note A statistical appendix to this paper and the data from which the faures were drawn may be obtained on request from Donald P. Forster.
References Anderson, O.W. (1972). Health Care: Can There be Equity? New York: John Wiley & Sons. Auster, R., Leveson, I. and Sarachek, D. (1972). “The production of health, an exploratory study”, in V. Fuchs, ed. Essays in the Economics of Health and Medical Care. New York: NBER Columbia University Press. Bandura, A. and McDonald, F.J. (1963). “Influence of social reinforcement and the behaviour of models on shaping childrens’ moral judgements,” Journal of Abnormal and Social Psychology 67: 274-281. Bewley, B.R., Johnson, M.R.D. and Banks, M.H. (1979). “Teachers’ Smoking,” Journal of Epidemiology and Community Health 33: 219-222. DHSS, Department of Health and Social Security (1976). Sharing Resources for Health in England. Report of the Resource Allocation Working Party. London: HMSO. Grossman, M. (1972). “On the concept of health capital and the demand for health,” Journal of PoliticalEconomy 80: 223-225. MacMahon, B. and Pugh, T.F. (1970). Epidemiology. Principles and Methods. Boston: Little Brown & co. McKeown, T. (1976). The Role of Medicine, Dream, Mirage or Nemesis? London: Nuffield Provincial Hospitals Trust. OPCS, Office of Population Censuses and Surveys (1976). Social Survey Division. The General Household Survey 1973. London: HMSO. OPCS, Office of Population Censuses and Surveys (1977). Social Survey Division. The General Household Survey 1974. London: HMSO. Pole, J.D. (1974). “Programmes, priorities and budgets,” British Journal of Preventive and Social Medicine 28: 191-195. Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society (1976). “Prevention of coronary heart disease,” Journal of the Royal College of Physicians of London 10: 213-275. Report of the Steering Committee on Resource Allocation in Wales (1977). Cardiff: Welsh Office. SHARE, Scottish Health Authorities Revenue Equalisation (1977). Report of the WorkingParty on Revenue Resource Allocation. Edinburgh: HMSO.
77
HEALTH AND EDUCATION EXPENDITURE IN THE UNITED KINGDOM: WHAT PRIORITY?
DONALD P. FORSTER* Department of Family & Community Medicine, Universityof Newcastle upon Tyne, Newcastle upon Tvne, NE1 7R U England BRIAN J. FRANCIS Centre for Applied Statistics, Universityof Lancaster, Bailrigg, Lancaster, LA1 4YL England C.E. BRIAN FROST Divisionof Economic Studies and Medical Care Research Unit, Universityof Sheffield, Sheffield, SI 0 2TN England PAUL J. HEATH Barnsley Area Health Authority, Bamsley, S75 2PY England
ABSTRACT Public expenditure on goods and services per head of population on the National Health Service (NHS) in the United Kingdom has risen less rapidly than some other forms of public expenditure such as education. Revenue expenditure at 1970 market prices on goods and services in the NHS per head of population rose by 38% during the period 1951 to 1968. During the same time interval, expenditure at 1970 market prices on goods and services in education per head of population rose by 84%. Health, as measured by standardised mortality ratios (SMRs), improved over a similar period. This paper argues that, in the long term, the priority given to education expenditure may not necessarily be detrimental to further improvements in community health.
Introduction Doctors within health services are familiar with the techniques for evaluating the effectiveness of medical treatments within limited spheres. For example, different medical treatments or services may be compared in a randomised controlled trial and evidence obtained as to which treatment or service is better in terms of reducing unwanted and unhealthy outcomes, one of which may be death. A much wider issue, however, is whether a given amount of money spent on direct health care improves health more than the *To whom correspondence
should be sent.
01652281/81/0000-0000/$02.50
0 1981 Elsevier Scientific Publishing Company
78 same amount devoted to other fields such as housing, nutrition or education. This is a complex problem depending not only on how health is defined but also on the efficiency with which each programme is put into effect. Some commentators have suggested that health services have a relatively small impact on health in economically developed countries (Anderson, 1972; McKeown, 1976). In the United Kingdom, the Education Act of 1944 and the National Health Service (NHS) Act of 1946 (implemented in 1948) placed these services firmly in the public sector such that only small proportions of expenditure lie within the private sphere. The structure of the NHS was extensively reorganised in 1974 and this paper proposes to examine, where relevant data are available, the period between the inception and reorganisation of the NHS in the U.K. The concept of community health can be simplified by referring to an improvement in age-adjusted death rates or standardised mortality ratios (SMRs). This restricts the definition of health markedly but is legitimate in the sense that these measures are officially used as indicators of the need for health care. Working parties on the allocation of health service funds in England, Scotland and Wales have each used mortality as a proxy indicator of health care needs (DHSS, 1976; Report of the Steering Committee on Resource Allocation in Wales, 1977; SHARE, 1977). In practice, equity in funding between regions has been sought by partially basing the level of health funds allocated to each region on its SMR. Mortality, however, may act not only as an indicator for health care but also as a measure of the outcome of health care and hence as a success indicator. The Report of the Resource Allocation Working Party (RAWP) in England was itself sceptical that a redistribution of funds between curative services would have a significant impact on mortality patterns (DHSS, 1976). The terms of reference of RAWP, however, were restricted to making recommendations for equity of funding relative to need. There are many gaps in our knowledge of what is achieved by public expenditure. For example, it would be important to know the effects of certain categories of public expenditure on health in terms of the outcome of mortality. One approach to this type of problem is that of Planning, Programming and Budgeting (PPB). In theory, PPB consists of specifying an objective and comparing the costs and effectiveness of various programs in achieving the objective and therefore it should be able to encompass inputs from a number of government departments. In practice, however, most PPB in the United Kingdom is restricted to a single department (Pole, 1974); hence, spillover effects between different public programs are overlooked. In this paper we develop the argument that there are possible benefits to health from another department, namely education, which should also be considered.
79 Trends in Expenditure Figure 1 shows the expenditure on the NHS per head of population in the United Kingdom at 1970 market prices for the period 195 1 to 1974. The data are derived from National Income and Expenditure publications for various years. Capital expenditure in the NHS at 1970 market prices has been estimated by applying the deflator of costs for Gross Domestic Capital Formation to the current expenditure on NHS capital formation in each year. It should be noted that, due to a change in definition, recording of expenditure on certain services such as child care and local welfare was transferred from the NHS to social services during 1969. Conversely, recording of expenditure on school health was transferred from education to the NHS in 1974. For these reasons, greater emphasis will be given to the percentage rise in real expenditure in the period 1951 to 1968.
20 t I
'?950 52
I1
54
56
I
I
I
I
I
I
I
58
1960
62
64
66
68
1970
I 72
I 74
Year Fig. 1. NHS expenditure per head of population at 1970 market prices (U.K.).
NHS revenue expenditure per capita (that is real expenditure on goods and services in the NHS per head of population) rose by 38% during the period 1951 to 1968. NHS capital expenditure rose at a higher rate than revenue (though starting from a small base value); hence the graph of revenue plus capital expenditure per head of population shows a greater increase than revenue alone, namely of 47% from 195 1 to 1968. On a semi-logarithmic scale, Fig. 2 shows the real increases in NHS revenue expenditure on goods and services per head of population compared to education and other kinds of public expenditure (excluding defence). Real expenditure on goods and services in education per head of the all-ages population shows an increase of 84% in the period 1951 to 1968. It can be
80 _..-•-=
f
l. . . . . ..-• ..*+ OTHER P”BL,C EXP!3JD,T”RE
100 90 90
......****
t
...........--
#.....*-*---"
70 60 I
5Ot
EDUCATION
40 -
_/NM
REVENUE REVENUE
30 -
20 -
lOl 1950
I 52
I
I
I
I1
54
56
66
1960
I 62
64
I 66
I 66
I 1970
I, 72
74
Year Fig. 2. Expenditure per head of population at 1970 market prices (U.K.).
argued that only a relatively small proportion of the all-ages population receives the benefits of education. However, even if the increase in real education expenditure is expressed per head of the principal recipients of education, namely the population aged 5-14 or 5-19, then the increases are 68% and 67% respectively from 195 1 to 1968. Similarly, the percentage increases in real education expenditure for the period 1969 to 1974 are considerably in excess of the increases in health spending. Figure 2 shows also that the increase in expenditure per head of population on goods and services for other public services, excluding defence, rose by 47% between 195 1 and 1968. Trends in Mortality Figure 3 shows the all causes SMRs for the United Kingdom, 1962 being the base year. The fall in SMR from 118 in 195 1 to 9 1 in 1974 represents a decrease of about 23%. This decrease could be considered to be a reduction in the need for health care as reflected by SMRs. Alternatively, the fall in SMR might suggest an improvement in outcome consequent upon a variety of inputs affecting health, some of which would involve health care itself whereas others would lie outside this field. Figure 4 shows restricted SMRs for the same period in the age groups O-64 and 65 and over. These age groups were selected on the grounds that mortality may reflect morbidity more adequately in persons under 65 (SHARE, 1977) and that if inputs, particularly health care inputs, have any effects, then these are more likely to occur in the younger age groups. Regression lines were fitted separately to the periods 195 1 to 1962 and 1963 to 1974 using the data in Figs. 3 and 4. These periods were chosen
81 SMR
130 125 F 120t 1151101051009590-
1:: 1950 52
54
56
58
1960
62
66
64
66
1970
72
74
Year
Fig. 3. Standardised mortality ratios for U.K. (1962 = 100) persons.
SMR
UNDER65 65ANDOVER
1950 52
54
56
56
1960
62
64
66
66
1970
72
74
76
78
1960
Year
Fig. 4. Restricted standardised mortality ratios for U.K. (1962 = 100) persons.
arbitrarily to divide our data at approximately the mid-point. No significant differences were observed between the trends in the two periods for persons aged 65 and over or when all ages together were considered. However, the SMR for the under 65s fell more rapidly in the early rather than the later period @ < 0.05). (The detailed method and tables are described in a statistical document which may be obtained from the authors upon request.)
82 Discussion It is clear that there has been an improvement in health in terms of the fall in the all causes SMRs in the period 1951 to 1974. Our results suggest that, in the time period 1963 to 1974 for the under 65s, the rate of fall in mortality was lower than in the period up to 1962. This can be viewed as less rapid reduction in need or a slowing down in the beneficial effects for the under 65s in terms of mortality in the latter time period. The position is complex, however, since in a consideration of all causes mortality both cross-sectional and birth cohort factors may be at work (MacMahon and Pugh, 1970). In addition, the time interval between the inputs to health, including health care, and the improvement in health may be variable. Our data suggests that, in the period considered, priority has been given in public expenditure to education rather than health care. We have emphasised education expenditure rather than spending on housing or environmental improvements, since, in an age when chronic diseases predominate and infectious diseases have in the main been controlled, the important influences will be in the fields likely to modify people’s life-styles. The question which arises is whether there are reduced gains in health because of this division of expenditure in favour of education. In a longitudinal analysis it is difficult to assess the effects of direct NHS expenditure on mortality relative to the effects of other kinds of expenditure such as education. What other evidence throws light on this problem? Auster et al. (1972) in a cross-sectional study between the states in the United States estimated that a ten per cent increase in health expenditure per head of population would reduce mortality by two-thirds of a per cent in the white population, whereas a ten per cent increase in education would reduce mortality by over two per cent. An important point here is the amount of health expenditure devoted to reducing mortality relative to the amount allocated to activities such as alleviating pain, reducing disability and caring for patients. It may be that as health expenditure rises, medical inputs will be increasingly direct to ‘care’ problems such as geriatrics, psychogeriatrics and community care rather than to ‘cure’ problems. Again in the American context, Grossman (1972) has suggested that the most important variable in the production of health is the level of education of a person. He has argued that the more educated demand more health but less medical care in that they would have an incentive to offset part of the increase in health caused by an increase in education by reducing their use of medical services. In Great Britain, the higher the educational qualification gained, the less likely a person is to be a current smoker (OPCS, 1977). Similarly, the older a person is when he leaves school, the more likely he is to take part in active sports and games during leisure time (OPCS, 1976). However, there is also
83
some evidence that physical activity at work may confer protection against coronary heart disease, one of the major causes of morbidity and mortality (Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society, 1976). Although the better educated appear to reduce the risks of earlier death by certain forms of behaviour, such as avoiding cigarette smoking, it cannot be assumed that this occurs across the whole spectrum of health risks. For example, little is known about the relationship of education to alcoholism or risk-taking while car driving. From many studies it is also often difficult to separate out the effects of education from those of related variables such as social class or income. It should be stressed that reference is being made to the possible effects of general education and not solely to specific health education in the school curricula, though this may have additional benefits. If education does effect health for the better, by what mechanism is this achieved? There is some evidence that children model their behaviour on that of adults (Bandura and McDonald, 1963). Bewley et al. (1979), for example, have shown that there is a significant relationship between boys’ smoking and that of their male teachers. The precise nature of the relationship between education and health needs to be explored in detail but it does appear that there is a positive association between length of schooling and the adoption of a healthy lifestyle. In this paper, we have considered the difficulties of assessing the effects of various kinds of expenditure on health. Overall, however, the balance of evidence suggests that those whose concern is the health of the community should not be too dismayed at the more rapid rise in real education expenditure during the period considered in the United Kingdom, since there may be important spinoffs for health, although there is likely to be a lag period between the expenditure and the improvements. The RAWP exercise in England can only be considered as a first step since it links the distribution of funds solely in the health care field to mortality and avoids the issue of using a reduction in SMRs as a success indicator. We conclude that in the long term, health or mortality cannot be considered in isolation from expenditure on programs outside the health care field. Acknowledgements The Medical Care Research Unit, Sheffield University, is supported by the Department of Health and Social Security and Trent Regional Health Authority. We are grateful to Professors J. Knowelden and J.H. Walker and Dr. J.G. Leece for helpful comments on an earlier version of this paper and to Mrs. Dawn Robinson for secretarial assistance.
84 Note A statistical appendix to this paper and the data from which the faures were drawn may be obtained on request from Donald P. Forster.
References Anderson, O.W. (1972). Health Care: Can There be Equity? New York: John Wiley & Sons. Auster, R., Leveson, I. and Sarachek, D. (1972). “The production of health, an exploratory study”, in V. Fuchs, ed. Essays in the Economics of Health and Medical Care. New York: NBER Columbia University Press. Bandura, A. and McDonald, F.J. (1963). “Influence of social reinforcement and the behaviour of models on shaping childrens’ moral judgements,” Journal of Abnormal and Social Psychology 67: 274-281. Bewley, B.R., Johnson, M.R.D. and Banks, M.H. (1979). “Teachers’ Smoking,” Journal of Epidemiology and Community Health 33: 219-222. DHSS, Department of Health and Social Security (1976). Sharing Resources for Health in England. Report of the Resource Allocation Working Party. London: HMSO. Grossman, M. (1972). “On the concept of health capital and the demand for health,” Journal of PoliticalEconomy 80: 223-225. MacMahon, B. and Pugh, T.F. (1970). Epidemiology. Principles and Methods. Boston: Little Brown & co. McKeown, T. (1976). The Role of Medicine, Dream, Mirage or Nemesis? London: Nuffield Provincial Hospitals Trust. OPCS, Office of Population Censuses and Surveys (1976). Social Survey Division. The General Household Survey 1973. London: HMSO. OPCS, Office of Population Censuses and Surveys (1977). Social Survey Division. The General Household Survey 1974. London: HMSO. Pole, J.D. (1974). “Programmes, priorities and budgets,” British Journal of Preventive and Social Medicine 28: 191-195. Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society (1976). “Prevention of coronary heart disease,” Journal of the Royal College of Physicians of London 10: 213-275. Report of the Steering Committee on Resource Allocation in Wales (1977). Cardiff: Welsh Office. SHARE, Scottish Health Authorities Revenue Equalisation (1977). Report of the WorkingParty on Revenue Resource Allocation. Edinburgh: HMSO.