Feature

Who gains from health promotion?

Health promotion in primary care does more for the doctors than the patients, says Steve Iliffe

Pevention is better than cure - and especially for other people. We all know that a stitch in time saves nine, and bow to its wisdom, but if several must have one stitch so that one can avoid ten the room empties and prevention has few takers.

Everyday experience tells us that those who do unhealthy things usually get away with it, the only possible exception to this prevention paradox being AIDS. Even the core preventive activity of the NHS, the immunisation of infants against infectious disease, can be avoided by those who have no access to the collective memory of diphtheria, whooping cough and polio. For them, what you don’t see is what you don’t get.

Why should preventive medicine become so popular in a culture that is so averse to thinking ahead? Why should this government, above all others, throw money into preventive activities in the community, often against the wishes of those destined to implement them? And why do people who think of themselves as ‘progressive’ carry a banner for prevention with such enthusiasm?

The answers do not lie in the ‘astonishing success’ of preventive medicine, which has a poor track record. Much of the current emphasis on prevention of illness through lifestyle change is of unproven value to the health of the people, and of undoubted costs to the community. Preventive medicine does not work in any way that is perceptible to the community or to those who carry it out, with the exception of blood pressure control to prevent stroke, cervical smears for the early detection of cervical precancer, and maybe - just maybe - mammography and smoking cessation.

Randomised controlled trials of interventions designed to promote lifestyle change in general practice have yielded disappointing results, with small changes in risk factors like cholesterol being obtained at great cost. This has not deterred the champions of prevention from writing the manuals and running the courses that tell others how to spend public money implementing health promotion processes of unknown efficacy and effectiveness. Running ahead of the evidence is a hallmark of professional development in medicine, and health promotion is no exception.

The seemingly irresistible rise of health promotion is driven by needs far from those of the overweight, inactive smokers who appear to be at the centre of attention. More important are the other players, whose gain from health promotion can be instant and sustained. Some doctors in ‘public health medicine’ can try to resolve the crisis of their discipline - what on earth are they for? - by overvaluing health promotion. Around them a cohort of non-medical professionals can create a new discipline of health promotion for themselves, building a career path that may take some out of uncomfortable positions like nursing and allow all to work on the enlightenment of that notoriously backward group, general practitioners.

Here they will find unexpected allies, because a core group of general practitioners seeking a role beyond the gatekeeper function has been preparing to adopt preventive medicine as its own path to identity and social worth. The emergence of advocates for health promotion in general practice coincides with decreasing satisfaction with GP performance amongst the younger generations, increasing demand for medical attention, and the continued rise in complaints and litigation against doctors. The tasks of health promotion, which demand attention to detail, enlargement of primary care teams, computerisation and long timescales, are useful defences against the threats to general practice. Health promoters can feel useful and with their busy staff be seen to be real doctors, surrounded by workers following the plans they devise. In unpromising areas where poverty dominates personal agendas the promotion of health can also attract political credit and satisfy the missionary impulse.

While the prevention paradox makes most members of the public reluctant supporters of health promotion, not all are so diffident. Those who do think ahead may welcome it for themselves as well as for others. Since far-sightedness and education are linked, and education is associated with better health, new health promotion services may find themselves oversubscribed by those who need them least.

This is no problem for a government spending public money to no great effect, because the votes of the far-sighted are worth much, and the message that ‘individual health promotion is the answer’ fits neatly into a commercialised culture strong on commodity exchange and short on social concern and collective action.

Here the Left has opened the door to the Right. The ‘progressive’ desire of the seventies for a real ‘health service’, not a ‘sickness service’, foreshadowed both the growth of health promotion and the decline of that undervalued sickness service. That desire expressed the passivity of the post-war generation, which felt that health could be delivered to it by professionals, and the weakness of civil society, which had little influence over the social causes of health and illness. Now the question is: will the Left be able to capitalise on the unhappy experience of preventive medicine, and give health promotion back to civil society, without undermining professional roles?