Feature

Clean up or cough up

As the nation’s use of health services keeps on rising, Richard Lawson asks why we don’t take prevention more seriously—and proposes a radical alternative to the Health of the Nation

There is more to healthy living than brown bread and jogging. Changes in personal habits are undoubtedly important, but they are limited by external conditions — for instance, low-fat, high-fibre joggers may do themselves more harm than good by exercising on days when traffic pollution has created poor air quality. Real health demands political, economic, social and environmental changes.

In July 1992, the government introduced the Health of the Nationstrategy, which set targets for improvements in five key areas of health: coronary heart disease and stroke, cancer, mental illness, HIV/AIDS and accidents.

At the beginning of the Health of the Nation consultation process, William Waldegrave, then secretary of state for health, recognised the role of his office in ‘causing reforms in other government departments that would improve health’. Success, he said, would come through public policies, by policy makers at all levels considering the health dimension when debating policies, with the aim of improving and maintaining health, not simply health care.

In the same vein Virginia Bottomley, the next secretary of state for health, emphasised in her introduction to the Health of the Nation white paper that the pursuit of ‘health’ in its widest sense was not just the responsibility of the Department of Health: ‘there is a commitment to the pursuit of “health” in its widest sense, both within Government and beyond. Within Government this reflects not only my role as Secretary of State for Health but also the responsibilities of my colleagues in other Departments.’

Clearly, then, at the heart of this exercise there is a recognition of the fact that there is more to health than handing out pills and providing hospital beds, and that public health is the responsibility of public policy. The buzzword is ‘intersectoral’ thinking, whereby employment, housing, industry, transport and welfare policies are developed with public health in mind.

But the perception of those toiling at the sharp end of the delivery of health care is that the responsibility for improving the nation’s health — health promotion — has fallen fair and square on to their shoulders. Health promotion tasks mean that doctors and nurses are to weigh, measure and record lifestyle habits such as smoking, drinking, diet and exercise. Although this is widely seen as a worthy exercise by the public, general practitioners (GPs) and primary health care teams are less than enthusiastic for three reasons.

First, they are having difficulty in meeting the demands of the core duty of diagnosing and treating ailments of all kinds from colds to cancer, at a time when the support that primary care expects of hospital services is severely constrained by waiting lists of varying lengths from the embarrassing to the surreal. Second, British physicians are not convinced that there is good scientific evidence that ‘health check-ups’ actually do anyone any good. In April 1995 the British Medical Journal published papers suggesting that health checks for unselected middle-aged people achieve little or no reduction in smoking or excessive drinking, and that intensive group health education offers little benefit over standard GP advice to reduce fat, increase exercise and stop smoking. Those who take up the offer to visit the doctor for a health check are usually the middle class ‘worried well’ rather than the low-waged, unskilled and unemployed people whose health is mainly at risk. Third, it is unanimously believed that if government wishes to reduce smoking related diseases such as lung cancer and coronary heart disease then tobacco advertising should be banned, but this is something that the government is singularly reluctant to do. The net result is that health care workers feel that they are being required to make bricks without straw.

The contribution of public policy to public health may well begin with the elimination of tobacco advertising, but by no means does it end there. Unemployment, poverty, poor housing, stress and environmental pollution are all known to have an impact on human health. A large amount of scientific work exists on these subjects, but little of this reaches the general public.

There is a perennial complaint from health care workers that the NHS is underfunded, which is met by a barrage of statistics from the health secretary to the effect that NHS spending is going up in real terms. Both are right. Spending has been going up, although much of the spending has been consumed by the huge administrative costs of the health service reforms in the late 1980s.

The NHS budget is planned to increase by one half per cent annually, and increased demands by an ageing population and increased costs owing to improvements in medical technology reduce this by one per cent annually, so that the budget is falling behind by half a percentage point each year. Increased administration costs further increase the shortfall. Add to this the increased demands created by environmentally-related illnesses, and the conclusion is that the NHS budget is falling behind year by year.

For this reason, it is now imperative that pressure from health professionals and voters alike creates the political will to examine the impact on health (and therefore on the NHS) of adverse social, economic and environmental conditions. It will rapidly become clear not only that these conditions combine to increase demand on the NHS, but also that measures aimed at rectifying these problems will result in savings for the NHS and for the economy as a whole.

This is an edited extract from Bills of Health, by Richard Lawson, published in September 1996 by Radcliffe Medical Press, at £17.50.