Welcome to episode 23 of the weekly wellbeing round-up! Some of you may have noticed an item or two in the news this week about the publication of the NHS’s vision for prevention, publicised by Matt Hancock the health secretary. Plenty to chew over there and for this reason I will be devoting this week’s post to the subject, looking at the positives, the negatives and the unanswered questions – for patients and for doctors – from a pragmatic perspective. Let’s jump straight into it!
Prevention is better than cure
OK, so it’s a pretty obvious title for a government paper on the subject, but one that is clearly appropriate and hard to argue with. The paper was published this week and you can read the full forty-one page document here, as well as Matt Hancock’s blog post on its publication here. Just in case you don’t have the time or inclination to read all of that, I have summarised some of the key points and some of the issues that arise as a result.
The importance of prevention
Whilst it’s not necessary to spend a lot of time agreeing with motherhood and apple pie, there are a few points made that are worth reflecting on. Firstly, how might we define prevention? Here it is described as “about staying people stay healthy, happy and independent for as long as possible”. Not a bad definition. It is worth remembering that we can’t prevent everything (ageing and death being two obvious examples) and sometimes it might be more accurate to use the term “delayative” rather than “preventative” medicine. However, it’s still very important as one key area is the number of years of life that we enjoy in good health… something we will touch on later. It is pointed out in the document that we spend over ten times more money on treating disease rather than preventing it (£97 billion vs £8 billion). This demonstrates that, whatever the rhetoric may have been, we clearly aren’t getting the balance right and it still needs to shift significantly. If we do what we’ve always done, we should be entirely unsurprised when we get what we have always got.
Funding for prevention
Much play is made of the increased funding for the NHS, an apparently rising amount up to £20.5 billion a year in five years’ time. Clearly this is welcome. The welcome should be a cautious one, however. First of all we need to be sure that none of this is simply rebadged money. Secondly, money absorbed into existing NHS deficits (e.g. overspent clinical commissioning groups and hospital trusts) is not available to be spent and therefore not a real terms increase, so we need to be clear about where it’s going. Thirdly, the big issue of funding for public health was not addressed by the health secretary when he was asked this question repeatedly on the Today program this week. Public health funding provides services such as smoking cessation, weight management and sexual health clinics. The budget has been slashed in the last few years. There has not been an announcement yet about the budget for next year. If this is further reduced (or in my view, not increased) then a lot of the rhetoric about funding will ring hollow.
Who is responsible for practising prevention?
There are a lot of references to personal responsibility in the vision document. Generally speaking, I’m a big fan of personal responsibility. Ultimately we all make our own decisions about what we put in our mouths, how much we drink and whether we are physically active. I really struggle when I talk to people about the risks they face to their long-term health and wellbeing and their response is either to shrug or to suggest that it’s up to the medical profession to sort it out for them. That said, life is not a level playing field. There is evidence of inequalities in society increasing rather than decreasing in some areas. Many factors influence a person’s wellbeing and the majority of them are not directly related to physical health e.g. housing, employment, education and social networks.
One area that is highlighted is the aim to halve reduce childhood obesity by 2030. In the UK we have one of the highest childhood obesity rates in Western Europe. Serious public policy is required here, not just telling kids and their parents to eat more fruit. People worry about the nanny state and curbs on freedom, but the biggest advances to health have often been the result of large-scale public health interventions such as safe drinking water, vaccination and smoking bans. I’m a massive fan of the nanny state. We need cities safe for cycling, better public transport, advertising bans and more tax on unhealthy foods and sugary drinks, mandatory calorie counts on menus, regulation of fast food shops on the high street and near schools, and increased input into the school curriculum. We need the government to take responsibility for this as well as expecting local authorities to do their bit. If this does not happen, then very little else will.
Social prescribing for prevention
Social prescribing involves helping patients to improve their health, wellbeing and social welfare by connecting them to community and other third-party services – for example those run by a council, local charity or lifestyle and wellbeing service provider. The vision document highlights the important part that social prescribing has to play in prevention. It is important to “change the mindset from condition management to health creation”.
Our clinical commissioning group has a strong social prescribing model which has received national recognition . We have a team of community navigators serving each of our local areas. My practice patient participation group has just launched a social prescribing group that dovetails in with this service, offering weekly clinics for primary care team members to refer into where we feel that a person’s needs might be better met by this than by a medical practitioner (e.g. to address loneliness and debt). However, we need to ensure that we don’t see social prescribing as an option to compensate for lack of funding and support from central government and local authorities, relying on the good will and free time of individuals and charities. If it works as a concept and in reality, it must be properly commissioned.
I was rather tickled to read this BBC news article which reports the health secretary advocating GP’s prescribing song playlists as well as medication. I like the idea although I’m not sure that this is necessarily something that will ever make it into the core general medical services contract. I’m also not sure that my sharing any of my playlists with my patients would be a kindness, but just in case you are interested, here are my apple music playlists for ambient music, jazz , electronic dance music and rock. A little something for whatever suits your mood, I hope.
Technology for prevention
Our secretary of state for health is very keen on his technology. I was rather suspicious at the beginning of his tenure that a lot of statements were made about using apps to transform the NHS. Don’t get me wrong – I’m proud to consider myself a bit of a geek and have always looked to use technology to help me work smarter and more efficiently – but it did raise the suspicion that this might be a message that all we need to do to save the NHS is to use our smartphones more. Maybe this isn’t entirely fair as there is going to be an increase in funding, which I have already covered. Two particular aspects of using technology caught my eye in this document.
The first aspect is use of a predictive technology to assess risk which is not just limited to a body system or a disease. Bearing in mind my earlier comments about the determinants of wellbeing outside of health, I think this is a really interesting idea and would be a considerable extension above and beyond current risk tools such as Qrisk2, which allow you to put in a postcode as part of calculating a person’s risk but nothing more than that. How such a tool would be developed and demonstrated to be valid is another issue altogether but one that I look forward to learning more about.
Oh how we love our telehealth in the NHS. The great solution to everything. The thing that everyone of every age demands and desires. The thing that will radically change the NHS. The thing that has lots of evidence behind it…oh, wait. No, it doesn’t. As someone who used to be responsible for telehealth developments in our clinical commissioning group, may I take this opportunity to say just how weary and cynical I am about the whole thing? It may augment NHS services if used in just the right group of people with just the right level of engagement. It will be convenient for some patients. However, an appointment with a doctor remains an appointment with a doctor and takes up the same amount of time as any other kind of appointment. Next time you are at your doctor’s surgery, try asking about the level of excitement they feel about now having to consider telehealth as well. See? Told you.
Prevention…what’s the point?
This is what it all comes down to. We need to be clear about this. We can’t stop people ageing or dying (despite NICE’s best efforts when it approves yet another drug with marginal gains for £20,000 per quality adjusted life year). So what is it all about? I was pleased to see that Matt Hancock states that the aim is for an extra five years of healthy independent life. Assuming I have understood this correctly, this is a welcome emphasis on quality rather than quantity of life – something that we can all get behind.
That’s all from me for this week. The weekly wellbeing round up will return. Until next week, take care of yourself!
Dr Richard Pile