By Dr Steve George, FPH Vice-President
Andrew Lansley’s commitment to public health, brought out in his interview with the Society Guardian (14/04), is welcome, but prompts a number of questions. The Conservative party’s health spokesman suggests that the Department of Health would be renamed the Department of Public Health, and that it would be given a new focus on prevention of illness. But if this was to translate into a genuine improvement in the health of the public, much more than the name of the body responsible for health would need to change.
Fundamentally, much of the Guardian interview is still focused on health care, or what might more aptly be called ‘illness care’. The public, and the politicians who represent them, must grasp the fact that ‘illness care’ has at best a tiny influence on the health of the public. Only after this realisation can there be any genuine change in the health of the public.
History has shown us that past improvements in health have appeared more as a by-product of a rising standard of living, rather than as a result of conscious policies to improve health. Certainly clinical medicine provides reassurance. It provides care and comfort. It provides treatment for acute emergencies. In certain instances it can provide cures, but these instances affect only a small proportion of people with morbidity. The USA and the UK have approximately equal life expectancies, despite the fact that the UK spends per head of population around a quarter of what is spent in the USA on health services.
So what about the proposed Department of Public Health? Lansley pledges that under a Conservative government patients would be given unprecedented detail on “good and not so good care.” Would this improve public health? Not a bit – even if patients learned the skills of adjusting results for case-mix – the mix of patients treated by a hospital/unit – and other confounding factors that are the bread and butter of people working in mainstream NHS public health.
What about the Tories’ proposal that hospitals would be paid variable sums based upon the quality and results of treatment? Would this produce improvements in public health, assuming that those results were interpreted correctly and correct measures of “quality” were in place? No, for the same reasons as above. It would almost certainly, however, make those responsible for hospital budgets reluctant to attempt to treat a patient likely to produce a poor result, and thereby drive down their tariff. And it’s by no means clear how a policy that would inevitably result in hospitals with poorer facilities and less well trained doctors receiving less funding would accord with the Tories’ promised moratorium on hospital closures.
What might improve public health is channelling money into improving social infrastructure in socially disadvantaged areas and reducing income inequalities. But neither seems likely, given that those inequalities have worsened over decades under successive governments of whatever political colour.
What we are likely to see instead is another health service reorganisation, and I’ll end with a quote often attributed to the Roman orator Gaius Petronius Arbiter:
“We trained hard, but it seemed that every time we were beginning to form up into teams, we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.”