Better Health For All

By Dr Frank Atherton, Chief Medical Officer, Wales

(This article is based on a presentation to the Faculty of Public Health Conference in Telford on 20 June 2017 – view slides from the presentation)

Public health should be proud of the fact that we are an evidence-based profession. We have brought both the ethos and the tools of evidence-based clinical practice to the NHS and the wider public sector. However, we should not lose sight of the fact that public health is both a science and an art; this requires us to bring judgment to bear alongside evidence.

There are plenty of reasons that can be deployed in order not to use evidence. Sometimes issues can be seen as “blindingly obvious”; I recently saw a video of Brian Cox using the fact that we can actually see cosmic background radiation to energetically (and using colourful language) rebut a claim that the Big Bang is just a theory and may not have happened: “YOU CAN JUST ****** SEE IT.” As a newly qualified doctor on my first surgical firm, I worked with the team that had led the development of highly selective vagotomy as a curative treatment for peptic ulcer. In addition to the small operative mortality, many of the patients were left with long-term side effects such as malabsorption or diarrhoea. If I had dared to suggest that peptic ulcer might be a consequence of infection and amenable to curative treatment with antibiotics I would have been ridiculed, or worse. And yet this was subsequently found to be true and most patients are now successfully treated by H.pylori eradication rather than surgical intervention. The lessons I draw for my public health practice is that we should beware of our hidden prejudices and the influence of received wisdom; we should always be willing to challenge our assumptions. Other, less noble reasons for ignoring evidence include laziness, incompetence, pressure of work, and vested interests in outcomes; all issues that we should recognise and guard against as part of the ethical management of our own work.

Sometimes the evidence is rock solid but it is still not used to drive population health. The classic example must be smoking; we have known about the link between smoking and lung cancer since the work of Doll and Hill in the 1950s. But it took until 2007 for smoke-free public places to be enshrined in legislation across the UK. The 10-year anniversary of this achievement is an opportunity to recognise and celebrate its impact but also to raise the important question about where accountability lies for the thousands of avoidable deaths that have resulted from the decades-long delay in effective action. The answer seems to be “nowhere”. It seems to me that there is a failure in public sector governance if there is no accountability for inaction in the face of convincing evidence. The horrific events at Grenfell Tower perhaps serve as a more recent example.

And, of course, the evidence base is never complete, and we are often faced with contradictory evidence that steers us towards different courses of action. The recent debate about regulation of electronic cigarettes is a useful example. Evidence of the benefits as a smoking cessation aid have to be balanced by currently unquantifiable risks including the direct and indirect effects of vaping, and the potential for a new generation of young people to become addicted to nicotine. When faced with these sorts of uncertainty we have several options. We can commission further research, but that takes time. We can use a trial and error approach, but that brings risk (think of the death and illness last year of fit young volunteers in pharmaceutical trials in France). We can use a risk management and mitigation approach – something we all do unthinkingly in our daily lives when we buckle our seatbelts. And we can use a precautionary approach but, if used inappropriately, this might stifle innovation and change that could have a positive impact on population health.

Our approach in Wales has been to follow the thread of evidence-based public health action, from our research and development commitments (£43m per year), through the programme of action for our government, the legislative framework of the Wellbeing of Future Generations Act which requires public bodies to plan and report on population health outcomes, then through to our recently passed Public Health Act which has incorporated health impact assessment into our policy and planning. In Wales, we believe that evidence matters, but judgment and compassion also need to factor into our decision-making.