Better Health For All

#futureofpublichealth: this is the second in a series of blogs that aims to champion the prevention delivered in NHS settings as part of the NHS at 70 celebrations and FPH’s public health funding campaign

The success in the decreasing prevalence of smokers in the UK is largely due to programmes and actions taken out of the hospital. Since 1999 the public has had access to free Stop Smoking Services; patients can be directed to a local smoking cessation service where trained staff can prescribe medications and give support to people attempting to quit. Other levers that have worked to reduce smoking include public policy initiatives – the introduction of smoking bans, restrictions on advertising and packaging and increased taxation on cigarettes. No single department of government is responsible for these policies, showing that prevention works best when there is joined up or complementary policy across the different domains of government.

It is easy to see how preventing disease is a challenge for health care professionals based in hospitals – so much of the work of prevention is implemented and paid for by local authorities and is best managed beyond hospital walls. That said, people working in a variety of NHS settings play a huge role in promoting and delivering prevention-based services to patients. In my current post working in obstetrics & gynaecology, some of my work in prevention involves encouraging pregnant women to stop smoking. Smoking in pregnancy increases the risk of complications in pregnancy such as premature birth and miscarriage. Parental smoking also increases the risk of sudden infant death syndrome and children developing health conditions, such as asthma, later in life. These dangers have led to many hospitals employing smoking in pregnancy specialist midwives. These midwives can be based at a hospital seeing pregnant women in clinics, in the community seeing women at home – or a mixture of both. They play a vital role in making sure that new mums get the support they need during pregnancy, from signposting to mental health services to breastfeeding advice.

There are many other hospital-based prevention schemes. For example, specialist staff in drug and alcohol addiction or multi-disciplinary teams working in strength conditioning in the elderly to prevent falls. All of them take advantage of both a captive audience when in hospital, and the close relationships between patients and staff. Unfortunately, there are problems on the horizon where the hospital-based models of preventative care described will not be enough.

Multi-morbidity, i.e. having more than one disease, is the great challenge for my generation of doctors and indeed all hospital-based health care staff. Many medical problems that we see in our patients, such as heart attacks, stroke and diabetes are connected to preventable conditions, like obesity. There are no easy solutions to the obesity epidemic, but what is clear, is that reminding patients of the recommended daily calorie intake or the recommended weekly amount of exercise and then signposting to local weight loss programmes alone isn’t going to solve the problem.

As the number of obese people grows, the NHS is seeing a rising demand for bariatric surgery and services. Whilst such operations are important and ‘preventative’ in that they contribute to tackling obesity-related diseases, the aim should be to avoid performing surgery in the first place. Obesity is a more complex problem than smoking. It touches upon many important areas of life – local government, education, transport, housing and planning, health and social care, food standards and so on. Therefore, like smoking, action at the population level is needed to address the growing epidemic.

Doctors working in the NHS have an important role to play in preventing disease in patients. However preventative medicine isn’t the primary role of a gastroenterologist, breast surgeon or a general practitioner. Furthermore health care is not the major contributor to the health of individuals. So, a future approach to delivering prevention must include, in addition to the health care system, broader public health activity in the community. Programmes are needed that focus on the wider determinants of health, such as socio-economic status or housing. Public health professionals are trained and best equipped for this field – not hospital doctors. Preventative interventions created and delivered by the NHS need to be supported with the work of public health professionals in developing and contributing to public policy and delivering effective programmes and support in communities.

Joined up thinking across national and local government is a pre-requisite and I do not believe we currently have a robust system to deliver this. I’d propose a ‘Cabinet of Public Health’ formed of senior public health professionals whereby cabinet members and their teams would work within and as part of government departments assessing the health impact of proposed policy. Regular meetings would aim to develop ways of joining up policy to tackle complex issues like obesity or poverty and the impact these have on health. There would need to be a role for contributions from primary and secondary care in such a system. This could be input from Royal Medical Colleges or by recruiting clinicians as National Medical Directors for various medical specialties or chronic conditions.

NHS clinicians that deliver prevention, as well as cure, will be important contributors to improving the health of the population and creating a sustainable health care system. However, it would be folly to think the NHS or the health and social care system can deliver prevention alone. Smart and connected public policy with the accompanying funding to enact it, must reflect this reality.

Written by Jason Sarfo-Annin, GP Registrar and Academic Clinical Fellow in Primary Care. You can follow Jason on Twitter @Dr_JSA.

Note from FPH: As we celebrate the NHS at 70, many in the health community are taking this moment to ask some big questions about the kind of future we envision for our health system and the level of funding support necessary to realise it. We believe that public health and prevention must be central in this national debate about the future of NHS funding and we’d like your support to help us make that case. If you’re an FPH member or work in the NHS delivering prevention, please consider joining our ‘sounding board’ of members and clinicians who are helping us develop policy on this issue. For more info, please email policy@fph.org.uk.