Better Health For All

The demand for healthcare is growing and the NHS is facing the challenge of treating patients with multiple long-term conditions in high-cost settings, with limited resource set aside for prevention.  To have any hope of reversing this trend, hospitals need to embed prevention into their strategies to address the growing demand for health services driven by a population growth, ageing and health inequalities.  Doctors have an important role in addressing health inequalities, by advocating for change in healthcare. 

An ageing population with multiple long-term conditions highlights the need for training tomorrow’s doctors with skills such as generalism, leadership and an interprofessional approach to patientcare.  COVID-19 has emphasised the significance of public health as a speciality and rekindled wider interest in health inequalities(1).

Whilst population health (public health) has become a prominent topic in undergraduate medical education, there is variability in the design and delivery of the topic.  Public health educators have challenges with integrating this topic into the undergraduate curriculum (both teaching and assessments).  It is often taught in isolation, without adequate integration into other aspects of curriculum, yet when integrated it can be overlooked or ignored by both students and tutors prioritising the immediate clinical aspects over broader conceptual issues.  Students seem to perceive public health to be just statistics and struggle to appreciate its relevance to their developing clinical practice.  However, there are signs of change in the long term perspective on medical education and training, which should be  to the advantage of public health – such as the NHS Long Term Plan(2)  and the GMC Outcomes for Graduates (3).

“Newly qualified doctors must be able to recognise sociological factors that contribute to illness, the course of the disease and the success of treatment and apply these to the care of patients − including issues relating to health inequalities and the social determinants of health, the links between occupation and health, and the effects of poverty and affluence.” (3)

We need to be conscious of recently proposed changes in medical education such as the 4-year undergraduate degree, apprenticeships and the Medical Licensing Assessment (MLA) which will begin to be rolled out in 2025. A compressed curriculum, and “teaching to the test” both risk squeezing out elements which are seen as non-core (4).

The recent moves to pool resources across primary, secondary and community sectors marks an unprecedented opportunity to take a population health management approach by pooling to tackle health inequalities.  This allows medical schools to explore collaboration with the Integrated Care Boards (ICBs, or equivalents) and develop multiprofessional system clinical leaders.

“Newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice.” (3)

Medical schools (as part of universities) are socially accountable to the communities they serve.  As anchor institutions, NHS and universities play an important role in the local society.  Some medical schools are already exploring community immersive opportunities for students, so they can gain hands on experience in health leadership, prevention, population health management and appreciate an interprofessional approach to tackling health inequalities. This approach should be encouraged and “scaled up”.

A flipped classroom approach to public health teaching along with experiential learning can provide medical students with patient-focused learning opportunities.  Further, to implement a competency-based public health curriculum, medical educators need to take on the role of mentors, supervisors and role models to create a supportive teaching environment facilitating the application of public health in clinical decisions.  This also requires institutional support and investment of resources.

Dr Bharathy Kumaravel and Dr Ellie Hothersall
Co-Chairs, FPH Public Health Educators in Medical Schools Special Interest Group

References

1.             Rodrigues V, Hothersall E, Davies M. Public Health Education in Medical Schools – The Impact of the COVID-19 Pandemic. J Med Educ Res [Internet]. 2021 Sep 2 [cited 2024 Apr 16];1(1). Available from: http://www.ubplj.org/index.php/jmer/article/view/1926

2.             NHS England. NHS Long Term Workforce PLan [Internet]. 2023. Available from: https://www.england.nhs.uk/long-read/nhs-long-term-workforce-plan-2/

3.             GMC-Outcomes for graduates [Internet]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/outcomes-for-graduates/outcomes-for-graduates

4.             Harden RM. Five myths and the case against a European or national licensing examination. Med Teach. 2009 Jan;31(3):217–20.

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The Adult Social Care SIG and the Musculoskeletal SIG got together to explore where our agendas overlap, using as a starting point the 2023 Chief Medical Officer for England’s report on population health in an ageing society. Its focuses on maintaining independence and delaying disease onset provide useful themes for our two-part blog.

We were curious about musculoskeletal (MSK) conditions and their impact on adult social care (ASC), and how we as public health professionals might raise awareness of both the challenges and the potential solutions.

The likelihood of having an MSK condition increases with age. In the UK, just under 1 in 3 in people aged 35-44 have an MSK condition. This increases to almost 2 in 3 people for those aged 65 and over.  

MSK conditions can have a serious impact on people’s daily lives and are one of the leading causes of morbidity. 21% of years lived with a disability are attributed to MSK conditions in the UK.

As well as morbidity due to MSK conditions themselves, these problems often co-exist with others. Among people aged 45 and over living with a long-term condition, more than three out of 10 also have an MSK condition. And the co-morbidity is often with a mental health condition. Primary care data in England reveals there is a 40% increase in the odds of a self-reported mental health condition among people with an MSK condition.

With the over 65 population in England and Wales set to rise from 11 million to 13 million in the next ten years, the burden of these issues are only going to increase, and will have a significant impact on health care and social care systems.  

Given the prevalence statistics above, we can imagine the impact on individuals in their daily lives and on health care systems, but what about adult social care? The answer is – it’s very hard to quantify.

A diverse range of adult social care services are offered by local authorities. However, there is little specific data about the services that people with musculoskeletal conditions access, or those that are provided, at either a local or national level.

However, some recent research indicates that adults with chronic MSK pain report significant social care use. In the study of over 900 participants across the UK with chronic pain, 54% received formal social care support and 74% received informal support. Authors do not report how many participants stated that they needed help. The study also found that the likelihood of social care being provided increased by 50% for each additional chronic disease reported. The authors point out that social care use is ‘frequently not considered when assessing the overall cost (both financial and societal) of MSK morbidity’, and they conclude that understanding the relationship between MSK diseases and social care may allow better design of social care services in this context, as well as opportunities to develop prevention strategies.

We would argue that in the current context of massively stretched adult social care budgets and rising thresholds for eligibility, we are missing an understanding of the relationship between population MSK need, ‘what works’ to prevent and improve these conditions in the social care context, and the design of programmes of support.

Reaching a place where we understand these dynamics and are able to formulate prevention strategies may be undermined by a number of features of adult social care which perhaps set it apart from health care systems. Research published in 2019, which sought to develop a framework for evaluation for prevention in adult social care prevention efforts, found challenges in data collection including a lack of longitudinal data and a short-term approach to evaluation. Authors suggested there may also be a lack of appetite to invest in data gathering and analytical capabilities, particularly in times of budget restrictions.

Public health data on musculoskeletal health is patchy, at least in England, with the latest prevalence figures in Fingertips being from 2012, and 2016/17. The limitations of public health data – and in fact the lack of recognition of MSK conditions as a public health priority – had been noted in 2011 in the England CMO’s report.

So, in concluding this first part of our joint blog, the impact of MSK conditions on adult social care will no doubt be great, but being able to say more than that is hampered by a lack of information. This has a significant impact on our ability to put in place prevention strategies and evidence-based interventions to address the needs of this population. We haven’t looked exhaustively at all the literature, including grey literature produced in the four UK nations, so please do get in touch with us if you can shed light on any of the issues highlighted.

The second part of our joint blog will focus on innovative community-focused programmes for responding to and preventing MSK conditions, and some ideas for how public health professionals can influence health care and social care systems to make a difference, including addressing the lack of data available to understand the needs of this population.

Sebastian Baugh, Eugenia Cronin, Benjamin Ellis & Elaine Rashbrook

Comments to: benjamin.ellis@nhs.net and elaine.rashbrook@dhsc.gov.uk

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