Published 2 October 2008, doi:10.1136/bmj.a1923
Cite this as: BMJ 2008;337:a1923

Editor's Choice

A plea for broader perspectives on health

Many factors influence health and are influenced by it. What does this mean for how we decide which interventions to invest in? In an editorial this week (doi:10.1136/bmj.a1204), Michael Drummond and colleagues say we must do what the textbooks tell us: consider all costs and benefits, no matter whether it’s the health service or other sectors that pick up the bill.

The National Institute for Health and Clinical Excellence gives "mixed messages" on this at the moment, says the editorial. When it appraises drugs and procedures, NICE takes the narrow health service view. When it appraises public health interventions it looks at the impact on employment, education, crime. (As an aside, NICE itself gets a mixed appraisal from Nigel Hawkes (doi:10.1136/bmj.a1906). He concludes that at least some of the media’s recent nastiness is down to NICE’s failure to engage critical clinicians, its refusal to offer up its economic models for scrutiny, and its arbitrary and out of date threshold for approving drugs. With a few changes, NICE could strengthen its hand.)

Our health economists’ plea for a broader perspective finds voice elsewhere this week. Should we take a population approach to preventing cardiovascular disease or treat only those people at high risk? It’s not a new question. Many may have thought it was resolved years ago by Geoffrey Rose’s neat demonstrations of how shifting the whole populationaverage would deliver greater benefits than treating people at the extreme. In our Head to Head, Simon Capewell agrees that reducing risk across a population is more cost effective (doi:10.1136/bmj.a1395), but Rod Jackson and colleagues argue for targeting drug treatment at people who have already had a cardiovascular event (doi:10.1136/bmj.a1371).

There is a third option: drug treatment for entire populations. Five years ago in the BMJ, Nick Wald and Malcolm Law proposed that everyone over 55 should be offered a "polypill" made up of a statin, aspirin, three antihypertensive drugs, and folic acid (doi:10.1136/bmj.326.7404.1419). Geoff Watts asks what happened to this idea (doi:10.1136/bmj.a1822). Trials are under way in secondary prevention but not yet on healthy populations, as originally proposed.

All three options stand accused of medicalising healthy people. Watts quotes Wald defending the polypill on this score by attacking the high risk approach. "[If you give people] a disease label, and then have them come back regularly to find out if things have changed, you’ve created a patient."

I’m sure Iona Heath, trenchant critic of the expanding ambitions of preventive medicine, would have something to say about that, but this week she reserves her ire for the proposed NHS constitution (doi:10.1136/bmj.a1857). The current draft is, she says, a mix of platitude, mendacity, and hypocrisy. She adds her own plea for a broader perspective on health: "There is a lot about the responsibility of individuals and families to contribute to their own good health but absolutely nothing about . . . how the organisation of society systematically undermines the health of its poorest and most vulnerable."

Cite this as: BMJ 2008;337:a1923

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