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Well said Iona Heath!
- AN Ghanem (5 January 2007)
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Agreed: the fundamental problem is not a lack of preventive care.
- Richard J Lyus (5 January 2007)
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Preventing ill health or averting the path to financial ruin and misery for all
- Nagpal Hoysal (5 January 2007)
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No defense needed.
- Christopher Buttery (6 January 2007)
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Promoting health?
- Dr Dominic C Horne (9 January 2007)
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Sickness will never go away
- Kevin Pearce (10 January 2007)
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In defence of a National Health Service
- David C Taylor-Robinson, Dr Mark Jackson, Head of Clinical Governance, The Cardiothoracic Centre Liverpool NHS Trust, L14 3PE (10 January 2007)
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National Sickness versus National Health.
- Alexander SD Spiers (11 January 2007)
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SIt is stopping disease in the villages
- Anne Savage (11 January 2007)
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Treating sickness is a doctor's first priority
- Peter G Davies (16 January 2007)
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Quite right
- Diane-Marie Campbell (13 February 2007)
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AN Ghanem, Uroloigist Job seeker but it is hiding
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Sir, I am writing to say well said Iona Heath. It is delightfully encouraging to see there are people like you around who believe in such values and morale, capable of saying and defending their stand. Such stand deserves not only hats off, secret admiration and a round of applause while delighting in reading but also full open active support of all people BELEIVING in such views and VALUES. Further observations on how the National Sickness Service (NSS) is deteriorating are abundant not only in relation to sick people, it existed to look after in the first place, but also in the way the rapid uncontrolled changes has affected the moral, employment and health of doctors who provide the service. It looks clear that planners have their ideas fixed. They consider the extreme and make a general role of it. They are obviously biased to the rich and probably secretly wish the sick and poor will quickly perish and die so they could achieve their goal of having completely healthy society! This is a total loss of common sense, sensibility and morality. I am not sure either whether they will take any notice of people such as Iona. Such stand shows the hidden side of democracy or "dictatorship of those in power": "You say what you want and we will do what we want"! Just some relevant observations and lingering questions on conflicting issues are mentioned. Now with the implement of total National banning of smoking, from where the money is collected from taxation on Tobacco and Cigarettes and spent on NSS will come from in future? What happens to the thousands of workers in tobacco industry? Will they export all their production to the developing countries to add to their poverty and sickness? Another conflict, which doctor in his right mind will dare to advise a patient to stop smoking, after a judge awarded a patient 45000 SP compensation because she was depressed after the anesthetist told her to stop smoking before her caesarian delivery, saying: "You will see you baby being born, but if you want to see her getting married stop smoking". This is according to a National news paper and report of insurance societies. Editorial note: After complaints, we removed an offensive final paragraph that had escaped our attention before posting. We apologise to readers for this oversight. Competing interests: None declared |
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Richard J Lyus, Resident in Family Medicine Seattle, WA, USA
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I agree with the article. I'd like to mention two important points: Firstly, preventive medicine must, like all interventions, be evidence based. For example, routine annual visits for the 'health maintenance' of low risk patients are probably not a cost effective enterprise. However, from my own experience I believe there is value in encouraging older people, or other people in whom disease is more prevalent (for example poorer people), to meet with a GP for assessment on a somewhat regular basis. But the point is well taken that encouraging the worried well (and well-off) to visit their doctor more frequently, and consume medicines more readily, is unlikely to improve our health outcomes and certain to consume valuable resources. We also run the risk of over- prescribing preventive medicines, 'just to be on the safe side', when their use is not backed up by data. Secondly, I trained in the UK and now work in the United States. I do not recall from my training meeting as many patients who are utterly disenfranchised, disempowered and disinterested in their health, as so many of my patients are here in the US. I work in a clinic which sees almost entirely the un- or under-insured. It seems that years of being unable to afford care, of worrying about paying rent or buying their children clothes, leaves people too exhausted to be concerned with even their current state of health, let alone their wellbeing in ten or twenty years. I thoroughly agree with the author (if I understand correctly) that the solution to healthcare disparity across classes is the eradication of social and economic disparity. The detrimental effects on health of being poor, or feeling poor, or being perceived as poor, are, as the author states, becoming better understood. And, even if poor people enjoyed the same health as the rest of society, would it still be ok to be poor? The answer is of course no. For argument, let's ignore that point and concern ourselves only with health. Should we then throw millions of pounds into lifestyle-change advertising campaigns and counseling sessions for motivational interviewing, while allowing multinational corporations to push their fast -food, cigarettes, alcohol and other mass produced junk on us all for huge profits? How to place restrictions on purveyors of goods which cause disease, without restricting the consumer, is a difficult issue, which can be argued many ways. What is clearer, however, is the moral obligation on policy-makers to prevent waste, inefficiency and unnecessary use of resources in any system which purports to serve society, and so the issue needs to be addressed. On the Venn diagram of preventive medicine and a National Sickness service, where the two overlap sits Primary Care. My experience in the US has totally convinced me that this is the most essential component of a utilitarian health system, not so much because of its effect at preventing disease in the healthy, but because it has cost-effective, evidence-based methods of controlling the course of common diseases in the chronically sick. This controls the need for specialist and tertiary care, which is expensive. The conspiracy theorists among us might tie it all together and think that the corporate CEOs want us to keep eating McDonald’s, never visit a GP (except to refill your statin), and then go and get our coronary angioplasty done and take clopidogrel for the rest of our lives. Disease is a profitable business. Health, at the moment, is not quite so lucrative, and the author is right to warn us against pouring our cash into the coffers of big-businesses who wish to change that; we probably won't get much for our money. Alas, the fundamental problem, as throughout history in so many areas of human experience, is the profit motive. Competing interests: None declared |
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Nagpal Hoysal, Specialist Registrar in Public Health North Yorkshire and York PCT, HG2 8RE
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No nation could ever afford to pay for a healthcare system that did nothing to prevent ill health or promote good health. Continuing and increasingly expensive advances in medicine promise to extend survival in chronic and terminal diseases but there are few real cures. Without any attention to prevention, Great Britain would be bankrupted as all of her wealth was consumed in treating the sick. The situation would be all too reminiscent of the state she was in when the NHS was founded and the cycle would be complete. The question Heath set out to answer is whether prevention should be placed ahead of treating sickness. The efforts we exert in preventing ill health and treating sickness sit on a balance. The balance has been loaded towards treating sickness since the foundation of the NHS; if the balance swings further that way, we will accelerate our path to financial ruin and misery for all. The only way we will ever be able to afford the increasingly expensive new treatments that everybody wants and deserves is to swing the balance a little the other way! Competing interests: I'm a Public Health Doctor |
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Christopher Buttery, Professor of Public Health Richmond, VA, 23298, USA
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I realise that extremes sometimes help thinking, but Dr. Heath is way off base. My most exasperating students are usually those who are already occupied in treating diseases, often specialists who have a narrow view of their profession and come to my classes to broaden their views. I do agree with Dr Heath that few countries have a "Health" system, most are varieties of sickeness systems. However, there is no way, as we all live longer, and as chronic diseases became a major factor in illness care, and expense to the system, that everyone can be treated for everything. We have to learn to intervene early in disease progress, we have to learn to screen our patients better, we have to take better family & genetic histories and apply the data to promote health, not sickness. We must use more primary prevention such as immunization and genetic counselling, with advice about diet and avoidance of substance abuse, for example. We also need to intervene with secondary prevention in chronic diseases such as diabetes, the arthritides, asthma, hypertension.
This will require changing the mindset of inviduals such as Dr. Heath who want to spend all their time treating disease, to put more effort into prevention. The pay off may not be as clinically dramatic but the population will be far healthier, and we can spend more of our GDP on education and community infrastructures to improve the quality of life, not just to treating the increasingly prevalent chronic diseases. We also need to change the way we train medical students and nurses and stop perpetuating the current illness system.
Competing interests: None declared |
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Dr Dominic C Horne, Salaried OOH GP GMED, Aberdeen, AB25 2ZY
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We all know the WHO definition of health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. Is this what the NHS should be striving for? Of course not, but where should the line be drawn? Clearly the vast majority of prevention needs to take place far further upstream than the GP consultation: what we have to offer is on the whole too little too late. Why spend money treating type 2 diabetes, hypertension, IHD, COPD, when all of these could be very effectively prevented by improving lifestyles at a population level? Of course there is a cohort of patients who already need treatment, but why sit back and accept that it is somehow inevitable that more and more individuals will appear in our surgeries on this perverse conveyor belt? Researchers are spending millions on developing ever more complex and ingenious ways to treat these conditions. Is this the best use of our collective intelligence? The interventions required are blindingly simple - top of the list would be banning smoking - but not within the remit of the NHS by any stretch of the imagination. When the NHS was founded it was anticipated that it would at some point do itself out of a job and that universal health would prevail. A laudable aim, but not achievable merely by treating disease and infirmity. However, treating disease and infirmity is what the NHS is for, what it does well and what it should be left to do. The rest is the responsibilty of our elected representatives. Don't hold your breath. Competing interests: None declared |
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Kevin Pearce, GP Harrow
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Supppose that we have only four diseases in the world. Each one has a 20% chance of killing us. If I prevent or eliminate one of those diseases the risk of dying from one of the remaining four goes up to 25%. If I prevent four diseases I am committed to dying from the fifth. This paradox - that preventing one disease actually increases the risk of others seems to be blythly ignored by many. Preventing illness does many good things. It may postpone death to a later age,it may prevent morbidity from certain diseases, it may postpone morbidity to a later age. Ischaemic heart disease is a good example ;interventional procedures for ischaemic heart disease haven't gone away. It is simply that nowadays the need for them is more in the 75 year old age group than the 50 year old group. Something will kill us and that something is most likely to be a disease. It is highly likely that before we die we will be subject to symptoms and morbidities from that disease.Of course we want a public health system that keeps as alive as long but it must not be at the expense of a sickness service which will help us deal with the symptoms of disease when it inevitably comes along. Competing interests: None declared |
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David C Taylor-Robinson, Clinical Lecturer Division of Public Health, University of Liverpool, L69 3GB, Dr Mark Jackson, Head of Clinical Governance, The Cardiothoracic Centre Liverpool NHS Trust, L14 3PE
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Heath (1) raises some important issues. It is a shame, however, that efforts to improve health within the NHS are equated to a narrow, drug focused ‘lifestylism’, and on this basis dismissed. Heath laments the fact that addressing lifestyle factors in this manner ignores the broader determinants of health, cited as ‘wealth and happiness’. We agree. We would argue, however, that these broader, upstream determinants of health are exactly the factors that a ‘sickness service’ re- conceptualised as a ‘health service’ are out to address. The WHO Health Promoting Hospitals initiative is a good example of this (2). We have instituted this in a tertiary hospital in Liverpool. The Cardiothoracic Centre (CTC) in Liverpool is becoming a ‘Health Promoting Hospital’, in addition to its role as a centre of excellence as a ‘sickness service’. The project entails interventions to improve the health of the hospital staff, patients and the surrounding community. Around one in 40 people in the UK work for the NHS (3). Improving working lives and promoting health in NHS staff (and their dependants) could reap dividends in terms of UK population health. Changes in CTC policies and the physical environment have been made in order to support staff health. Patient health will be improved through measures such as promotion of the expert patient programme which empowers patients with chronic illness and facilitates self-management (4). The health of the local community can be influenced through the purchasing power of a large organization with an £80 million budget acting as a good corporate citizen. The NHS accounts for around 10% of local GDP (5), more so in deprived areas, and small changes in procurement can invigorate local economies. These examples illustrate how the National Health Service can function to influence ‘wealth and happiness’ in a population, whilst continuing to be a ‘sickness service’ respected throughout the world. Approaches like these are being implemented in many hospitals, motivated in part by the public health domain in ‘Standards for Better Health’ (6). Heath’s analysis does not seem to take into account initiatives such as this. References (1) Heath I. In defence of a National Sickness Service. BMJ. 2007 Jan 6;334(7583):19. (2) WHO 2006. Health promoting hospitals. http://www.euro.who.int/ healthpromohosp (last accessed 5th Jan 2007) (3) NHS employers 2006. Key facts and figures. http:// www.nhsemployers.org/pay-conditions/pay-conditions-251.cfm (last accessed 5th Jan 2007) (4) Expert patients programme http://www.expertpatients.nhs.uk/public/ default.aspx?load=PublicHome (last accessed 5th Jan 2007) (5) Sustainable Development Commission 2005.http:// www.corporatecitizen.nhs.uk (last accessed 5th Jan 2007) (6) Department of Health 2004. Standards for Better Health. http:// www.dh.gov.uk/assetRoot/04/08/66/66/04086666.pdf (last accessed 5th Jan 2007) Competing interests: None declared |
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Alexander SD Spiers, Professor of Medicine (retired). N/A
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I agree emphatically with Dr. Iona Heath that the primary responsibility of the physician, and of the Health Service, is to care for the sick. Hippocrates wrote the same thing. As doctors we are expected to diagnose illness, to cure it when possible, to reduce its ravages when cure is not possible, to alleviate suffering, and finally to oversee a dignified and pain-free death. This concentration upon disease and the sick has led to the gibe - and that is all it is - that we provide a National Sickness Service. The call by politicians and other attention seekers that we should be providing a genuine National Health Service is a platitude mainly devised by nonphysicians that sounds very worthy but is impractical and would tend to concentrate on the needs of the healthy at the expense of the much more pressing needs of the sick. Providing medical care for those who are ill is rewarding. The patient perceives a problem and seeks our aid. In this setting our attentions are welcomed and patient compliance is high. The patient/doctor relationship is very special because the aims of doctor and patient are so similar: both wish the alleviation of the clinical problem. This is not always the case in ordinary business relationships. Promoting the health of the nation is a much thornier exercise, because we are approaching the public rather than the reverse. While almost everyone approves of clean water supplies, clean air and efficient sewers, many public health measures are controversial and provoke much opposition. For example, fluoridation of water, vaccination of children, seat belts for motorists, helmets for motorcyclists, speed limits on the highways and banning of smoking in public places are all worthwhile measures but all have their opponents. Those who feel well and consider themselves to be healthy do not as a rule welcome unsought advice to stop smoking, drink less alcohol, follow a healthier diet, or take more exercise. It seems that the promotion of healthier lifestyles among those who feel well is much less cost effective than the care of the sick. Of course doctors and the Government should continue to offer health- promoting advice, but not at the cost of diverting too many resources to the care of the well instead of the ill. Competing interests: None declared |
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Anne Savage, retired NA
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When I worked in Zambia many years ago the Times of Zambia headlined a query 'Why' it asked' do all these doctors work in hospitals. Why don't they go into the villages and stop the diseases before they develop'. This is the same irrational idea that is expressed by academics here, though with added jargon. Only eat the right foods and go for a daily walk and the hospitals will be empty. Apart from alcoholic disease, that government initiatives have fostered, there are few genuinely preventable conditions. But now, as I know from voluntary work and personal experience, the old and complicated are being denied necessary treatmentas being not worth the expense. Iona Heath has once again hit the nail on the head. Let's hope somebody listens. Competing interests: None declared |
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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Iona Heath is absolutely right.(1) Treating sickness is the main job of the doctor. As Jesus said, "Who needs a doctor: the healthy or the sick? (Mt9:12) If we had a proper national sickness service that concentrated on treating the sick we might have a better service than we do now. There is a role for salutogenesis (2) However we need to be realistic that health generation is a political act, and that even at its best health promotion is only illness and death postponement. Humans will always eventually need sickness treatment. (1) Heath, I (2007) In defence of a National Sickness Service BMJ 2007; 334: 19 (2) Lindstrom, B, Lindstrom,M (2005) Salutogenesis Journal of Epidemiology and Community Health 59: 440-442 Competing interests: None declared |
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Diane-Marie Campbell, itinerant emergency physician Newcastle 2291
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Well said Drs Heath and Pearce! The death rate/person in the UK will always be 100%. Preventive Care does not prevent death, it defers it. To the acute care of the patient who infarcts at 75 instead of 50 must be added the cost of 25 years of antihypertensives, statins and surgery visits. Basic simple arithmetic which seems beyond most Health Care economists and many Public Health physicians! The extra 25 years of health should be seen for what it is - an added good, for which we must expect to pay. Why are we arguing about whether healthy patients or sick patients should receive a larger slice of the funding cake? Just like housing, nutrition and interventions to keep the workplace safe - all of which help determine health status - "Wellness" care is separate from care of the sick. Get another cake. Competing interests: None declared |
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