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Editor's Choice

On the line between patient and population health

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1408 (Published 29 March 2018) Cite this as: BMJ 2018;360:k1408
  1. Fiona Godlee, editor in chief
  1. The BMJ
  1. fgodlee{at}bmj.com
    Follow Fiona on Twitter @fgodlee

A host of well known risk factors exist for chronic disease and premature death. But one is easily overlooked because it seems far beyond the everyday reach of doctors: low socioeconomic status. Research published in The BMJ this week says that socioeconomic adversity not only shortens lives but also accelerates disability, the very opposite of healthy ageing (doi:10.1136/bmj.k1046). Using walking speed as a measure of the number of years of physical function lost by age 60, the researchers found socioeconomic status to be just as important as risk factors such as obesity, smoking, alcohol, hypertension, diabetes, and physical inactivity. As Rachel Cooper says in her linked Editorial, it seems that “people who have experienced socioeconomic adversity are not only more likely to live shorter lives but also to live more of their shorter lives with disability” (doi:10.1136/bmj.k1288). These results add to the urgency of tackling social inequality.

Expensive new drugs are not the answer, says health economist Karl Claxton (doi:10.1136/bmj.k1373). In fact, in a financially constrained system they can make things worse by diverting funds from other forms of healthcare. “The direct beneficiaries of making a new drug available are easily identifiable,” he says, “but people who will ultimately pay for those new drugs through the fact that they won’t get as good healthcare and outcomes as a consequence—we don’t exactly know who they are.”

This tension between the rights of individual patients and the needs of the population is played out in hospitals and general practices every day. It contributes to a growing feeling of moral distress among doctors, says David Oliver: knowing what a patient needs but being unable to provide it owing to constraints in the system. (doi:10.1136/bmj.k1333) Rebecca Rosen makes a similar point (doi:10.1136/bmj.k1366). Discomfort in not being able to do one’s job well is a major cause of dissatisfaction among GPs. Working to reduce antibiotic prescribing is particularly stressful, she says, because NICE guidance asks GPs to act as guardians of both individual and population health.

Rapid point of care testing for microbial infection would help us all: doctors, patients, and the public. So here’s the good news: genomics is already delivering drug resistance profiling for tuberculosis strains, reports Ingrid Torjesen (doi:10.1136/bmj.k1267), and genetic targeting of treatments for cancer and infections is on the way. We will all need to get smarter about genomics.

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