What are the best societal investments for improving people’s health?BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3377 (Published 30 August 2018) Cite this as: BMJ 2018;362:k3377
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Different and conflicting demands of health promotion and provision of care must be recognized in the allocation of resources
Dr Webber and her colleagues are absolutely correct in emphasizing the need for health promotion with particular emphasis on population measures. However, in the light of 70 years of experience of the NHS, I am less convinced that ‘compressed morbidity’ will reduce financial need in the long term. However, whether costs increase or decrease is irrelevant, as in health systems money should always be a measure of input and never of output, but the mechanisms whereby finance allocated by government is distributed are critical.
It is not surprising that as health and disease are not antithesis of each other, promotion of health and treatment of disease are not easy bedfellows. They compete with each other for resources, require different approaches and do not have the same primary outcome measures: overall population healthy survival in the former, as opposed to individual cure and amelioration in the latter. In contrast, there is a continuum between medical treatment and social care of the frail. Where there is conflict of resources compassion will favour immediate care of the sick over possible long term benefit. Contrary to the long established status quo, not only should the allocation of budgets and management responsibility for medical and social care be combined, but also health promotion divorced from both. The former proposal is recognised as desirable by many but the latter might seem counterproductive. The skills required by practitioners caring for the individual are inter alia depth of knowledge, judgement, discretion and empathy. Health promotion needs expertise in public education and not to be over-influenced by disease specific lobbies. Where carefully researched primary prevention is believed to be appropriate, people with the ability closely to follow protocols without deviation are best suited. They should be able to persuade individuals to accept for the public good, interventions of which even the most effective are more likely to inconvenience clients than to be of distant benefit to them.
Such an approach would require some transfer of resources from the care sector, but joint needs such as laboratory tests could, if relevant, be financed jointly at provider level. This would have the great advantage of freeing carers, in particular general practice, of work not requiring their skills, enabling them to concentrate on treating the sick, albeit with some loss of resources. Clearly immediate implementation is impracticable but full recognition of the conflict with incremental change towards the proposed structure could produce nothing but benefit.
Competing interests: No competing interests
There seems to be no mention of easy access to, and efficient provision of, contraception.
As long ago as 2006 Mavranezouli and Wilkinson published a paper entitled Long-acting reversible contraceptives: not only effective, but also a cost-effective option for the National Health Service. The position has not changed since, and guidance from Public Health England in August 2018 concludes:_
When considering total cost savings across the public sector (including both
healthcare and non-healthcare cost savings), the ROI is £1.86 after one year
(exceeding break-even) and £4.64 over 5 years. Over 10 years, the ROI is
£9.00, or in other words, there is an £9.00 saving for every £1 invested in
publicly provided contraception.
At a time when contraceptive service budgets are under threat, should this not have been included?
1)Long-acting reversible contraceptives: not only effective,
but also a cost-effective option for the National Health
Ifigeneia Mavranezouli, Christopher Wilkinson; J Fam Plann Reprod Health Care 2006: 32(1)
Competing interests: I am a retired SRH consultant, still active clinically and in the Faculty of Sexual and Reproductive Health
Having recently moved from North London to Basildon, Essex, a ‘New Town’ developed in the wake of World War II, the differences in the environment and the resulting lifestyle differences are stark. While in London people predominantly travel actively, with walking or cycling making up at least some part of the journey, Basildon’s housing estates, retail parks, industrial estates and leisure parks mandate driving to work, driving to shop and driving to play. It is clear, here, the potential for wider societal change to relieve pressure on the NHS from both ends - through prevention of illness on the one hand, and with improved social care taking people out of hospitals and avoiding readmission. Improving towns and cities to encourage healthy living is one potential avenue for public health improvement.
Webber et al. highlight the promise of NHS England’s Healthy New Towns project and call on the government to make health promotion a ubiquitous priority across government departments . The government may be slowly grasping the potential of indirect health promotion; however, private and voluntary sector organisations have the potential to lead the way in this essential revolution. Healthy employees take less sick leave, are more productive when they are at work and make for a happier work environment . This demonstrates that there should be adequate motivation for employers to work to improve the wellbeing of their staff. Tech companies are leading the way with work-life balance and an enjoyable work environment. Simple measures, such as having high quality shower and change facilities, go a long way to encourage an active commute. Running or cycling to work is good for physical health, mental health and is cheaper and less stressful than other modes of transport.
With the growing potential of health apps and wearable fitness trackers, employers and/or the government could, in the future, directly incentivise healthy living. Sweatcoin is an app that allows users to earn ‘credits’ for the number of steps you do each day. These credits can then be redeemed for rewards and gifts. With further development and research into the efficacy of direct incentivisation for healthy living, it is not hard to imagine a future in which the NHS or employers rewarded people for exercise through fitness tracking apps and hardware.
Preventing illness stretches well-beyond the remit of doctors. Pushing health onto agendas beyond the Department of Health and Social Care, throughout government and the private sector, is key to ensuring the NHS can flourish for another 70 years and beyond.
 Webber Laura, Chalkidou Kalipso, Morrow Susie, Ferguson Brian, McPherson Klim. What are the best societal investments for improving people’s health? BMJ, 2018; 362 :k3377
 Marsden, D., Moriconi, S. The value of rude health. London School of Economics, 2008.
Competing interests: No competing interests