Prevention green paper lacks ambition, say criticsBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4829 (Published 23 July 2019) Cite this as: BMJ 2019;366:l4829
All rapid responses
Prevention is the best way of reducing health care costs. It is helpful if you know the cause of the conditions that wish to prevent. Women’s health problems, particularly the classical obstetric and gynaecological syndromes, almost entirely result from injuries to pelvic autonomic nerves caused by “difficult” (induced) first labours, common gynaecological surgical procedures for evacuation of the uterus, and, interestingly, prolonged or persistent physical efforts during defaecation.(1, 2) Teenage, or nulliparous, stage 4, “endometriosis” is, almost entirely, the consequence of straining on the toilet (2). It is therefore, largely preventable.
This condition has recently emerged in Shanghai as Chinese women are increasingly exposed to Western diets and sitting (not squat) toilets, that permit physical efforts to evacuate reduced stool weights (3, 4). We have had this bathroom porcelain since 1861. It is not surprising we are slightly ahead of the Chinese in terms of our incidence of Western or, non-communicable diseases – but they are largely preventable, simply by rearranging our bathroom furniture, bathroom behaviours, or both !
The political class are well aware of the sources of chronic NCDs, but do not discuss this simple advice in the green paper. Medicine is not aware of the sources of chronic diseases. We “lost” the morphology of the autonomic plexi and nerves shortly after 1945 when we were taught their anatomy in formalin-embalmed cadavers (that destroy autonomic nerves) rather than alcohol-embalmed material (that preserves autonomic nerves). Doctors can improve their prevention credentials by asking two questions: 1) “Do you go to the toilet once per day, once per week, once per month ?” 2) “Do you have to strain to start, or finish, opening your bowels (20-30% of an urban UK population did so in 1993, 5). You may be surprised at the amount of prevention that you achieve !
1) Atwal G, du Plessis D, Armstrong G, Slade R, Quinn M. Uterine innervation after hysterectomy for chronic pelvic pain with, and without, endometriosis. Am J Obstet Gynecol. 2005 Nov;193(5):1650-5.
2) Quinn MJ. "Endometriosis"--the role of radical surgery in a regional pain syndrome. Ann Surg. 2013 Jun;257(6):e17.
3) Quinn M. Origins of Western diseases. J R Soc Med. 2011 Nov;104(11):449-56.
4) Quinn MJ. Autonomic denervation and Western diseases. Am J Med. 2014 Jan;127(1):3-4.
5) Heaton KW, Cripps HA. Straining at stool and laxative taking in an English population. Dig Dis Sci. 1993 Jun;38(6):1004-8.
Competing interests: No competing interests
We welcome the publication of the government’s green paper on preventing ill health as we are now a step closer to having a health strategy that is urgently needed to tackle pressing public health issues.(1,2) These include accidents, alcohol misuse, mental health, obesity, smoking and the ubiquitous problem of inequality. We are aware that with the current changes in government the strategy may be very different to this consultation document. However, we hope that the final strategy can be produced as quickly as possible before the end of the year and designed to minimize disparities and help to unite the country.
A positive health strategy is required that creates a culture that supports health and for this to be achieved we need a fundamental change of approaches.(3-5) To clarify, the strategy needs to include:
• a focus more on health rather than healthcare;
• a focus more on population health rather than individual lifestyle;
• evidence-based approaches;
• funding that is adequate for the significant tasks;
• firm political commitment at a national level.
It is positive that the green paper has a commitment for the NHS “to move from a national treatment service (focused on illness) to a national 'wellness' service (focused on creating good health).” We were surprised however that health promoting hospitals were not mentioned as this approach would ensure that health promoting environments are created that are not only positive for the patients but also for all the staff that work in them. We have long advocated for health promoting hospitals and health promoting general practices.(6-9)
Potentially there are many opportunities for doctors, nurses and other dedicated staff to be involved in health promotion but in many cases this will not be turned into reality if investments are not made. A major concern is the staffing crisis. Vacancies need to be filled and then hard-pressed staff may have more time to promote health.(9-11)
Schools are another key setting discussed in the green paper and recently the Department for Education has launched a narrow “Healthy schools rating scheme” that only includes a small number of topics.(12) This needs to be further developed and based on the considerable amount of academic literature that has been produced on this, including theoretical papers, descriptive studies and evaluations.(6-8,13) Health promoting schools should be promoted nationally and supported locally by public health specialists as they were in the 1990s and early ‘noughties’.
Some important priorities have been mentioned in the green paper including alcohol misuse, obesity and mental health and although some of the initiatives proposed are welcomed the complexity and scale of the challenges are not being addressed. In addition, it has not been recognised that although some initiatives may result in behaviour change this does not always equate to improvements in health. In relation to obesity for example a long-term positive multi-faceted healthy eating strategy is required.(14,15)
The health strategy should also focus more on evidence-based approaches rather than simplistic “silver bullets”. The important topic of accident prevention, for example can now draw upon a considerable base of evidence of effectiveness and should be firmly included in the new health strategy.(16,17) A comprehensive plan has been developed by the Royal Society for the Prevention of Accidents in conjunction with many eminent organisations including the Royal College of Paediatrics and Child Health and the Faculty of Public Health.(17) However, what is needed now is firm government support to ensure that this plan is fully implemented.
We were pleased that the crucial roles that directors of public health play in public health including having an impact on the wider determinants of health was highlighted. Directors and their teams could stimulate and coordinate action in different sectors.(18) But they will only be able to realise their potential if substantial improvements to their budgets are made and protected so they have adequate resources for the scale of the current and future public health challenges.(19-25)
In conclusion we would like the new health strategy to be far more ambitious. One that creates a vision for health, recognises the complexity of public health issues, as well as developing structures and a culture for health. Such a health strategy should be targeting three goals: to lengthen lives, improve the quality of lives, and ensure that no one is left behind.(4,5)
1) Department of Health and Social Care. Advancing our health: prevention in the 2020s—consultation document. Jul 2019.
2) Mahase E. Prevention green paper lacks ambition, say critics. BMJ 2019;366:l4829
3) Whitehead M. Swimming Upstream. Trends and Prospects in Education for Health. London: Kings Fund Institute, 1989.
4) Jacobson B, Smith A, Whitehead M. The nations' health-a strategy for the 1990s. London: King Edward's Hospital Fund for London, 1991. (Revised ed.)
5) Galea S. Well. What We Need To Talk About When We Talk About Health. Oxford: Oxford University Press, 2019.
6) Baric L. Health Promotion and Health Education in Practice. Module 2. The organisational model. Altrincham: Barns Publications, 1994.
7) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.
8) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
9) Watson M C and Lloyd J. Pressure on general practice in England. Time to put GPs first by investing in general practice. BMJ 2019;365:l4158
10) Watson M C and Forshaw M. TACKLING THE CRISIS IN GENERAL PRACTICE. Prioritising prevention and health promotion. BMJ 2016;352:i1333.
11) Watson M C and Lloyd J. NHS long term plan: all patients to have access to online GP consultations by 2023-24. British Medical Journal Rapid Response 22nd January 2019.
12) Department for Education. Healthy schools rating scheme. Guidance for schools. London: Department for Education, 2019.
13) Poland B, Green L and Rootman I (eds). Settings for Health Promotion. London: Sage Publications, 2000.
14) Watson M C and Lloyd J. (2015) Taxing sugar should be just one element of a multifaceted campaign. BMJ 2015;351:h4388.
15) Watson M C, Theaker T. Re: Fight childhood obesity with multiple methods, not just more taxes, MPs hear. BMJ Rapid Response. 7th May 2018. https://www.bmj.com/content/361/bmj.k1963/rr
16) Institute of Health Promotion and Education. IHPE Position Statement: Unintentional Home Injuries to Children (Under 5s) (June 2019). Lead Authors: Dr Michael C. Watson and Dr John Lloyd, Welwyn: Institute of Health Promotion and Education, 2019.
17) Royal Society for the Prevention of Accidents. Safe and active at all ages: a national strategy to prevent serious accidental injuries in England. Birmingham: RoSPA, 2018.
18) Watson M C and Tilford S. Directors of public health are pivotal in tackling health inequalities. BMJ 2016;354:i5013.
19) Wanless D. Securing our future health: taking a long-term view. Final report. 2002.
20) Marmot M. Fair society, healthy lives: strategic review of health inequalities in England post-2010. 2010.
21) Watson M C and Lloyd J. Raiding the public health budget. Action is needed to tackle current public health threats BMJ 2014;348:g2721
22) BMA. Public health and healthcare delivery task and finish group: final report. Jan 2015. http://bit.ly/2cpiHIp
23) Watson M C and Lloyd J, 2016. Need for increased investment in public health BMJ 2016;352:i761.
24) BMA. Funding for ill-health prevention and public health in the UK. May 2017. http://bit.ly/2quLN3K
25) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
Competing interests: No competing interests