Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Challenging the government’s new strategic framework for major conditions

BMJ 2023; 382 doi: (Published 20 September 2023) Cite this as: BMJ 2023;382:p2122
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on X/Twitter @scarlettmcnally

The Department of Health and Social Care’s new Major Conditions Strategy1 starts strongly, detailing how the nation’s health has deteriorated and the large volume of ill health looming. Unfortunately, it follows this with recommendations entirely focused on rearranging health services, not making society healthier.

The evidence base is stunning. The strategy includes over 230 references and footnotes cataloguing the long term impact of common conditions—especially multiple comorbidities—on patients, society, and the economy. Nearly half a million more people are economically inactive from long term sickness than before the pandemic.2 The strategy acknowledges that over 40% of the burden of ill health is attributable to identified risk factors: tobacco smoking, obesity and diet related factors, low physical activity, pollution, and alcohol.3 Health inequalities are detailed in the strategy, including a 19 year difference in years of good health between people in the most and least socially deprived areas of the UK.4

Unfortunately, the baton has been dropped between the case for change and the actions required to achieve it. The strategy declares that actions should be based on three underpinning “cross-cutting enablers”: innovation, research, and leadership. These concepts seem reasonable. But innovation should start with fixing our computer systems so that healthcare professionals can log in and navigate between systems more quickly; instant availability of relevant information for each patient; and technology to enable automatic self-populating of discharge summaries or communications between systems. In terms of research much has already been done, but not implemented, to show the benefits of preventive measures such as minimum unit pricing for alcohol5 or 150 minutes’ exercise a week.

Leadership is something we already have in the NHS. We should support and develop clinical leaders who can balance general care pathways with personalised patient care. There’s an effective collaborative style that comes with more diverse clinical leaders, such as women doctors6 and those from non-traditional backgrounds.

Beware of “personalised” prevention

The strategy’s five priority areas are “personalised” prevention, early diagnosis, managing multiple conditions, connection of physical and mental health services, and giving people choice. Each of these areas is contentious. We need general prevention interventions involving public sector workers, communities, and community groups, without requiring healthcare to take a gatekeeping and coaching role as implied by the “personalised” approach. This includes supporting general exercise, nutrition, and environmental factors for people with medical conditions. “Early diagnosis” may be good for cancer—but it’s far less useful for musculoskeletal conditions, so why does the strategy recommend this? Charities such as Versus Arthritis provide generalised advice about keeping moving, which can be more useful to people with musculoskeletal conditions than me as an orthopaedic surgeon.

The chapter on “Managing multiple conditions” thankfully recommends shared decision making, which means balancing the benefits, risks, alternatives, and non-treatment options with patient input. Rather than pitting generalists against specialists, we should make use of all doctors’ medical education and experience in dealing with complexity and use the specialists to help understand the options. “Integrating physical and mental health” should be about not just services but also the physical and social environments that allow people to flourish.

The department’s commitment to “giving people the choice of five providers” is a shocking own goal. The illusion of choice can encourage people to demand more options from healthcare services while simultaneously remaining passive by not realising what they can do without permission. Excess choice is the opposite of patient empowerment. Instead, people should be given real control over what maintains and improves health: food, exercise, spaces, reduced stress, community connection, and the knowledge to seek help for particular issues.

Let’s be radical in our approach. We need health at the heart of all policies—transport, planning, food regulations, pollution, and education, with funding and prioritisation. Health is about more than healthcare.


  • Competing interests: Scarlett McNally is a consultant orthopaedic surgeon, president of the Medical Women’s Federation, and deputy director at the Centre for Perioperative Care.

  • Provenance and peer review: Commissioned, not externally peer reviewed.