Much of the political rhetoric surrounding the NHS reforms has centred on results. Regarding the NHS Outcomes Framework:
‘The framework sets direction of travel in the journey towards improving outcomes, and offers an opportunity for the NHS to begin to understand what an NHS focused on outcomes means for individuals, organisations and health economies.’1
Suggesting that doctors have the power to really influence outcomes on a population basis is however a sleight of hand; while we are distracted by the shiny coins given to GPs, we fail to see who is really holding the cards.
Even a novice student of medical sociology will be familiar with the graph showing mortality from tuberculosis in the UK. From the middle of the 19th century, deaths attributable to the disease went into a steady decline. By the time that the BCG vaccine was introduced in 1953 and antibiotics became available in the 1940s, death rates had already fallen to about one-sixth of those seen 80 years earlier. The vast majority of the improvement in outcomes was not related to medicine at all, but rather to better food, less overcrowding, and more sanitary living conditions.
As doctors we rather like the idea that we can make a significant contribution to our patient's health; that is after all why we went into this profession in the first place. The reality however is that the few minutes spent with a GP in the consulting room is not, on the whole, likely to equate to better health. The conceit that we are important to our patients feeds our professional vanity. Our patients live their lives outside of our consulting rooms
The main determinants of health are social, and doctors have only a modicum of influence over these. We can lobby politicians, we can talk to the media, but we cannot effect change. It is extremely difficult for doctors to have a direct impact on public health today and there are few modern equivalents to John Snow's removal of the pump handle from the choleric well in Broad Street.
Advancing public health depends much more on politicians than on doctors. It requires tenacity and courage from government. The public smoking ban is an example of what can be achieved; although some may say it did not go far enough, it is still to be applauded and will undeniably be an important milestone on the road to better health. Minimum pricing for alcohol may yet prove to be another.
There are some less triumphant stories to consider though. The ‘Barker hypothesis’ noted an increased susceptibility to chronic disease in later life as a consequence of an impaired and restricted intrauterine environment.2 There is a parallel to be drawn with childhood poverty and one can conceive of a socioeconomic form of the same theory; where health in later life is damaged by formative experiences which lead to restricted opportunities, blighted ambition and lifestyles which inexorably lead to morbidity and early death.
The gulf between the richest and poorest in society has not diminished over the last 30 years; this is a serious indictment of successive governments. The top 10% are 100 times wealthier than the bottom 10%.3
The number of children living in poverty has increased from 10% in 1979 to 30% today.4 Charging parents to use local authority play areas, as Wandsworth council plans to do,5 is unlikely to help matters.
Doctors can inform the debate, but despite our egos, we are only a very small part of it.
We can advise patients to stop smoking, drink less alcohol, and take more exercise. We can be encouraging, sympathetic, or even lean heavily on the relationship which the continuity of care (of which we are so enamoured) has allowed us to build in an effort to make a difference. But at some point our patients must leave our rarefied consulting rooms, adorned with colourful health promotion posters, promising salubrious immortality and step back into the real world. A real world with single parent families struggling to raise children on the minimum wage while holding down three jobs; where running shoes are supplanted by flat screen TVs; where it is cheaper to purchase appalling microwaveable cheeseburgers in supermarkets resembling ‘Village of the Damned’, than to buy fresh fruit and vegetables; where any thoughts of educational advancement are destroyed by the fear of incurring immense debts; a real world where mere survival trumps the priorities beloved of the middle classes.
It is obvious, therefore, where the real focus on improving health should be. It is not in our hospitals, it is not even in our GP surgeries. Rather it is with our politicians and our councillors, from the chambers of Westminster to the County Halls and local government offices across the land, where real accountability lies.
There are great challenges ahead, not helped by the perpetual political churning of the health service. Ars longa, ministerium brevis, to paraphrase. When mistakes are made and our patients' health suffers, it is we who are left to pick up the pieces and the politicians will be long forgotten.
We will advise and help where we can, but the tackling the health of the nation is a prodigious task. There is danger in overestimating what doctors can do, and forgetting that many of the problems to be tackled are outside the realm of the medical profession.
- © British Journal of General Practice 2012