“The NHS should pay more attention to prevention”
The first great wave of gains in public health arguably owed as much to plumbers as to any other profession. From the mid-19th century onwards, improvements in sanitation and access to clean water had a huge impact in reducing infectious diseases and improving both life expectancy and quality of life.
In the 20th century, a wide range of initiatives then contributed to improving health. The Center for Disease Control in the USA proposed the following as the ten most important public health achievements of the last century:
· Control of infectious diseases
· Declines in deaths from heart disease and stroke
· Healthier mothers and babies
· Fluoridation of drinking water to prevent dental caries
Translated to a UK context, we would note the involvement of the NHS in the majority of these, but as leading in fewer — with substantial roles for employers, industry, legal regulation, local authorities, and a wide range of lobby groups.
And much of this now looks like an historic agenda — not as battles which have been completely won, of course, but as ones where the gains of the next century are not likely to match those of the past. Managing climate change, reduction of use of the internal combustion engine, and sustainable energy could be the main public health challenges facing us over the next 100 years.
Alongside these big-picture environmental issues, there remains a big untackled agenda — sadly,still — the consequences of poverty and material inequality. The healthy life expectancy gap between the most and least deprived parts of the UK is 19 years,[1] with poverty lying at the root of both behaviours and life experiences. Secure, meaningful and adequately-paid work; access to healthy food; reasons to make personal investments in health; decent and affordable housing; access to green spaces — these and many other factors of a healthy lifestyle are constrained by poverty.
I recall hearing a psychiatrist once describing, with both sadness and anger, how he’s too often asked to assess and treat the “depression” of people living in precarious housing, with insufficient money to meet daily needs. “These aren’t patients, they’re just poor” — and what they need isn’t either medication or talking therapies, but help with the many practical problems of their lives.
So I’m not arguing that prevention of ill-health doesn’t matter, quite the reverse. But this isn’t an agenda on which the NHS should presume to be leading in coming years. The main responsibility lies elsewhere, and the NHS is not well-placed to act on most of it. The NHS will — sadly, still — be required to pick up the pieces of the consequences of environmental problems, of poverty and material inequality. But society as a whole — central and local government, employers, industry, voluntary organisation, and ultimately all of us — need to pay substantially more attention to addressing this century’s agenda, if this century’s next wave of major public health benefits are to be realised.
[1] https://www.health.org.uk/infographic/poverty-and-health
