I’ll briefly repeat my 6 point (bullet) plan for the NHS to preface my focus for today’s section on 4. Preventative treatment.
- Education – underpinned by philosophy
- Screening – underpinned by data
- Testing – from birth to death
- Preventative treatment – promotion of healthy life styles
- Research –on preventative medical conditions
- Evaluation – led by self-scrutiny
4. Preventative treatment – promotion of healthy life styles
We are now moving into the phase of considering solutions to the problems posed by the current inadequately designed NHS system. I want to explore some of these solutions in some detail whilst eliciting a longer list that I and you together are able to compile for further consideration.
Did you know that between 1 and 10% of the population may not have the father they think they do? This includes many whose mother is aware of the facts but also some who are equally in the dark! How do we know this? Well, in the heat of the scare of the threat of Acquired Immunodeficiency Syndrome (AIDS) quite a few facts that probably shouldn’t did emerge, including some blood grouping data (legitimately undertaken for obvious reasons) but which revealed that some haemophiliacs and other ‘high risk’ groups tested for Human Immunodeficiency Virus (HIV) and AIDS had ‘impossible blood group types’, based upon parental blood group matching. I will not insult you by explaining why this is possible, but look to nature’s driving forces for a clue!
So what, you say? I say this is a big deal. Without accurate genetic data on individuals it is very easy to make errors of judgement when making decisions about treatments of people with illnesses. I think this strengthens my case for global genetic typing of individuals at birth and providing this information as accessibly as possible (to relevant parties (eg Medical professionals) but keeping it well away from others (eg Health and actuarial insurance companies).
I say these things because I believe we need desperately to move to a system of preventative medicine coupled to promotion of healthy life styles, and mass screening, where relevant. Let’s look at a couple of examples but before we do it’s time for a tune!
I have noticed I have been very amiss in representing the female side of even my own record collection so I’d like to put the record (pardon the pun!) straight by sharing my enthusiasm for three female artists from the last six decades of rock and popular music. First, Joni Mitchell. I particularly like her Jazz era but I’ll start instead with one of her 60s hits (“Chelsea Morning”, Track 2, Side one from the album, “Clouds”, 1969). Marvellous song and brings to mind a trip to London only a year later I took to protest about cuts in government spending on higher education. Whatever happened to politicised students and student unions that did things?
My second choice is Joan Armatrading from the 80s onwards who inspired a generation including Tracy Chapman (sadly not one of my three) – but is one of three black women who I admire greatly. The third is Ruthie Foster whom most of you will not know but has become my favourite female artist of all time (not an easy decision) for her range of eclectic music tastes, her vocal range and the range of her resilience to be almost unknown in her country (USA) and yet admired by a select bunch of us, who think she should be better recognised. I have seen her play live in Melbourne and in Glasgow – brilliant.
Returning to Joan Armatrading, what track would you choose – again not easy? I am going for “Me, Myself, I”, from her eponymous LP of 1980. This song has particular poignancy right now, as whilst I am totally committed to team work, there comes a point, like now for me and this damned cancer, where all you have to rely on is yourself. I think the triple assertion of the title of Joan Armatrading’s song underpins my current views precisely. So, despite all the wonderful assistance and well wishes from all of you I am, unfortunately, going to have to rely on me, myself and I to get over the final hurdle.
And so, to Ruthie Foster – only one track represents the lot – blues, jazz rock, guitar solos, pathos and her own song writing: “Lost In the City”, from her compilation CD, “Stages”, 2004). And if her range isn’t wide enough take a listen to her definitive (in my opinion) Reggae track (“Real Love”) and an amazingly insightful gospel song, “Church” (both on the same album, “Stages”).
And so, back to Section 4.
Preventative treatment and promotion of healthy life styles.
As you will note, although I have divided this plan into six sections they are all intimately linked and the integrated plan should be read as a whole. I’ll provide a summary (with diagram) at the end. Hence, this section should be read very closely together with sections 2, 3 and 6 as screening and a more open, personal approach to evaluation will provide underpinnings to the basis for adopting a preventative treatment programme.
Early diagnosis for a healthy population – the key.
Let us take one of my own examples (I have or have had plenty to chose from!) to commence. During the course of my stomach illness prior to being diagnosed with stomach cancer I was variously treated for over-acid production and gastric reflux into my oesophagus, gastric ulcer or suspected ulcers, and helicobacter pylori. In the early part of this phase of what now turns out to be gastric cancer, I was never once given a physical examination involving palpation or feeling for lumps. Even if present, they may have been too small to detect and my treatment would have proceeded the same way. However, this simple procedure would have detected much larger lumps and I could have been on my way to an early diagnosis – something the government and NHS say they want to happen – for patient health and to make financial savings.
I was given Omeprazole, a Proton Pump Inhibitor (PPI), but not the one that scares banks (Payment Protection Insurance). This seemed to work (for a short time) and I was quickly taken off it. However, the pain recurred some few weeks later and I was put back on it. At the time I was told that I might have helicobacter pylori and a schedule of treatment would be designed so that this could also be screened for. I was also told that I could also have endoscopy which would be confirmatory. Now, as I have said before I am not saying that mistakes were made, so that is not my point here, but in the end I had to have an endoscopy as well as a CT scan, no doubt at some cost, and this was already in addition to the cost of drugs as well as GP time (three visits) to my surgery. This, in my view, is a classic case where an apparently expensive investment up front (gastroscopy in this case) might have not only been a better medical decision (for me) but also a cheaper one if it had detected my cancer or early lesions in a timely manner – in other words, early detection of disease. This is the key.
Early detection is good for all concerned – most importantly the patient, but secondly doctors and GPs (their success rates are better), the NHS (it is cheaper in the long term) and governments – it saves money and the service is both more effective and efficient (normally nearly impossible to achieve) in the long run. As little as a month later I visited the surgery again (my own actual GP this time) overwhelmed with pain. Dr M reviewed my case and treatment and then gave me a physical examination and immediately detected a large lump in my abdomen. He pointed for me to feel it (which I did) and he said that we have to consider this may be a tumour and ordered a CT scan and gastroscopy immediately. These took 2-3 weeks to be scheduled but at least I was now on my way – with the right diagnosis, but too late in my opinion, and after other costly treatments.
Please see Appendix I for supportive government information regarding proactive approaches to healthcare.
Education, education education
My second example focuses on education. I have already mentioned the many patients that accumulate in a very attractive outdoor garden at the main entrance to Ninewells hospital smoking in a very clearly demarcated area designated as ‘non-smoking’. These same people are often visited and supported by friends and relatives that also smoke and who both with their loved-one or family member, the “patient”, may already be an amputee. Now, I have not checked and there may be other reasons for the amputation but it is common that smoking is associated with heart and circulatory disease which my lead to blood clotting, particularly in the leg veins, and even result in amputation if the leg cannot recover from treatment with clot-busting drugs.
Is this not a case for more education for family members as well as patients to warn of the dangers of continuing with bad or even life-threatening behaviours and habits particularly when good options for reducing the offending behaviour are available (eg reducing smoke/nicoteen dependence through patches or nicorette gum; using e-cigarettes; stop being a poor role model for family members, especially young impressionable minds of off-spring). None of this is easy and maybe other measures are required such as a ‘one-off warnings’ that continued bad habits might (would definitely?) limit further treatment and access to both GP and hospital medical services, and social services. This may sound drastic or draconian but what else will our increasingly ‘pushed’ NHS do anyway?
As demand not only rises but places unfair decisions at the door of overworked medical, nursing and other carer staff then not all demands will be met, not only short term but also long term. Prioritisation and limiting access to ‘deserving’ patients may become the norm. Making decisions about such cases will increase tensions on medical services, particulaly consultants, who will have to deal with an increasing ethical workload as well as a medical one. This has implications for the medical curriculum as all doctors, including established GPs and hospital staff as well as those in training (students, house officers, senior house officers, registrars, senior registrars) will need to be better equipped to be able to take decisions that save lives and others that may cost them.
My third example draws on the link of this programme with the sixth step:
“Evaluation – led by self scrutiny”.
In higher education we have been wrestling with learning and teaching evaluation for more than two decades – at institutional level with Enhancement-Led Institutional Review (ELIR) and more locally at Departmental review and course and module reviews. The most difficult topic remains at a personal level through teaching reviews. These might include 360 degree appraisal, peer review of teaching, self review of teaching and even the preparation of teaching profiles and portfolios for ‘probation’, ‘continuation’ and ‘promotion’ and even accreditation (eg the Higher Education Academy HEA membership and fellowship schemes). There is still no requirement for a teacher in higher education (HE) to have a teaching qualification (or experience) before taking their first class!
I believe the sequence described lies at the heart of the difficulty in getting all evaluation right. Perhaps if we focused more on self-evaluation with a strong emphasis on openness, honesty and critical friends to corroborate or verify (or deny) these self diagnoses then the flow back up the sequence to ELIR or institutional level review would be much easier and testable. I think the latter is still true in Medicine although the concept of the reflective practitioner and critical friends whether pairs (eg Mentors and line managers) or groups (eg Multi-disciplinary Teams, MDTs) is much more established. Perhaps it still isn’t working as well as it should.
There is a lot of past as well as current evidence that this is the case. The example of Harold Shipman springs to mind. Also, there is the disturbing fictional series, “Bodies”, featuring a Consultant surgeon and a keen, honest junior doctor working alongside him. His attempts to whistle-blow on his superior, the surgeon, were thwarted by the power differential of the boss-report relationship and by the fear of other staff, well aware of the situation, to do anything about the errant consultant or even support their junior colleague. The abuse from above by the consultant was astonishing. Surely, it can’t be like this in real life, can it?
The culture must change. Honest, blunt communication sometimes is what is needed. This must be a responsibility of patients and medical and social care staff alike if the system is to work. Hierarchies are inherently non-permissive for such exchanges but this must be tackled and changed in the New NHS. Staff need to be able to self-diagnose their own mistakes, listen to feedback from others (patients as well as colleagues) and then act upon it. Rewards for staff for their openness and honesty need to be geared towards this approach rather than only rewarding good work or excellence. The latter must still happen but it needs re-balancing. My own consultant, thus far, has demonstrated these qualities aplenty, though I do hope still to persuade him that I should be considered to be a “curative care” rather than a “palliative care” patient. Also, I do wonder what discussions, if any, have taken place at my own GP surgery amongst all the doctors who dealt with my case.
In the last three days I have just become aware of the government’s own review of the NHS and its intention to provide a more proactive, health and well-being oriented service. These are the key issues and the date and agenda for the first conference arising from the review.
[NHS Five Year Plan: Responding to the Prevention Challenge -22nd March 2016, Royal National Hotel London
One year on since the NHS Five Year Forward View was published, the roadmap for change is taking traction with new initiatives and projects helping to secure the future of the nation’s healthcare system. The NHS Five Year Plan: Responding to the Prevention Challenge conference will explore how to make the NHS sustainable by incentivising and supporting healthier lifestyles. A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. Our agenda aims to support the NHS and wider health economy, at a local and national level, to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
The future of the NHS, improving the quality and access to health services and supporting a healthier population all depend on a radical upgrade in prevention and public health strategies. NHS England recognises that more needs to be done to respond to the prevention challenge. The NHS Prevention Programme Board, which was established in January 2015, has made a strong start in getting serious about prevention. Evidence shows that by investing in early interventions greater costs can be reduced further down the care pathway, however, this approach requires joined-up care and treatment, often across a range of service providers, that is centred around a patient’s needs. Following the Five Year Forward View how will new models of care drive better outcomes for patients and for the health system?
Join us for the opportunity to learn about the key activities and priorities for responding to the prevention and public health agenda, providing strategic direction and oversight to stimulate national action on the wider determinants of health. The NHS Five Year Plan: Responding to the Prevention Challenge will give you the opportunity to build contacts and benefit from knowledge sharing and networking to respond to the prevention challenge.]
09:30 Keynote Address
Simon Stevens, Chief Executive, NHS England (invited)
‘Getting Serious about Prevention’
NHS England recognises that more needs to be done to respond to the prevention challenge. The NHS Prevention Programme Board, which was established in January 2015, has made a strong start in getting serious about prevention. Evidence shows that by investing in early interventions greater costs can be reduced further down the care pathway, however, this approach requires joined-up care and treatment, often across a range of service providers, that is centred around a patient’s needs.
09:50 Professor Kate Ardern, Director of Public Health, Wigan Council (invited)
‘Prevention Policy in Practice’
A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. The key for stakeholders, at a local and national level, is to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
10:10 Sharing Best Practice
Dr Diane Reeves, Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group (CCG) (confirmed)
‘Diabetes, an Early Priority’
More people in Birmingham are set to avoid developing diabetes as a local clinical commissioning group has been chosen to pilot a national diabetes prevention scheme. The NHS Diabetes Prevention Programme was an early priority for the Prevention Board. Type 2 diabetes is one the biggest public health challenges of our time, costing the NHS £8.8bn a year. However, the World Health Organisation (WHO) estimates that 80% of Type 2 diabetes cases are preventable.
10:30 Main Sponsor
10:50 Question and Answer Session
11:00 Coffee in the Networking Area
11:45 Case Study
12:05 Dr Debbie Smith, Lecturer in Health Psychology, University of Manchester (confirmed)
‘Behaviour and Lifestyle Change’
This presentation will explore the benefits that a behavioural change could have in terms of improve outcomes and reduce costs in the short-medium term. Supporting healthier lifestyles could help to reduce risk factors through a focus on healthy eating, physical activity and positive mental health.
12:25 Sharing Best Practice
Phil Veasey, Public Health and Community Engagement Associate, C3 Collaborating for Health (confirmed)
‘The Realities and Practicalities in Exercise for Health’
A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. Our agenda aims to support the NHS and wider health economy, at a local and national level, to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
12:45 Case Study
13:05 Question and Answer Session
13:15 Lunch in the Networking Area
14:15 Chair’s Afternoon Address
14:20 Case Study
14:40 Pinki Sahota, Chair, Association for the Study of Obesity (invited)
‘Bringing Obesity Up the National Agenda’
Action on obesity can have short-term and well as long-term benefits, underlining the importance of bringing obesity up the national agenda. The NHS Prevention Board will continue to play an active role in the wider prevention debate, providing strategic direction and oversight to stimulate national action on obesity.
15:00 Danny Mortimer, Chief Executive of NHS Employers (invited)
‘NHS Workforce – Role Models for Healthy Lifestyles’
Improving the health of the workforce of the NHS is another key priority with NHS England pledging £5 million for a programme of work designed to develop and support new workplace incentives to promote employee health and to cut sickness-related absence. Prevention is cheaper than cure and supporting people to manage their own health and healthcare can both improve outcomes and reduce costs.
15:20 Question and Answer Session
15:30 Panel Discussion
‘Collaboration to Promote Healthier Communities’
The 5YFV argues that large scale system change can only be achieved in collaboration with other key players. Delivery of a successful prevention strategy will require concerted action from individuals, local government and other public, private and third sector bodies alongside the health service. How can such integrated working be achieved?
Michele Moran, Chief Executive, Manchester Mental Health Social Care Trust (invited)
Councillor Richard Leese, Leader Manchester City Council (invited)
Alistair Smyth, Head of Policy, National Housing Federation (confirmed)
Dr Diane Reeves, Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group (CCG) (confirmed)
Professor Kate Ardern,Director of Public Health, Wigan Council (invited)
16:30 Chair’s Closing Remarks and Event Close