WHAT DETERMINES HEALTH?
14. The Public Health Green Paper Reducing Health
Inequalities: An Action Report analysed the factors affecting
health, dividing these into five categories:
Fixed: Genes,
Sex, Ageing
Social and Economic: Poverty,
Employment, Social Exclusion
Environment: Air
Quality, Housing, Water Quality, Social Environment
Lifestyle: Diet,
Physical Activity, Smoking, Alcohol, Sexual Behaviour, Drugs
Access to Services: Education,
NHS, Social Services, Transport, Leisure
15. Any number of similar models can and have been
constructed and we received a great deal of evidence which pointed
to the fact that health was determined by a wide range of factors.[14]
16. What these analyses make clear - and this was
reinforced time and again in evidence to us - is that the health
of the population in the UK is not predominately determined by
curative services
within the NHS. The Chartered Institute of Environmental
Health affirmed that "mass vaccination programmes, the engineering
works of the mid 19th century and the creation of social and welfare
structures that addressed the needs of the poor" underlay
the greatest strides in public health in the modern era. Moving
away from a purely historical perspective, the Health Development
Agency suggested to us: "It has been estimated that over
70 per cent of what determines a people's health lies outside
the domain of health services and in their demographic, social,
economic and environmental conditions".[15]
With so many factors at play, and with so many different organizations
and individuals involved, it is not surprising that the RCN should
conclude: "it is important to recognize that in some senses,
public health is everybody's business".[16]
17. The Chartered Institute of Public Health suggested
that the model of public health within the NHS was not sustainable
since "action was starved of resources by the insatiable
'treat and cure' model of care within the UK".[17]
Dr Donnelly made explicit this gap in health service priorities
when he told us: "When you [the Director of Public Health]
go to the annual review you do not get beaten up because your
statistics on smoking and your statistics on the consumption of
food are bad; you get beaten up over waiting lists and issues
such as that."[18]
(We discuss this further at paragraph 204). But the Secretary
of State for Health dismissed suggestions that the NHS prioritised
treat and cure services over more general public health. He told
us that the ingrained culture of the NHS needed to change so that
people realized it was not merely a "service to treat sick
people". He felt that, as well as increasing the amount of
primary prevention by means of, for example, increasing the amount
of screening "for everything from chlamydia to colon/rectal
cancer" he also wanted to increase the amount of "secondary
prevention". Here he cited work which had impressed him in
Bradford, where a register had been constructed of those in the
Asian population deemed to be especially at risk of coronary heart
disease and diabetes, and in the Northumberland Health Action
Zone which was establishing a register of people who were vulnerable
to heart disease and tasking those in primary care to do "everything
they can to get cholesterol levels down".[19]
18. Whilst such initiatives seem to us commendable
we are still not convinced that the mind set of the NHS - let
alone the limitations on its capacity and resources - allow it
to get as far beyond the medical model as the Secretary of State
would seem to imply. Even when talking of the need to take public
health out of the ghetto, or in describing the benefits of secondary
prevention, he seemed always drawn to medical interventions, to
discussion of the provision of defibrillators or additional screening.
The RCN felt that the very culture of the NHS was not conducive
to it dealing effectively with public health. Its core business
was perceived both by those working within it and the public at
large to be "the care or cure of individuals who are ill".
They noted that Department of Health circulars prioritised issues
such as waiting lists (which has come to represent, quite mistakenly
in our view, the litmus test of an effective health service) but
failed to prioritise public health issues such as "the involvement
of local communities in health promotion".[20]
19. We believe far more impetus must be given to
public health policies in the UK. At present public health seems
to be largely locked into the medical community - the occupational
protectionists described by the Secretary of State. Yet ironically
public health medicine is seen as a marginal discipline within
that community. We witnessed a radically different model of health
care in Cuba. The Chartered Institute of Environmental Health
in their memorandum suggested "in Western civilisations,
economic success ... has enabled society to regard health as something
which deteriorates but which can be restored by medical intervention".
In Cuba, resources for health care are scant. So the expensive
"cure and mend" medical model cannot be sustained. Even
so, Cuba manages to achieve rates of mortality and morbidity which
are close to those of First World Countries spending vastly more
on health care. Life expectancy is currently 76 years at birth,
and we were frequently told that Cuba was "a Third World
Country whose inhabitants die from First World Diseases".
On our visit to Cuba we saw a number of different factors which
underlie the success of the Cuban health care system.
20. In Cuba, there is a strong emphasis on disease
prevention. Budgetary limitations and trade barriers make it difficult
for Cuba to import drugs. The health care professionals we spoke
to in Cuba observed no divide between proactive, disease prevention
policies and disease management. There is a commitment to the
practice of medicine in a community. Following alterations in
the medical curriculum in the 1980s the great majority of Cuban
medical graduates complete at least three years in General Practice,
and are encouraged to analyse social and psychological factors
in diagnosis, as well as physiological ones. Partly as a consequence
of scarce resources and the wide dispersal of the population,
primary and secondary care are much more closely integrated. Each
neighbourhood has a consultario (waiting room plus examination
room) staffed by a doctor and a nurse. Since the building is provided
by the Government and doubles as living quarters there is a great
incentive for the health care staff to remain in one site, in
the heart of their community and access to them is straightforward
21. Every patient is obliged to attend their consultario
at least twice a year. We were told that babies were examined
daily during the first six months of life. Extremely high levels
of immunisation were recorded. In the absence of expensive imported
pharmaceutical products, considerable emphasis is placed on herbal
and other alternative remedies. Every 10 to 15 family practices
are supported by a polyclinic staffed by specialists in areas
such as paediatrics, gynaecology and psychiatry. The presence
of the polyclinics limits the numbers of patients referred to
hospital and generally allows for treatment to take place close
to the patient's home. Patients are heavily involved in decision
making at every level. Cuban society also places great emphasis
on the role of exercise. The Cuban Health Ministry and Health
Committee are also responsible for sport (see below, paragraph
200).
22. There are clearly huge disparities between the
UK and Cuban social systems. The Cuban system has elements of
compulsion that would not be accepted in the UK. The prevalence
of Cuban doctors allows a doctor patient ratio of 1:175 (compared
with 1:600 in the UK). We believe that there are lessons to be
learned from the Cuban model for public health in the UK and we
note that the Department of Health has itself financed an ongoing
study of the Cuban healthcare system.[21]
The Cuban primary care system is extremely responsive to the needs
of its community; patients are far more directly involved in their
own health and well being; moreover prevention is prioritised
over cure.
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