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Protecting the National Health Service:
A Prescription for the Millennium?

As a nation, we are living longer but, paradoxically, levels of illness are increasing, leading to additional strain on an already hard-pressed health service. The cause of this apparent paradox is multifactorial: the present patterns of health care, clinical research and animal research, which place greater emphasis on drug treatment and drug development than on prevention of illness, are key factors.

Morbidity levels can be reduced, over time, by moving towards a prevention-based, health-promoting pattern of health care and research. A model is proposed which will facilitate such change, be readily integrated into management and planning of health care and research and which will inform decisions taken outside the NHS which affect the public health.

Introduction

The health of the nation is deteriorating. Annual attendances at hospital out-patient departments in England rose from 37.4 million in 1985 to 49.1 million in 1995-6. In the same period, hospital in-patient stays rose from 8.0 million to 11.2 million. The total number of prescription items dispensed in the community rose from 318.7 million in 1985 to 484.9 million in 1996, an increase of 52% (1). UK expenditure on health, adjusted to 1995 prices, rose from 126 billion in 1981 to £41 billion in 1995 (2). Demand on the NHS is becoming progressively more difficult to contain and the Government had to find additional emergency funds to help meet the workload last winter. Doctors, nurses and other health service staff are under continuing, growing pressure to meet the needs of patients against a background of rising demand and limited resources.

Paradoxically, the reason for the rising demand is that, we, as a nation, are living longer but less healthy lives. For example, fewer people die prematurely from heart attacks, but more people are suffering from angina. The cause of this apparent paradox is multifactorial: improved surgical techniques, diagnosis and treatment regimes; reduction in cigarette smoking, notably in men; healthier eating patterns and regular exercise, in a minority of people, are some of the positive factors. Drug treatment which is palliative rather than curative; pollution and microbial contamination of our food, air and water; the processing of excessive quantities of refined sugar, saturated fat and salt into foodstuffs; unhealthy eating patterns and lack of exercise in the majority of people, particularly Scots; the social divide; the stress of modern life; and alcohol and drug addiction are some of the negative factors.

Overall, the negative factors are more dominant. Our increased life expectancy has not brought "extra years of healthy life". (2)

The need for a change in approach to health care and research

While responsibility for many of the environmental, nutritional and social factors contributing to ill-health rests with the Government, with industry and with the individual person, the Health Service has a major part to play, both in the pattern of health care it provides and in the direction of medical research.

In the Fourth National Study of General Practice, which compared levels of ill-health in 1991-1992 with those in 1981-82, reference was made to the fact that for many conditions, including certain types of cancer, consultation rates had not fallen. The report stated:

"Perhaps we should be asking ourselves why, as advances in medical care, prevention and socio-economic conditions might be expected to reduce burdens of illness". (3)

The answer might be in the different levels of priority accorded to drug treatment and to prevention in health care and research. The magnitude of the increase in the number of prescriptions dispensed is indicative of the pre-eminence of drug treatment: by 1995, every person in the UK was receiving, on average, some ten prescriptions each year. Drug development also dominates clinical research. For example, in one of Scotland's most important centres of clinical research, more than half of the proposals submitted to the Research Ethics Committee in recent years have been drug related (4). (Table 1).

Table 1: Numbers of proposals submitted to Tayside Committee on Medical Research Ethics, by type of research, 1994 and 1995.

Of the 311 studies submitted in 1995, only 45 were concerned, directly or indirectly, with health promotion or prevention of disease.

In the other main field of medical research, namely animal research, applied studies in respect of human medicine and dentistry accounted for 1,012,193 of the 2,716,587 experiments carried out in 1996, with fundamental biological research and cancer research accounting for 884,841 and 257,841 respectively (5). The huge investment in animal research over many decades has not led to the hoped-for reductions in incidence or prevalence of major diseases such as cancer, cardiovascular disease, stroke, diabetes, asthma, depression and dementia.

In respect of animal tests for safety of drugs for human use, the incidence of suspected adverse drug reactions in human beings is an indicator of the reliability of such tests. In the year 1996-7, the total number of suspected adverse drug-reaction reports to the Committee on Safety of Medicines was 16,133, of which 51% were described as serious, with 2% leading to fatalities. (6) It is considered that these figures are underestimates: in 1988, Bateman and Chaplin stated:

"...it is estimated that even for serious and fatal adverse reactions only about 10% are reported to the Committee on Safety of Medicines." (7)

The morbidity and mortality arising from adverse drug reactions is a matter of public concern. Animal tests cannot be relied upon, and the question of whether or not we allow such testing to continue should be debated.

Present patterns of medical care, clinical research and animal-based research have unfortunately been associated with rising levels of ill health. It would be logical to move towards a more prevention-based, health-promoting model for health care and research.

Is change to a prevention-based model feasible?

Prevention can be subdivided into primary, secondary and tertiary categories.

Primary prevention is concerned both with active promotion of good health and with prevention of disease occurring in the first place. Examples include:

• Prevention of pollution and microbial contamination of water, food and air, so reducing the risk of food poisoning, asthma, bronchitis and transmission of diseases such as BSE.
• Promotion of vigorous good health and prevention of cancer, coronary heart disease, stroke, obesity and diabetes by avoiding cigarettes, taking regular exercise and eating a diet rich in fruit, vegetables and complex carbohydrates, low in animal fat and refined sugar and modest in salt content.
• Immunisation against infectious diseases.

Secondary prevention is concerned with detecting and treating disease before it causes significant damage to health. Examples include:

• Ante-natal screening for anaemia, high blood pressure and diabetes.
• The cervical smear test for detection of cancer of the cervix before it becomes invasive.
• Mammography for detection of breast cancer as early as possible.

Tertiary prevention is concerned with the prevention of deterioration and complications in people who have established disease. Examples include:

• Healthy eating patterns and weight control in people with diabetes, high blood pressure or arthritis.
• Regular exercise in people who have osteoporosis.
• Prophylactic use of antibiotics in people who have chronic bronchitis and emphysema.

The considerable reduction in incidence of lung cancer in men shows the beneficial effects of reduction in cigarette smoking. Reduction in lung cancer in women has been smaller and slower from 1992, reflecting the smaller reduction in cigarette smoking in women. The increases in cancer of the breast, colon and prostate point to our lack of knowledge of the causes and therefore of appropriate preventive measures. In respect of cancer of the stomach, Swerdlow and his colleagues, in their study of cancer in Scotland. stated:

"The decrease in stomach cancer is numerically the largest beneficial change in the adult mortality rate over the last 40 years, although it cannot be attributed either to deliberate preventive measures or to improvement in survival, which remains poor. The precise reasons for the decrease are unknown.

The importance of prevention and the need for greater investment in human-based epidemiological research are illustrated by consideration of the data on incidence of certain cancers (Table 2).

Table 2: Cancer Registrations by Selected Site of Cancer, Sex and Year of Diagnosis, Scotland 1985-1994. Rates per 100,000 of population.

Swerdlow highlighted the need for investigation of the causes of cancers and, "when causes are known, for preventive action". (9) Examples of human-based epidemiological research leading to prevention of disease include the work of Hill, Doll and Peto. (10;11) Their studies of the relationship of cigarette smoking to lung cancer, coronary heart disease and certain other diseases were the stimulus for the reduction in cigarette smoking, particularly in men, and the resulting fall in incidence and premature deaths from lung cancer. Such research demonstrates the feasibility and value of moving towards a prevention-based approach to health care and research.

A prevention-based model for management and planning of health care and medical research

The introduction of a prevention-based model into health-service planning is simple. In all reviews of existing services; forward-planning; problem solving, option appraisal and objective setting, the key question should be: "What are the implications for prevention of disease and promotion of good health?"

The establishment of primary prevention, including the promotion of good health, secondary and tertiary prevention of disease as the core criteria for all planning of health care and medical research. would have the following advantages:

• It is ethical.
• It is comprehensive, being relevant for all diseases and states of health.
• It is relevant to all stages of the planning process.
• It should promote purposeful management and reduce the need for entrepreneurial or crisis management.
• It is applicable at all levels of decision making in the NHS, from the consulting room to the Department of Health.
• It would provide a stable and fair base line for allocation of priority to different proposals for development or research and would encourage rigour in the preparation of such proposals.
• It is applicable to all clinical and epidemiological research.
• It would inform decisions on funding by the NHS, Government and charitable organisatons.

The use of the model can be extended beyond health-care provision and medical research. Decisions taken by the Government Departments concerned with transport, roads, food, agriculture, industry and the environment may have implications for public health. Where this is so, the implications of such decisions, positively or negatively, for the prevention of disease and promotion of health should be core considerations.

Caveat

Change to a prevention-based, health-promoting model will lead to reduced morbidity and improved health, but the change will be evolutionary over a period of some 5 to 10 years. During that time, demand on the NHS can be expected to rise further, before it falls. Additional funding for the service will therefore still be required over this period.

References

1. Health and Personal Social Services Statistics for England, 1997, Department of Health. Government Statistical Service. London, The Stationery Office.
2. Social Trends 27, Office for National Statistics, London. The Stationery Office, 1997.
3. Morbidity Statistics from General Practice. Fourth National Study, 1991-1992. OPCS, Series MB5, No.3. London, HMSO.
4. Tayside Committee on Medical Research Ethics, Annual Reports, 1994 and 1995. Tayside Health Board. Dundee.
5. Statistics of Scientific Procedures on Living Animals. Great Britain, 1996 (CM 3722). The Home Office.
6. Medicines Control Agency Annual Report and Accounts, 1996-7. London, The Stationery Office.
7. Bateman, D N and Chaplin. S. Adverse Reactions 1. B.M.J., 1988, 296: 761-764.
8. Scottish Health Statistics, 1996. Information and Services Division. NHS in Scotland, Edinburgh 1996.
9. Swerdlow A J et al. Trends in cancer incidence and mortality in Scotland: description and possible explanations. British Journal of Cancer, 1998, 77 (supplement 3): 1-16.
10. Doll, R and Hill, A B. British Medical Journal, 1956, 2:1071-1081.
11. Doll, R and Peto, R. British Medical Journal, 1976, 2:1525-1536.

Edward Moore OStJ, MB, ChB, MFHom, MFCM, DipSocMed; Specialist in Public Health. DLRM Newsletter No 3, Summer/Autumn 1998.