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.
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
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
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
"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: Numbers of proposals
submitted to Tayside Committee on Medical Research Ethics,
by type of research, 1994 and 1995.
|Type of research
|Clinical Trials and other Drug Research
|Basic Clinical Research
|Others (Surgical Procedures etc)
Of the 311 studies submitted in 1995, only 45 were concerned,
directly or indirectly, with health promotion or prevention
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
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
"...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
Is change to a prevention-based model feasible?
Prevention can be subdivided into primary, secondary and
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
- 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
- Ante-natal screening for anaemia, high blood pressure
- The cervical smear test for detection of cancer of the
cervix before it becomes invasive.
- Mammography for detection of breast cancer as early as
Tertiary prevention is concerned with the prevention of deterioration
and complications in people who have established disease.
- 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
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: Cancer Registrations
by Selected Site of Cancer, Sex and Year of Diagnosis, Scotland
1985-1994. Rates per 100,000 of population.
|Trachea, bronchus and lung
|Trachea, bronchus and lung
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.
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.
- Health and Personal Social Services Statistics for England,
1997, Department of Health. Government Statistical Service.
London, The Stationery Office.
- Social Trends 27, Office for National Statistics, London.
The Stationery Office, 1997.
- Morbidity Statistics from General Practice. Fourth National
Study, 1991-1992. OPCS, Series MB5, No.3. London, HMSO.
- Tayside Committee on Medical Research Ethics, Annual Reports,
1994 and 1995. Tayside Health Board. Dundee.
- Statistics of Scientific Procedures on Living Animals.
Great Britain, 1996 (CM 3722). The Home Office.
- Medicines Control Agency Annual Report and Accounts, 1996-7.
London, The Stationery Office.
- Bateman, D N and Chaplin. S. Adverse Reactions 1. B.M.J.,
1988, 296: 761-764.
- Scottish Health Statistics, 1996. Information and Services
Division. NHS in Scotland, Edinburgh 1996.
- 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.
- Doll, R and Hill, A B. British Medical Journal, 1956,
- 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.