We take a cold, hard look at the reality of a system that prioritises reactive over preventative healthcare.
In a primary care setting, the effects of a system failing to prioritise public health is extremely salient. There's rampant over-demand for services from a population with ever more complex health needs. This issue runs parallel with a high-stress workplace that has led to extraordinarily high vacancy rates.
If you work in primary care, there's no doubt that you or someone on your team has been asked by your local Public Health England (PHE) department to improve the delivery and uptake public health programs. However, few link the challenges they face in their everyday life with a problem like low uptake of public health programs. But, it'll come as no surprise that there's a good reason for public health professionals to keep on badgering you.
A system that delivers effective public health programs would have large economic, fiscal, and health benefits for patients and primary care organisations.
In this article we will look at the consequences of failing public health programs: for the individual, the population, and for primary care organisations. We'll also dive into England's cardiovascular screening program (the NHS Health Check) to show you the gain in health benefits if it achieved the targeted rate of uptake.
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Primary care professionals will be the first to tell you that their daily work life is stressful. Mind released research that showed 90% of primary care workers find their work-life stressful (compared to 56% of the wider UK public, n=1,000). 43% had resigned or considered resigning, and 21% say it has led them to develop a mental health problem.
Dr Simon Braybrook, a GP based in Cardiff who has experienced mental health problems and workplace stress, said: “Stress and mental illness is becoming rife amongst primary care workers and we urgently need to talk more about how we can best look after ourselves and each other. It’s so important because that’s the only way that we are going to do the best for our patients. We can’t give out something that we haven’t got there to start with. I am a better person and doctor through having experienced mental illness and, although I would not wish it on anyone, I think facing and overcoming our mental health problems working in health care will benefit ourselves, our colleagues and our patients.”
We see clear evidence for this when we look at the NHS vacancy rate, which in 2018 stood at 8.5% (that’s around 100,000 vacancies for NHS healthcare professionals).
The stressful work life of primary care professionals is symptomatic of ineffective public health. The NHS is failing to provide appropriate support for staff. As patient demands increase and more staff leave the NHS in search of a less stressful career, the problem only worsens for the staff who remain who now have longer and more intense working hours. As the largest employer in England (1m staff), there is a real opportunity being missed to improve population health by providing health support to NHS professionals.
Indeed, the NHS Five Year Forward View identified staff well-being as a critical area of improvement. Still, much more must be done to ensure that NHS professionals are free of diabetes, heart disease, and cancer risk factors as well as being less stressed.
The second part of the problem is that we are seeing a dramatic overdemand for services caused by population lifestyle factors like obesity. 64.3% of people in England are overweight or obese. Excess weight may increase the risk of health problems like type 2 diabetes, high blood pressure, heart disease, certain types of cancer, fatty liver disease, kidney disease, and pregnancy problems.
With such a large proportion of people at risk of a complex array of health issues, no wonder NHS services are under pressure from patients with increasingly long-term conditions and chronic diseases. People with long-term conditions account for about 50% of all GP appointments, so preventing the risk factors of these diseases would lead to a significant reduction in demand for primary care services.
Of course, obesity is just one of the many public health risk factors. Smoking is the number one cause of early disease and death in the UK. While rates of smoking are falling, there is still a significant number of people puffing away (six million adults, according to PHE). The result is 485,000 hospital admissions and £2.5bn of unnecessary costs a year to the NHS.
It’s sad to see, but we have (currently failing) public health programs in place that could provide quick win solutions to problems like these. Take the NHS Health Check program, for example, that we have written about numerous times in the past on this blog. The NHS Health Check is a preventative appointment that most GP practices offer free to adults in England aged 40 to 74. The check is designed to spot early signs of a stroke, kidney disease, heart disease, and type 2 diabetes so that we can reduce risk factors and prevent disease.
The program works well at combatting these risk factors. However, at the time of writing, national uptake by those eligible for an NHS Health Check is just 39.5%. That’s 35% lower than the desired target uptake rate. Considering that 100,000 people in the UK die every year from coronary heart disease alone, it is vital to improve NHS Health Checks uptake. Often the Health Check program is sidelined by primary care as the urgent day-to-day issues force the invitation process (named call and recall) aside.
The crowding out of call and recall is a natural consequence of its design (I won’t go into because Appt’s founder recently wrote a lengthy article on why patient recall is failing to achieve high uptake.) But, the consequence of not screening at-risk patients for heart disease is that in 10 years there will be more patients who’s risk factors have turn into disease, adding further pressure to services.
The consequence of not screening at-risk patients for heart disease is that in 10 years there will be more patients who’s risk factors have turn into disease, adding further pressure to services.
The natural conclusion here is that poor public health is adding to overdemand which is adding to the stressful NHS work-life environment. We need to collectively focus on boosting uptake of programs like the NHS Health Check if we are to improve the life of primary care professionals.
Overdemand for services as a result of poor public health has dire consequences for the individual patient, too.
Patients often struggle to get the appointment they want from busy GP surgeries. And for many, reduced access to the health care they want means not getting the care they need. According to the GP Survey 2019, 29% of patients who wanted an appointment but didn't receive one that suited them, went on to not see or speak to anyone.
We can remedy reduced access for those who have unavoidable healthcare needs by improving access to appointments that prevent ill-health in the first place. We are building one method of achieving this, but there are many more options.
It's staggering that 84% of deaths in the UK were from a cause considered preventable (ONS, 2017). It's also staggering that people spend around 20% of their life in poor health. For patients then, the burden of poor public health services is not just a lack of access to care for unavoidable illnesses. The reality is a shorter life, more of which is spent in ill-health.
At Appt Health, we are always asking ourselves why patients don't attend appointments that are proven to extend and better their lives. We've found that it so often comes down to access: access to knowledge, time, headspace, transport, flexibility, motivation, and so on.
The problem with barriers to access is that people are not receiving care and education in a timely fashion. The population is now living with more complex illnesses for longer. We now predict that by 2036 the proportion of over-65s with four or more disease will double, and a third of those will have a mental health problem. What a terrifying prospect for an already overburdened healthcare system.
We need to get public health access right because so much of this is preventable. More than 50% is linked to behavioural and social factors that we can change before they turn into diseases that need treatment. A 50% reduction is certainly worth investing in taking down as many barriers to access as possible, as soon as possible.
These worrying statistics, all symptomatic of failing public health programs, are not distributed equally.
Excess weight is 11 percentage points higher in the most deprived areas of England than the least. (Source: prevention is better than a cure). Furthermore, a boy born today in the most deprived area of England can expect to live about 19 fewer years in good health and die nine years earlier than a boy born into the least deprived area.
Rampant health inequalities like this mean that any improvements to public health we make must consciously not improve the health of just the wealthy parts of the population. Michael Marmot suggests universal proportionalism as a route to delinking health and income, something that we fully support at Appt.
Our removal of barriers to access, therefore, must start with the biggest obstacles for those at a disadvantage. By disproportionately focusing resources on those who are worse off, we can make a larger total gain to the health of the population.
Symptoms of failing public health care at an individual level, of course, collected together create an incredible impact at a national level.
More people becoming ill unnecessarily and earlier on in their lives has high fiscal costs. Treatment and care for people with long-term (mostly preventable) conditions take up around £7 in every £10 of total health and social care expenditure.
This means that 40% of the NHS financial burden may be completely avoidable. Yet only 4-5% of the UK health budget is spent on prevention. At a time when the NHS is struggling with its budget, spending more money on developing efficacious public health programs is an opportunity to reduce expenditure overall.
Obesity-related conditions alone are estimated to cost the NHS around £6 billion a year, and £27 billion in total costs to broader society. PHE, Health matters: obesity and the food environment, 2017.
And, the truth is prevention like the existing screening programs are good value for money. The incremental cost per QALY gained for women screening for cervical cancer is approximately £726 of one additional QALY is £18,000-£40,000, it is evidentially worth it.
The numbers for all primary care-led screening programs are similar. They quite clearly demonstrate the cost-effectiveness of public health care - £726 for something worth up to £40,000!
The economic effect of avoidable ill-health permeates beyond the health budget through to productivity. Working aged people in ill-health currently cost the UK economy £100 billion a year due to a reduction in productivity and completely missed days of work (2. DWP and DHSC, Work, health and disability green paper: data pack, 2017.)
Think about the number of people who take sick days at your workplace. A 2019 UK government study found that 12.8m work days were lost due to work-related stress, depression, or anxiety.
Taking preventative measure around mental health at work would mean a more productive (and happy) workforce.
Failures of public health are illustrated well at a national level by looking at the opportunity cost of failing to meet screening program targets.
The NHS Health Check has an uptake rate of 39.5%, which is roughly 6,186,988 people receiving a health check over five years.
These are the benefits according to this evaluation of the NHS Health Check program:
The early detection and ability to treat discovered disease is a powerful way to prevent further ill-health. The potential public health gains from an increase from 39.5% to 75% (the desired uptake of NHS Health Checks) are as followed:
The evidence speaks for itself here. There is a large health opportunity left on the table at a population level on just one screening program.
A BJGB study delved into the literature to understand why patients don't attend the NHS Health Check program. The significant themes centred around awareness, education, misinformation, and practical barriers.
It's easy to generate awareness by increasing the marketing budget of screening programs. In this Health Expectations study, just 70% of people were aware of the NHS Health Check program before being invited. A reason that often surfaces is that patients 'don't want to bother their GP if they are asymptomatic'—an addressable misunderstanding of the value of public health.
It's also easy to remove some of the barriers patients face when booking public health appointments. More patients than with any other method book an appointment using our two-way SMS booking service. We offer patients three available appointment slots at their local GP practice (via SMS) and allow them to simply choose a suitable appointment time by replying to the text message.
The simple combination of effortless booking, flexible appointment choice, and opportunity to learn more about the appointment (by clicking a link in the SMS) means patients book appointments in high numbers. And there are a number of other simple methods to increase uptake of programs like the NHS Health Check. We just need to spread the word.
Many challenges we face are symptoms of a broader problem: failing public health. Failing public health contributes to stressful and overworked primary care organisations, and a population with increasingly complex healthcare needs. For the individual, there is a missed opportunity for a longer and healthier life, and that affects people disproportionately based on their income – a link that should never exist. And finally, at a national level, failing public health exacerbates economic and fiscal crises and statistically leaves lives on the table.
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