Rights, responsibilities and rhetoric: health and politics
9 October 2016
The Conservative Party Conference last week came hot on the heels of the emergence of a new Prime Minister and government. Brexit dominated much of the discussions, with science and health taking a relative backseat, but some recurring themes pertaining to health were evident.
Making use of technology in public services
The scope for better, more efficient operation of public services enabled by new and emerging science and technology (including digital health) was widely discussed, with encouraging enthusiasm for embracing these opportunities for transformative change. An increasingly tech-savvy population was said to be not merely amenable to change but actively demanding more accessible and convenient information and services.
The imperative for the public sector to learn from commercial service providers on meeting customer needs and expectations was manifest, alongside the need to simultaneously maintain a high level of public trust. One event on ownership of patient data noted that the NHS actually has an excellent record of maintaining the privacy of confidential records, in sharp contrast to many major companies in recent years, and that provided this standard was maintained then current fears over inappropriate disclosure of patient records would hopefully prove groundless.
The problem of pockets
Siloes or 'pockets' were repeatedly referred to as a barrier to the implementation of innovations in the NHS, in two main areas. The first is a fundamental problem: siloed budgets. Cost is of course a primary consideration and financial data are essential for decision-makers (although they can be hard to calculate, especially where a new technology does not simply replace an existing one) including an estimated monetary value for expected improvements in patient experience and outcome. Unfortunately, if the expenditure to implement an innovation and the reduced costs expected from its use fall within different budgets, there may be no incentive for anyone to approve it, even if it is obviously cost-effective.
However, as there are different budgets and responsibility for specialised commissioning of genetics services and for provision of cardiovascular disease services, access to cascade screening in England remains patchy. This seems to be a common problem in the NHS
For example, the premature cardiovascular disease and death caused by familial hypercholesterolaemia (FH) can be prevented with prompt diagnosis and treatment with statins, an approach highlighted in NHS England's Personalised Medicine Strategy. The costs of 'cascade screening' (testing at-risk relatives of FH patients) was many years ago shown to be easily outweighed by the expected reduction in cost from premature heart attacks and related disease. However, as there are different budgets and responsibility for specialised commissioning of genetics services and for provision of cardiovascular disease services, access to cascade screening in England remains patchy. This seems to be a common problem in the NHS.
This also highlights the second problematic 'pocket' of clinical excellence. Piloting innovations to demonstrate clinical benefits and trial frontline health service implementation is of course an essential step along the road from ‘bench to bedside’. The problem is in moving from isolated pockets of good practice to national implementation and equitable patient access to the best clinical service.
Many at the conference looked to the long-anticipated Accelerated Access Review (AAR) for solutions; interim reports have suggested that the Academic Health Science Networks (AHSNs) should lead on national implementation, but this is unlikely to be enough. Whilst the AHSNs can hopefully help spread awareness of pockets of excellence in Academic Health Science Centres, they are not fundamentally suited to enabling comprehensive national uptake, nor is the current trend towards localism in health service commissioning and delivery helpful in this respect.
Taking personal responsibility for health
The third recurring health theme was the need for citizens to take personal responsibility for their health, with an active role in disease prevention. In health terms the economic incentives to shift the NHS and the general population increasingly from a model based essentially on treating disease to one of prevention were widely agreed on. Moreover, many proponents said (or implied) that those who fail to maintain their own health (by eschewing alcohol, tobacco and unhealthy foods, and by embracing health exercise, oral hygiene and other beneficial habits) could not expect to receive publicly funded health services for free.
This all sounds very logical, but unfortunately suggests an alarming disregard for evidence from both biological and behavioural science
This all sounds very logical, but unfortunately suggests an alarming disregard for evidence from both biological and behavioural science. In reality, health is not such a cut and dried issue. Certainly, obesity is associated with a starkly increased chance of developing a host of dangerous (and expensive) diseases; excessive smoking or drinking have a similar effect on lung and liver disease risks. But complex diseases are just that: complex. Causation is not a simple, linear progression; it is a process still poorly understood, but known to involve the interaction of multiple genetic, environmental and behavioural factors. For example, only this week new research has revealed genetic influences on high birthweight and on innate preferences for higher-fat diets, both factors associated with an increased risk of disease.
How reasonable is it, therefore, to compare the behaviour of two individuals without taking into account the many factors that may motivate that behaviour – whether internal (genetic, epigenetic, psychological) or external (life circumstances, wealth, education)? What about those who are born with disease and disability – should they be debarred from free health care, or merely held accountable for maximising their future health? And if we are all charged with this responsibility, who assesses whether or not we have achieved it, and on what criteria? To whom does responsibility for vulnerable people devolve?
The true health imperative
Preventing disease is indeed an agenda we should all embrace, both as individuals and to inform public policy, not only health but housing and education and transport and many more besides. However, the future of personalised healthcare should be focused on helping individuals, health professionals and policy-makers work together to predict, prevent and treat disease. Harnessing technology should help, but the whole endeavour must also be grounded in sound science and practical reality.