Tough on disease, tougher on the causes of disease

It was more of a pep-talk than a policy statement. More about dressing the stall than shifting the tectonics. More for the media than the health community. But to me as a public health person, the Prime Minister’s New Year speech on the next big leap for the NHS came across as an event of some significance, says Dr Alan Maryon-Davis

Why? Because it was so clearly pushing the prevention agenda – at least in terms of the rhetoric. The PM really did seem to have fully taken on board the resounding message from Wanless that, if we’re ever going to succeed in tackling the rising tide of long-term illness with its huge burden on health and social care services, we have to shift more of our efforts and resources upstream. Of course we must continue to be tough on disease – but also much tougher on the causes of disease.

So we were hearing Gordon Brown talking about people taking responsibility for their own and their family’s health, about empowering the disadvantaged to adopt healthier lifestyles, about using social marketing techniques to target particular groups with particular needs, about gearing up primary care to identify and manage people with risk factors, and in particular about an extension of the current regime of screening and check-ups.

On the screening front, the PM mentioned moves to extend the current breast and bowel cancer screening programmes – although he gave no details of either. The NHS Breast Screening Programme has been developed over a period of 20 years and has only quite recently had further changes made to its protocol. It will be interesting to see what ‘extension’ is being planned.

As for bowel cancer screening, the pilot phase finished about a year ago and the ‘extension’ is already well underway, with the programme being rolled out across the country. Indeed, it should be fully nationwide by 2009 – so no real news there then.

Mr Brown’s main set-piece announcements on prevention were in the cardiovascular field. First, he trailed a new targeted screening programme to detect abdominal aortic aneurysm (Triple ‘A’) – a weakening of the main artery to the abdomen – which can all too easily burst and cause a massive internal haemorrhage. The disorder kills over 3,000 men a year in the UK – and the Triple ‘A’ screening programme, aimed at men aged 65 and over, could eventually save more than 1,600 lives each year. This firm commitment went down well with most observers and nearly all the subsequent comment has been positive – the main concern being the urgent need to build enough surgical capacity to deal with all the new cases that would be picked up.

But perhaps the most controversial of the PM’s preventive proposals was in the area of vascular ‘check-ups’. Sometime soon we can expect Alan Johnson to lay out plans for a national vascular risk management programme offering regular check-ups to monitor risk factors for heart disease, stroke, diabetes and chronic kidney disease – conditions which affect the lives of 6.2 million people, cause 200,000 deaths each year and account for a fifth of all hospital admissions.

However, quite what form this programme will take is not yet clear. Will it, for instance, simply be an extension of the current opportunistic check-ups undertaken in general practice as part of QOF-funded cardiovascular risk assessments? Blood pressure, cholesterol, BMI, and blood glucose are all part of current protocols. The PM has talked of adding ECGs and “in some cases ultrasounds” to the mix – but no details have been given.

Or might the vascular programme be much more than merely opportunistic check-ups on patients who happen to come by for a flu-jab or sicknote? Might it, as most commentators have assumed, be a full blown systematic call-recall screening programme along the lines of the current national cancer screening programmes? This would be a different ball game altogether – a suite of community-based tests offered proactively by a variety of providers to a defined segment of the adult population-perhaps all people aged 45 or over- to detect those at higher vascular risk.

It was this latter prospect that stirred up most reaction to the PM’s speech. The BMA immediately countered that they couldn’t support the proposals because the practical implications hadn’t been thought through – particularly the impact on already overstretched resources in primary care. Perhaps there was also an unspoken concern that much of the funding would be diverted to the private sector.

Certainly, a comprehensive national vascular screening programme would require an enormous injection of recurrent cash, not just into primary care itself, but also into a range of community-based healthy lifestyle services to support the work in primary care. As recent NICE guidance on obesity has shown, what works best is personally tailored behaviour change counselling from a specially trained professional, together with ongoing phone follow-up and support to help patients maintain the changes. So, as well as thousands of extra practice nurses, we’ll need shed loads of community dietitians, exercise facilitators and health trainers – not to mention behavioural psychologists and health promotion specialists. And all this will need to be built into our much-vaunted local area agreements and ‘world class commissioning’.

I very much welcome Gordon Brown’s strong commitment to prevention, and look forward to Alan Johnson’s more detailed announcement about vascular screening. But when the time comes to roll out this programme, it is absolutely vital that we have, ready and available, a well-trained, fully geared-up, fit-for-purpose, healthy lifestyle army.

Anything less would, in my opinion, be bordering on the unethical.

Dr Alan Maryon-Davis is president of the UK Faculty of Public Health