What can the NHS do?

Doctors know the health risks arising from obesity only too well. Their patients are increasingly exhibiting lifestyle related illness such as obesity and type 2 diabetes,

However, doctors are mainly trained to diagnose and treat illness, not prevent it. This process starts at medical school, where the curriculum is designed to achieve the outcomes in the GMC’s guidelines, Tomorrow’s Doctors. There is potential here under The doctor as a scholar and a scientist as this refers to ways of preventing common diseases, nutrition and psychology. What is needed is for these objectives to carry forward into The doctor as practitioner - instead of assuming that the doctor should simply wait until a patient presents with symptoms.

Responsibility for Public Health has been transferred to local authorities. However, the resources for Public Health were already limited and have been reduced further in recent years.

Lifestyle related illness is an increasing burden for the NHS. However the cuts in funding for Public Health and the limited progress on public health achieved through the Responsibility Deals with the food and drinks industries mean that the NHS’ role in prevention has become increasingly important. As the NHS Five Year Forward View recognises, ‘the NHS has a distinct role in secondary prevention. Proactive primary care is central to this.’

This is also recognised in the Five Year Forward View which identifies that the NHS needs to make different investment decisions - ‘for example, it makes little sense that the NHS is now spending more on bariatric surgery for obesity than on a national roll-out of intensive lifestyle intervention programmes that were first shown to cut obesity and prevent diabetes over a decade ago.’

The need is clear. However, how can we ensure doctors (and other health professionals) have the confidence and skills to address lifestyle issues effectively with their patients before they start to make them ill? The following questions may help here:

• Where and when can doctors most effectively intervene – ideally as early as possible in life?
• What training and support do they need to achieve this – ideally starting at medical school, plus continuing professional development (CPD) for existing doctors and other health professionals?
• How much are doctors taught about the importance of exercise and diet, both to prevent illness and to assist recovery? And do they act on this knowledge e.g. exercise on prescription?
• Where unhappiness is a possible cause of obesity, with people turning to ‘comfort food’ (or smoking or alcohol) to try to compensate, are GPs trained and do they have the time to help their patients address the issues here, as opposed to the traditional route of providing medication or referring to a specialist?   
• How can we ensure that the objectives in the GMC’s Tomorrow’s Doctors correlate with the needs of the NHS and in particular the identified need for, ‘a radical upgrade in prevention and public health’ as set out in the NHS Five Year Forward Plan?
• How can we ensure health professionals are effective role models? Overweight nurses, midwives and doctors are unlikely to have credibility when advising patients to lose weight. Should this perhaps (with support) become a Fitness to Practice issue?
• How can hospitals also lead by example, for instance through the quality of food they provide to patients, in canteens and in vending machines? This is a point Simon Stevens has recognised but progress here remains slow. We visited a number of London hospitals in summer 2015 and each still had vending machines selling primarily food high in sugar, salt, saturated fat and refined carbohydrate (S3RC).
• How active a role should Public Health England play? In previous generations the UK used hard hitting public health advertising to warn of the danger of AIDS and later of smoking. Is it time for similar action in relation to food that increases the risk of obesity, type 2 diabetes and cardiovascular disease?

This probably raises a more fundamental question about the role of doctors in the 21^st century:

Are doctors the last line of defence when public health measures have failed, waiting in their medical centres and hospitals for the casualties of life to make their way there for diagnosis and treatment?

Or do they have a more active role to play in helping maintain health by preventing illness – and so reducing the number of people who need treatment? If so is this likely to involve new ways of working, including outside their traditional medical environments?

Or would this require too great a change and provide too little job satisfaction?

If so, should we be looking to health trainers, midwives, community nurses and others (perhaps in the private and voluntary sectors) to lead on prevention rather than doctors – where appropriate redirecting resources and recruitment to support this vital preventative work?