The last couple of months have been a whirlwind of milestone family birthdays for me.
Both of my sons are August born and the younger one has just turned thirteen to a fanfare of slamming doors. I have a niece and a nephew who have recently celebrated their first birthdays; there has been a big 40 in the family (no names!) and of course, the NHS has celebrated its 70th. Having been a doctor for 20 years, I do feel like part of the NHS family.
I’m enormously proud of our NHS – firstly because it’s an ideal of mine that everyone should have access to health care that’s free at the point of delivery. Secondly, there have been some tangible improvements in public health in the last 70 years:
• People live on average 13 years longer;
• Infant mortality has fallen from 39/1000 births to just 3.9 / thousand live births;
• Far fewer people die from infectious diseases thanks to a comprehensive vaccination programme; and
• Fewer people die of heart attacks and strokes.
Compared with 70 years ago – after allowing for inflation – we spend 12 times more on health care, and the NHS employs over three times as many nurses and ten times as many doctors.
So you’d think we should all be much healthier. But actually although people are living longer we are seeing an increase in the numbers of people living with long term health problems such as diabetes, obesity, depression and dementia.
Proportionately more people die of cancer and Cancer Research UK estimates that 38% of cancers are preventable.
And we certainly haven’t curbed the demand for healthcare. On average the NHS treats a million patients every 24 hours and A&E attendances have risen by a third in the last 12 years. The mean number of GP consultations per person per year increases annually with a paper published in the lancet in 2014 having shown an increase of 16% over the previous 7 years. With the aging population this is only set to rise further.
Morale amongst NHS workers is low. Over the last three years 10 % of nurses have left the NHS annually with workload issues being the most commonly cited reason for leaving. A study of 2,000 doctors revealed that 82% of doctors in England had experienced a mental health problem.
The WHO definition of health is a “State of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”
I believe that with the resource pressures of the NHS we have become rather too disease focused and I would love to see a shift back towards promoting health – in its most holistic sense.
There are already plenty of examples of public health campaigns educating people about; the evils of smoking, sugar and alcohol and the perils of spending too long on the sofa.
However, knowledge alone often doesn’t result in behaviour change. Legislation can help, as we have seen with the results of making seatbelts mandatory and banning smoking in public places – however I believe that it’s less autocratic and ultimately more effective to empower people to make changes of their own volition.
I remember clearly my first day as a GP registrar. I’d landed a training post in my dream practice. I’d always wanted to be a GP and after 5 years at medical school and a further four years’ training in hospital posts, I felt quietly confident that I’d be able to handle whatever the day threw at me.
I walked into my consultation room, feeling a mixture of nerves and excitement, hung up my tweed jacket, donned the obligatory stethoscope around my neck and called my first patient.
Keen to make a good first impression, I gave said patient a big, encouraging smile, greeted him warmly and invited him to take a seat – whereupon he promptly burst into tears. Great – less than five minutes into my chosen career and I’d already made someone cry! I listened and made supportive noises as he poured out his woes about problems at work, financial pressures, his unhappy marriage and the fact he was drinking too much.
My little bubble of confidence went ‘pop’ – we hadn’t really covered this sort of thing at medical school. Sure we’d covered depression. But this man didn’t have depression per se. Sure we’d covered alcohol issues – I could have told him that he was drinking too much and given him a long list of potential detrimental effects on his health – but he already knew that.
I could have prescribed him Antabuse – a medication that wold have made him feel ill if he drank alcohol (there weren’t many other medication options in those days) – but that wasn’t really what he was after and he certainly didn’t consider himself to be an alcoholic.
Confronted with someone who didn’t have a definite disease that I could diagnose and treat I realised I was at a loss. Although he didn’t have a disease it was abundantly evident this man did not feel well.
I blundered my way through the consultation, mumbling something about referring him for counselling. He and I both knew that there would be a several month wait for this by which time there was a serious risk that he would have lost his job, separated from his wife and caused significant damage to his liver.
Mainly to ease my own conscience, in a falsely bright voice I suggested that he come back in two weeks’ time to tell me how he was getting on.
He never did.
I soon realised that in order to be a really effective GP I would need to learn how to help people by having the right conversations with them – not just by doing the right tests and writing the right prescription.
I now think of health as being like a bank account. There are actions we take that make deposits in the bank account (e.g. exercising, sleeping well, eating well, having meaningful relationships with others) and actions that make withdrawals (e.g. smoking, drinking too much, becoming over–weight and living in a way that causes us too much stress).
Unfortunately the world isn’t fair. Thanks to the genetic lottery, we are not all born with the same health credit in our accounts and we don’t all receive the same amount of interest on our health deposits nor pay the same charges when we go overdrawn.
However, any of us can have to face an unexpected withdrawal from our account in the form of an illness or other life setback which threatens our well-being. The healthier the bank balance to start with the less likely we are to go overdrawn. Therefore it makes sense to keep the bank balance as healthy as possible.
However, just as in the financial world there is a wide range of ways of making investments and a vast number of things for which we may need or want to make a withdrawal – so it is with well-being.
Had I known on my first day as a GP what I know now, I might have been able to help that man to identify positive things he could do to make investments in his well-being account – be that exercising more, spending quality time with his children or thinking and responding in different ways to his challenges at work and in his relationship.
We know that physical and psychological health are intricately linked. There are strong correlations between living with long term physical problems such as obesity, heart disease or diabetes and having depression and vice versa.
Positive psychology is the study of what’s right with people. It focuses on identifying the building blocks of happiness and resilience.
Experts suggest that happiness (i.e. psychological health) is approximately 40% governed by inherited traits, 10% attributable to life circumstances and about 40% influenced by behaviours and attitudes that we can control.
The wonderful implication of this being that by consciously cultivating the appropriate building blocks we can increase our psychological health reserves by 40%!
I haven’t seen any research that gives a comparable breakdown for the factors governing physical health but my intuitive guess is that they are likely to be similar. There is research underway at the University of Pennsylvania to identify the fundamental building blocks of physical health.
This is exciting and necessary research – and I await the results with baited breath. However, given the current issues facing the NHS I don’t think we can afford to wait for the results before we take action. I also believe that we can already take an educated guess as to what the building blocks of positive health are likely to be.
Statistically 1 in 3 of us will face cancer in a lifetime and 1 in 4 will have a mental health problem. It is estimated that by 2025, four million people in the UK will have type 2 diabetes. By focusing on building positive health reserves we may be able to alter these figures.
I think we urgently need to give people both the information and psychological tools to be able to do this for themselves.
We may then be able to build a population who are physically and psychologically resilient and who fare better when disease does strike – ultimately needing less NHS resource.
I know that many people would argue that given the funding difficulties with the NHS we cannot afford to fund initiatives to make the healthy even healthier.
I would argue that if we want to see the NHS celebrate its 80th birthday, we can’t afford not to!