Criticising our over stretched health and social care service is less of a public pass-time than it was five years ago. This is good and perhaps reflects a growing maturity as we begin to realise that these vital services, on which we all rely, can only do so much. In the social contract – the basis of the 1948 Health Service Act – there were two sides; (1) government agrees to provide a health service free at the point of access and (2) the public agree to take better care of themselves; prevent illness and self-treat when possible (Self Care).
Over the past 70 years since 1948 our understanding of what increases the risk of long-term conditions (and worsens them when we get one) turned out to be relatively few and relatively simple; smoking, poor nutrition, lack of exercise and too much stress (alcohol misuse). The paradox is that raising awareness of the danger of these behaviours risks nanny-state accusations. Some successes have been achieved; smoking has declined from 33% to 22% over 20 years (still could do better) but behaviour change is difficult and perhaps we don’t know how to do it.
An acquaintance who always had “a weight problem”, has just had the shock of a type 2 diabetes diagnosis. In his late 50s he is just coming to terms with the badge of a long-term condition with the same quiet stoicism he dealt with his long-term gross obesity; in denial. Over the years his obesity was in plain sight but seldom, if ever, discussed. Ten years ago something happened and he decided to lose weight and ask for help. A month or two later, not noticing any obvious weight loss, I casually asked about his diet. He aggressively censured me to mind my own business. Suitably admonished I never again broached the issue. In recent months a skin infection hospitalised him twice, and kept overnight on both occasions, he was released into the care of his GP without any comment on the obvious need to address his corpulence. The only advice he got, following his second hospital visit, was to see his GP as his blood glucose was “raised”. It was indeed raised at 23 mmol/L and when starving himself he could get it down to a respectful 12 mmol/L but too far from the normal of 4-8 mmol/L. He hadn’t visited his GP for years knowing the consequence would be a tough conversation he didn’t want.
He is now a fully signed up type 2 diabetic with; a concerned GP, a dedicated practice nurse and a highly trained consultant diabetologist. His management over the coming 20 years or so will prove expensive for our health service, a cost I certainly don’t begrudge him but prevention might have saved him, his family and the state a lot of future cost and grief. The evidence is clear a 50% to 60% reduction in diabetes prevalence with small changes to diet and exercise or put another way about 50 out of every 100 patients with type 2 diabetes, with a little restraint, would not have developed the disease.
My acquaintance manifests the challenge of our health service as it struggles to transform. He, like those of us who; smoke, drink too much, eat too many calories and take little exercise, was an obvious target for primary prevention that didn’t happen. Of the £4.5 billion we consume annually in providing our health and social care services only 2% is targeted at prevention much less in supporting self-care.
Terry Maguire is a pharmacist in Belfast