In an excerpt from their new book, Saving Sick Britain: Why We Need the Health Society, Martin Yuille and Bill Ollier argue that UK public policy should put greater focus on prevention.
Covid-19 shows what happens when public policy is not fit for purpose. The UK public policy response to the pandemic has:
resulted in one of the highest mortality rates in the world
created a debt mountain
imposed half-hearted lockdowns that have had to be re-imposed
forced businesses to shut up shop
raised the risk of homelessness
ignored the use of social solidarity to inform and support communities
put the most socially disadvantaged at highest risk of delayed vaccination.
None of this was inevitable: one needs only to compare the UK with New Zealand. The root of our problem has been how the UK seeks to prevent disease. This is not primarily a medical question, but a question about the orientation of the entirety of public policy. Effective prevention of disease requires the right policies not on health alone but on education, life at work, transport, business, housing, communities, culture, planning, infrastructure and so on. Effective prevention is a question of what vision the country has for itself.
The people most at risk of death from Covid-19 are those enduring obesity, diabetes and heart disease. These conditions, and related ones like mental ill health, arise from our way of life with its social isolation, non-optimal nutrition and inadequate physical exercise – all exacerbated by inequality. These conditions are the “modern plagues”. Epidemiologists put the start date for these plagues as 1947 – the year that heart disease displaced infections like TB as the leading cause of death in the UK. Public policy has still not yet caught up with this “epidemiological transition”.
Policy has focussed on treatment, not on prevention. There is no denying that health care policies have extended lifespan. However, this has acted to lengthen the years of our lives that we endure living with disabilities. Increases in healthspan – the years of our lives that we spend without any form of disability – have not kept up with increases in lifespan. The consequence is that people live decades with preventable disabilities that are risk factors not only for each other but also for infectious disease.
The modern plagues make it necessary to re-assess public policy as a whole. This re-assessment is one of the aims of our new book, Saving Sick Britain.[_] We came at the problem of prevention not as ‘policy wonks’ but as working scientists. For us, it is second nature to “follow the science”. Our investigations have led us to propose a set of public policy reforms that would construct what we call the ‘Health Society’. This is a non-technical way of referring to ‘systems prevention’ – an extension of modern systems biology.[_]
The Health Society is one where the needs of health underpin all of public policy, where health always comes first, where society recognises that “my health is your health”. We define health not as the absence of disease, but as the optimal satisfaction of human needs. Those needs change over time and are subject to debate (in a democracy). They encompass three classes of need: vital needs (e.g., nutrition, housing), social needs (e.g., transport) and agency needs (having a voice).[_] The evidence demonstrates that their satisfaction increases healthspan.
Building the Health Society requires changes in institutions, in communities and in technology. The changes need to be concurrent since they depend on each other for their effectiveness.
Figure 1 - The Health Society Pillars
The first pillar of the Health Society we may mention is institutional change. We propose that a Deputy Prime Minister have responsibility for improving prevention policy and action across each and every department of government. Even the Ministry of Defence has a problem: 61,000 of its workforce in the armed forces are overweight.[_] The National Risk Register should include the risk of the modern plagues of diabetes, depression, heart disease and cancer. At present, this register – along with the community risk registers – puts a duty on national and local government to act to reduce risks of flood and flu. We need to add the risk due to the modern plagues.
Community change is concerned with empowering and involving people in prevention. We propose that this change is driven by what we call Health Society professionals and Health Society Champions. The professionals evolve from the work of the NHS Health Check – the currently disregarded attempt to provide a prevention service against heart disease. Health Society professionals not only deliver the Health Check to individuals but also seek to involve those individuals in activating others in their community. Such individuals are the Health Society Champions, active in workplaces, schools, places of worship, leisure facilities and so on. Their prototypes today are the Covid-19 volunteers. The professionals support the champions in dealing with employers, teachers, community activists and so on with the intention of engaging more people in the two key activities of physical exercise and optimal nutrition.
The key components of the technology that the Health Society requires are improved management of data pertinent to health (i.e., to our needs) and improved testing of the risk of the modern plagues. It was when we were thinking as research scientists about how best to use these modern technologies that we first started on the road to defining the Health Society.
There is a disarmingly simple reason why the UK needs these changes. For over seven decades, there have been timid initiatives to end the modern plagues. They have all failed. So, do we continue with more half-measures leading to more failure? Or do we go back to first principles, to basic scientific principles and set ourselves the goal of saving sick Britain? Do we follow the science toward improved population health through public policy reform or do we dither and tinker – mainly to avoid the special pleading of vested interests?
Does Britain choose to adopt this new narrative of the Health Society? Can it transcend the stultifying block to progress due to the clash of 19th and 20th century narratives based on wealth trickling down, or on the clash of classes or on the innate superiority of one nation or one kind of person? We argue in Saving Sick Britain that the Health Society is inevitable and that the only question is whether or not we seek consciously to construct it.
Making a conscious choice to do so would enable sustainable economic growth, ensure technology innovation and 21st century infrastructure development, favour public service reform, reduce the burden of disease, minimise numbers of people and communities “left behind” and create a role for the UK in the world of which we would be proud.
Martin Yuille is Honorary Reader and Bill Ollier is Emeritus Professor in the Epidemiology and Public Health Group at the University of Manchester. Their book, Saving Sick Britain: Why We Need the Health Society, is published by Manchester University Press.