In June the UK Government presented to Parliament a green paper outlining plans ‘‘to improve further the healthy life of the people of England’’. Wide consultation and discussion is invited and in the introduction William Waldegrave writes: ‘‘We are clear about one thing: a strategy imposed by government which takes no heed of the views of those who will have to implement it, including the people themselves, is valueless.’’ A summarised version has been sent to every practising doctor in the country. Comments and suggestions are requested by the Department of Health from all interested parties by the end of October.
At last then, we have the government expressing concern with preventative medicine and a willingness to attempt to alter lifestyles and environmental factors affecting health rather than altering yet again the administrative system by which we supply treatment for disease. The underlying philosophy is that better health cannot be imposed. The individual must actively seek it and ‘‘education is the key’’. Many will find it disappointing that so little is spelled out about the government’s own commitment and that so much is tentative with an initial demand limited largely to the setting of targets.
In 1985 at Copenhagen the European Office of the World Health Organisation launched ‘‘Health for All by the year 2000’’ which sets targets for improvements from a baseline of 1985. Firstly this called for at least a 25% reduction in differences between European countries and between groups within countries.
Both in longevity and infant mortality rates Japan is easily the world leader but England has done well with an average life expectancy of 75 years and a loss of only 20 infants per l,000 live births; both surpassing the set European targets. The WHO recommended that, between 1980 and 2000, deaths below age 65 from circulatory diseases should be reduced by at least l5%. England has already achieved a fall of 29%.
WHO hopes for a fall of l5% in European cancer deaths under age 65. English men under 65 have already seen their cancer mortality fall by 29%. Female mortality remains unaltered since 1980. This is attributed to the fact that reduction in smoking is occurring later in women. Total cancer mortality has so far fallen by only 8%.
In England accidental deaths have fallen by 24% in the last nine years against a WHO target of 25% by 2000. Drug abuse appears to have risen dramatically. New and notified drug addicts have risen sixfold from 2,233 in 1980 to l3,700 in 1980 but the base line in 1980 is suspect. Prescriptions for tranquillisers have fallen by 22%. Alcohol consumption in 1980 was 9.0 litres. In 1989 it was 9.3 litres despite falls in 1981 and 1982. Men are drinking less and women more than in 1980.
Our national diet has theoretically improved with a reduction in calories and fat (of which we still eat too much): mainly because we eat less red meat (25% less) and less full fat dairy products but more fibre, white meat and fruit. Between 1980 and 1987 the proportion of overweight adults aged 16-64 increased from 39 to 45% of men and 32 to 36% of women.
The paper discusses areas which should be targeted and outlines the criteria upon which they are to be selected:-
In summary the following areas were selected and targets set:-
Coronary heart disease. Allocated a target of reduction in deaths under age 65 of 30% between 1988 and 2000. Provision to be made for increased numbers of coronary by-pass operations.
Stroke. 30% reduction in deaths under 65 years 1988 to 2000 and 25% reduction in deaths aged 65-74.
Cancers. Too wide for general targets. Increase in screening for cancer of Cervix and of Breast.
Accidents. Views invited on monitoring techniques.
Mental Health. Improved facilities for care in local hospitals and in community. More of the 90 remaining large mental hospitals to be closed.
Diabetes. Improvement of current clinical facilities. No mention of new techniques such as islet-cell transplantation.
Asthma. Improved clinical management. No mention of research into causation of recently increased incidence.
Smoking. Reduce smoking by men to 22% and by women to 21% by 2000.
Diet and Alcohol. By 2005 less than l in 6 men and l in 8 women drinking in excess of agreed sensible limits. Also by 2005 obese adults to be 7% or less and reductions in total fat intakes and particularly in saturated fats.
Physical Exercise. Role uncertain. No recommendations.
Health of Pregnant Women, Infants and Children. No single target possible. All Regional Health Authorities, District Health Authorities and Family Health Service Authorities to have agreed individual targets by 1993. Increase in breast feeding at birth and at 6 weeks. Targets for teeth care.
Rehabilitation for Physical Disability. Not at present appropriate to set National Targets.
Environmental Quality. To European Community standards for drinking water and bathing by 1995. On 1990 baseline reduction of levels of nitrogen oxides by at least 50% to meet W.H.O. guide-lines on peak ozone concentration by 2000.
HIV/AIDS. Promote safer sexual and intravenous drug user behaviour. Targets not feasible in present state of knowledge.
Other communicable Diseases. Childhood immunisations from present 90% to 95% by 1995. 90% reduction in measles by 1995.
Food Safety. At present it is not feasible to set targets to reduce incidence of food poisoning by a stated amount by a given date. Monitoring of actions by enforcement officers may allow of this later.
Many obvious subjects are omitted. The potential reduction in osteoporosis, heart disease and stroke in postmenopausal women which could be achieved by wider usage of Hormone Replacement Therapy is well established. Reduction in the l65,000 abortions needed annually by English women is surely a target worth considering?
The NHS has failed to close the gap in mortality and morbidity rates between the rich and the poor. The present paper suggests only that improved health education may help. In practice education reaches the affluent and privileged more effectively than the poor and immigrant groups. Therefore, used alone, it can only widen the gap. The Black Report showed quite clearly that to improve the health of the poor the root causes of poverty must be tackled.
The Health of the Nation. - A consultative document on health in England. June 1991. London H.M.S.O. Cmnd 15123. Price £11.80.
Peter Diggory