A recent report from The King’s Fund argues that reversing the stall in life expectancy will require a shift from our current focus on diagnosing and treating illness to promoting the health and wellbeing of the entire population. While GPs see increasing numbers of patients with mental health problems and chronic diseases such as diabetes and cardiovascular disease, responsibility for addressing the major drivers of these conditions lies elsewhere. GPs currently lack the specific resources to address the broader determinants of health. Issues like poor housing, school meals, fast food takeaways and the price of alcohol have a major impact on the physical and mental health of the patients we see, but we feel poorly equipped to influence them in our current system.
Situated within communities, GPs are well placed to understand the local factors that shape behaviours and lifestyles. Hippocrates reminded us that ‘it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’, a statement that still today captures the holistic approach of general practice. In our consultations with patients, we actively look to identify the wider causes behind their illnesses, giving us a unique insight into the local factors influencing health and wellbeing in our communities.
As doctors, we have a responsibility for prevention set by our professional bodies, with General Medical Council guidance making special mention of helping people to ‘improve and maintain’ their health. One of the 13 core Royal College of General Practitioners competencies for being a GP is ‘community orientation’: ‘the management of the health and social care of the practice population and local community’. Despite this, there is a disconnect between the expectations and realities of general practice, with workload and incentives leading to a focus within rather than outside the practice. Social prescribing initiatives are an encouraging move towards giving us the tools to address social determinants but tend to target people only after they present with a problem.
Beyond our professional duties to engage in community level prevention, GPs are also required to offer ‘relevant health promotion advice’ to their registered population under the General Medical Services contract. Many public health services, such as cervical screening, immunisations and NHS health checks are provided by GPs, with others incentivised through the Quality and Outcomes Framework. Early detection and individual-level counselling are great, but do not fundamentally address the underlying causes of unhealthy behaviours and ill health. Encouragingly, there are a number of examples of innovative practices that seriously engage with population health – think of Bromley by Bow – however these centres have flourished because of a few committed ‘champions’, rather than being the norm.
The Health and Social Care Secretary’s vision for ‘putting prevention at the heart of our nation’s health’ emphasises the central role of primary care in meeting the government’s ambition to increase healthy life expectancy by five years by 2035. Its ambitions to expand the workforce, retain experienced GPs, and encourage more collaborative working are much needed, but won’t be enough to realise a vision of GPs engaged in population health. Any GP will tell you that there simply isn’t capacity to take on any new responsibilities at the moment. We currently lack the time to engage in prevention activities outside of clinics or the resources to employ and train staff with population health skills, while the payback is often felt over too long a period to directly benefit the practice without additional financial incentives.
GPs have a unique role in identifying the non-medical causes of disease in our patients and the data, skills, and insight to make significant contributions to population health. The new NHS long-term plan has promised additional funding for general practice and proposed an expansion of primary care networks – how this can translate into a greater emphasis on prevention is not clear, but it would be a lost opportunity if we don’t utilise our potential to address population health in the future. As GPs, we need to rediscover ways of keeping one eye on the individual patient sitting in front on us and another on the wider community.
The biggest public health issues we face use the obesity epidemic with associated diabetes. The cause is almost singular.... Dietary refined carbohydrates.
"It's more complex than that" I hear you say. Well actually no it isn't. Cut out refined carbs and you can reverse type 2 diabetes. You don't when you cut out fat for example.
In deprived areas try and walk 2 paces without coming across a high carb, highly refined fast food outlet. Impossible. Yet we blame the patient as if they have a choice.
Exercise is very important but not nearly anywhere near as important a determinant in this epidemic as dietary refined carbs.
We can advise on this in the consultation room, but it takes more to stop our governmental representatives to get out of the pockets of big sugar.