Cardiovascular disease and population health: thinking beyond the hospital ward

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Despite the perception of tremendous advances in modern medicine and the management of cardiovascular disease over several decades, last year the British Heart Foundation revealed that premature death rates for the condition have risen for the first time in 50 years. How can this be explained?

One of the barriers to progress in improving population health and quality of care in the NHS is a lack of knowledge of the various interconnected contributions to wellbeing and longevity. For example, it is often forgotten that 50 per cent of the decline in cardiovascular disease mortality since 1970 is directly due to reduction in smoking prevalence, with the remainder attributed to removal of trans fats from the food supply, better acute care and the development of coronary care units. In one study, the majority of the public believed modern medicine has provided the greatest increase in life expectancy in the past 150 years, when nothing could be further from the truth. When asked how much medical care had added to the 40 year average extension of life expectancy since the mid-1800s in America the overwhelming majority surveyed estimated 32 years, when in fact the best estimates suggest it’s only added 3.5 years. And even most of that relatively smaller increase can be attributed to antibiotics for life-threatening infections, certain vaccinations and emergency care. Such misperceptions about what contributes to our health result in uneven distribution of public spending and efforts to address important health-related social issues such as poor diet, better housing and severe loneliness.

'In one study, the majority of the public believed modern medicine has provided the greatest increase in life expectancy in the past 150 years, when nothing could be further from the truth.'

Secretary of State for Health and Social Care Matt Hancock has said ‘each year we are spending £97 billion of public money on treating disease and only £8 billion in preventing it across the UK – that’s an imbalance of urgent need of correction’. And such statements do reflect the evidence. In the United States, for example, people living in areas of high Medicare spend have neither improved patient satisfaction nor better outcomes. In fact, mortality is slightly worse.

Success in the reduction of cigarette consumption was a result of political action and effective policy interventions that addressed the availability, affordability and acceptability of tobacco. The very same approach needs to be utilised to combat ultra-processed food consumption which now represents a staggering half of the British diet leading to an explosion of obesity and type 2 diabetes, now the single condition contributing the most towards NHS costs.

Even our hospitals have become a branding opportunity for the junk food industry, with over 50 per cent of staff now overweight or obese. How did the medical profession allow this to happen? As pointed out by pioneering German Physician, Rudolf Virchow, ‘medicine as a social science, as the science of human beings, has the obligation to point problems and attempt their theoretical solution’. All those in public life whose responsibility is to serve the needs of the people including doctors are required to uphold the seven Nolan Principles: selflessness, integrity, objectivity, accountability, honesty, openness and, last but not least, leadership. This means being able to actively promote the principles and being able to challenge poor behaviour wherever it occurs. Doctors who stay silent about the sale and promotion of the very foods at the root of the chronic disease epidemic in their own work environments are in my view neglecting their duty to patients. If we’re going to make real inroads in solving the health care crisis we will need to fix the food.

But this is not so much a deliberate act by physicians but a combination of lack of understanding of the wider determinants of health, subsequent maldistribution of resources, perverse incentives to overprescribe using biased information from drug company sponsored clinical trials and failure of regulation to protect the public from the excesses and manipulations of industry. As former Chief Executive of The King’s Fund Chris Ham said a few years ago in response to the latest crisis in accident and emergency, ‘the system is broken and no amount of money will fix it’. The failure to tackle prevention effectively, exacerbated by staff shortages of 100,000 across NHS trusts, leads to staff burnout, compassion fatigue, increased likelihood of medical error and an unmanageable workload. This is also about self-preservation. The recent Marmot review revealed ‘a poor quality or stressful job can be more damaging to health than being unemployed.’

'The failure to tackle prevention effectively, exacerbated by staff shortages of 100,000 across NHS trusts, leads to staff burnout, compassion fatigue, increased likelihood of medical error and an unmanageable workload.'

Doctors have a pivotal role to play in ensuring the sustainability of health and care systems. This is not about a new breed of doctor or a challenge for the next generation: this is a responsibility for all doctors today. Duty to the individual patient should be supplemented by duty to the population as a whole. Clinicians should take on a broader population perspective. For example, cardiologists should not just be responsible for patients who happen to be admitted to the hospital but for the cardiovascular health of the all the people of that locality.

It’s clear for individuals changes in diet (and lifestyle) can have significant impact on health and quality of life within weeks of implementation. But making those changes, for instance quitting cigarettes, is much more likely if backed with powerful policy change across the population, such as high tobacco taxes, smoke-free pubs and a ban on tobacco advertising. Furthermore, a European Heart Journal review has shown that demonstrable changes to population health and a more manageable health service could be achieved within a couple of years, well within one electoral term.

As Virchow also said, ‘if medicine is to fulfil her greatest task then she must enter the political and social life too.’

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