Richard Smith: Are doctors part of the solution or part of the problem?

Richard Smith
The Royal College of Physicians and various other medical bodies want doctors to be serious about tackling the social determinants of health, and have held a conference on the topic. There were some brilliant speeches (plus some duds of course), but all day I found myself asking whether doctors were part of the solution or part of the problem.

By the end I concluded, sadly, that they were mostly part of the problem. I arrived at the BMJ in May 1979 a few weeks before the publication of the Black Report on health inequalities, which was made famous by its clumsy suppression by the new Tory government. Later I played a small part in the independent inquiry into health inequalities set up by the new Labour government in 1997, and I’ ve been hugely impressed by the two magnificent reports on the social determinants of health from Michael Marmot, who appeared on video at the conference. But while we’ ve been churning out these learned reports the gap between life expectancy of the rich and poor has been widening not narrowing.

Then in his excellent talk Peter Rubin, chair of the General Medical Council, pointed out that the college of physicians had published a plea just like its recent one in 1944 – at a time when the country was much more open to tackling big social problems. Yet since then clinical medicine has eclipsed public health. Everybody at the meeting – which was called a “love in” by David Pencheon, director of the NHS Sustainable Development Unit – agreed that public health teaching was boring and that doctors knew little or nothing about the social determinants of health, despite them being so powerful (much more powerful than clinical medicine) in determining length and quality of life. Students, said Rubin, want to get on with the “real stuff” like biochemistry and putting up drips.

The president of the college said how he’ d been sent to the dean for missing all his public health teaching and that he knew nothing about health inequalities until he was in his 50s. Then the president elect of the college summed up by saying that you couldn’ t tell “those people” [the poor] anything, that he’ d never been into a Morrisons, and that he thought gardening might help solve the problem.

All of the reports I mentioned were produced by teams chaired by doctors – and at least some doctors have been fretting about the health conditions of the poor for well over a century. (I was about to quote Edwin Chadwick, whose report, The Sanitary Condition of the Labouring Population (1842), as a leading example of a 19th century doctor concerned about health inequalities when I discovered that he was a lawyer and a writer – perhaps supporting my general thesis.) But while all these doctors have been fretting and writing reports we’ ve gone backwards. So it’ s surely time to let others take the lead.

But the main reason that doctors are part of the problem rather than part of the solution is that they swallow up resources that could be used more effectively. Ruth Hussey, regional director of public health in NHS North West, said that in order to make progress we needed to move from “illness to wellness” and from “I” to “we.” But doctors aren’ t interested in wellness. Medical textbooks are all about disease; they usually have nothing on health or wellness. And doctors are about individual patients not communities. Society wants doctors to concentrate on sickness and individuals, and they are happy to oblige. Unfortunately their high status and incomes and their everyday decisions over what happens in the NHS mean that attention is focused on sickness and that less than 2% of NHS expenditure is on prevention.

There’ s also the problem that most doctors come from middle class families and haven’ t a clue about the lives of the poor. They are then trained in institutions – colleges and hospitals – where the poor feel extremely uncomfortable and powerless. So doctors should get out of the way and hand over to politicians, lawyers, social scientists, and community health workers (people who come from the disadvantaged communities and can connect with them in ways that doctors can never match.)

Richard Smith was the editor of the BMJ until 2004.