The coalition government seems keen to engage with individuals and organisations, to help them help themselves lead healthier lives. This, we are told, will be done through encouragement and collaboration as outlined in a paper by the Cabinet Office behavioural insights team at the end of last year. As doctors, we are delighted to see a shift in focus back towards preventive medicine. Many of the problems presenting to clinicians are the result of accumulated years of avoidable, unhealthy and risky behaviours.
So the emphasis placed in last year’s white paper on public health is very welcome.
At a practical level however, what do we need to do to, as a profession, to ensure that those under our care understand that simple lifestyle choices impact so profoundly later? How do we encourage modification behaviour without coming across as preachy or nannying?
The carrot and stick approach to behaviour modification is said to work since it induces behaviours based on the principles of reward and punishment. This assumes that individuals are motivated and will somehow come to a sensible conclusion after weighing the evidence and making the “right” choice.
Problems however, inevitability arise, since not all of us are in a position to make straightforward decisions. Social inequalities further complicate choice. Alternatively, there is now a move towards “nudging” individuals towards making rational decisions. This approach is still paternalistic since the objective is to steer individuals towards an anticipated course of action. Call it what you want, a nudge, a gentle push or a well-positioned bump; the purpose, it seems, is to direct others towards doing the things you want them to do. Anyone with children will know the subtleties involved.
The situation is complex in women’s health, where there is often a fine line between suggesting the best course of action for the woman without causing offense or hurt. The promise of choice sometimes raises expectations and healthcare professionals can find themselves providing treatment that isn’t in the best interest of their patient because the woman wants it. The move towards treating patients as consumers and the use of independent providers means that the taxpayer now make demands adding further pressures on an already cash-strapped NHS.
Which is why controversial issues must be tackled head-on. We need to nip problems in the bud. The obesity epidemic is a case in point. We have to find ways to broach the topic of significant maternal and fetal risk in a sensitive manner and relay the advice to overweight women appropriately. Therein lay the challenges.
Recently I learnt about an emergency caesarean section for a woman with a very, very large BMI. It is not for doctors to judge or to tell people how they should live their lives, but we would be remiss if we do not address the health issues around obesity. A routine surgical process becomes a major life threat. This isn’t an isolated occurrence, indeed, the recent report from the Centre for Maternal and Child Enquiries (CMACE) on maternal obesity highlighted that 5% of the maternal population are now severely obese – one in every 20 pregnancies. This puts a tremendous strain on resources. How do we tackle this problem? Action needs to be undertaken at a much earlier stage. Indeed, society must tackle this problem in childhood to prevent the problem arising in the first place. The joint CMACE/RCOG clinical guideline on maternal obesity recommends better preconception care for women with a BMI 30+ with the aim of weight loss before women fall pregnant. Likewise overweight women will need support postnatally. The difficulty of course is that not all will want to be told and doctors may be accused of crossing the line.
My modest proposal is for information about staying healthy to be introduced at school age. There should be lessons on a range of health topics, from diet and nutrition through to fertility. The previous government felt it necessary to include financial training in our national schools curriculum, surely this present government could think about including these health and wellbeing lessons within the framework.
Anthony Falconer is president of the Royal College of Obstetricians and Gynaecologists (RCOG) and consultant obstetrician and gynaecologist at Derriford Hospital in Plymouth.