Richard Smith: Putting the H back into the NHS

richard_smith_2014The H in NHS stands not for hospital or healthcare but health, and the NHS needs to do better at promoting health, said Simon Stevens, chief executive of NHS England, this week at a meeting organised by the University of Southampton. If England can’t do better at prevention then the NHS will be overwhelmed, said Stevens. Premature deaths from heart attacks have come down by 40% in the past decade: imagine, he said, the pressure on the NHS if that hadn’t happened. But what can the NHS do to counter the “new smoking” of obesity and the 20 year gap in healthy life expectancy between the richest and poorest?

Stevens sees five approaches.

The first is to form partnerships in communities with local people and organisations to create health. The NHS has the great advantage that it is “embedded” in almost all communities—with general practices, clinics, and hospitals. It also has much greater resources than local organisations. But does it know how to share power with local people and act on what they see as the priorities for “health,” perhaps leaking roofs and crime rather than obesity and blood pressure?

Next, those in the NHS must be willing “to stand up and be counted” in advocating for health. He was perhaps thinking of himself and those around him at the centre, and he mentioned the forthcoming government plan on childhood obesity. It’s easy for a consultant paediatrician or general practitioner to speak in favour of, for example, a soda tax, which the government doesn’t seem to favour, but much riskier for Stevens and others in NHS England: they risk losing their jobs.

The third requirement is to catch up with developments in understanding how to change behaviour. The NHS, argued Stevens, has been left behind but is beginning to catch up with developments like the National Diabetes Prevention Programme.

Fourthly, the NHS must support primary care. This may come as something of a surprise to general practitioners, who have seen their share of NHS expenditure steadily decline and find themselves under tremendous pressure. But Stevens is familiar enough with the evidence on health systems to know that the stronger primary care the better health outcomes, the higher patient satisfaction, and the lower costs. He recognises, however, the need to reinvent the model of primary care and that reinvention is underway with examination of new clinical, staffing, and business models. At the very end of the meeting Stevens urged the University of Southampton to impress on its medical students that there is no career more intellectually stimulating, socially impactful, and satisfying than general practice.

Finally, the NHS, as the largest employer in Britain, must “be the change we want to be” and “practice what we preach.” The NHS has not done well in caring for its staff: sickness rates and stress levels are high; and obesity and musculoskeletal and mental health problems are common. And NHS hospitals commonly sell junk food. Stevens had visited the University Hospital in Southampton the week before the meeting and been shocked to see W H Smiths offering “two for one” deals on chocolate and sweets. (The hospital had, however, got rid of its Burger King outlet a few weeks before his visit.) NHS England has introduced pilots to improve workplace health and is instituting its own soda tax.

The audience was generally supportive of Stevens’s proposals, but one member asked if the NHS was capable of the cultural change necessary. Stevens said that was crucial. Sir Michael Marmot, the world’s leading expert on the social determinants of health, also spoke at the meeting and said that it would be impossible to solve the obesity problem without reducing inequalities; and England has not managed to do that despite long recognition of the problem.

But the stakes are now very high: the NHS has to change in order to survive.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: RS worked with and for Simon Stevens and is a friend. The University of Southampton gave him a good dinner and a notebook, and his daughter will be starting at the medical school in September.