STPs, prevention and the the ever changing ask of “public health”

Been thinking a lot on this.
I’m thinking there’s a standard assumption that PH = “prevention” and thus prevention aspects of our STPs will be “done” by PH.

Two fab studies have focused my attention on this issue of prevention how it fits in STP world, one on obesity, one on hip fracture. I could have picked countless others.

Key points of both studies are noted at the bottom of the blog, to keep the main points of the blog short.

Both studies highlighted the lack of a population approach to managing risk and reducing disease incidence, as we spend our time “managing illness in the prevalent population”. We can choose to ignore this, but ever increasing cost of care is in no small part attributed to disease incidence (see many of my other blogs).

I’ve said it before, I’ll say it again in the future – the only surefire way to reduce cost in health care is to not provide health care.
You can either choose to stop providing some interventions and deal with the political and clinical consequences, or you can prevent the need for health care.
Again, again, and again in any system of care primary prevention is the most efficient way to reduce cost and improve outcomes.

“Public health” will not have the reach and depth to address these risk factors at the scale needed.

Thus “the system” needs to decide whether it wants to remain in the business of “providing excellent care” (which by and large it does) or managing and reducing population risk (i.e. Primary, secondary, tertiary prevention mindset) and thus reducing burden of disease and improving outcomes

“Public Health” is:

  • A Function – a responsibility of local government as a whole
  • A set of Services – things traditionally thought of as “public health services” – smoking, obesity, health visiting, sexual health etc. The line between those services as “public health” and any other service is pretty murky, esp if you have a broad definition of the concepts
  • Some source of Expertise – clinical, epidemiological, economic, other. To apply to any issue, problem or opportunity.
  • There’s also some Strategic leadership sort of stuff.

Public health is NOT

  • prevention
  • The public health grant
  • Health inequalities. How many meetings about health inequalities have you been to that are loaded with PH types (often as it’s seen that PH will sort this)
  • It is also not the medical model or the social model. It is both.

Doing public health (or anything) when there’s tons of cash is easy – do the right thing with the £ available
When there’s no £ – you have to do the right thing with what you’ve got but change the overall mission of the system.

My core job wont change over the years = how we continue to get to allocative efficiency i.e. to get more outomes out of £ envelope.

I should be clear here, I’m not really shirking out of my responsibilities- I accept them. I’m reflecting on what is doable, not doable and trying to get a common understanding. We should think about this when we are thinking who “does” prevention in your STP.

Studies

Hip Fracture
Hip fracture, falls, fear of falling is a big deal for both the NHS and social services.
Here is an awesome (mainly Scandinavian) epi study Papadimitriou et al considering the burden of hip fracture.

My key points are below.

  • Prospective cohort study aiming to quantify the Burden of hip fracture and risk factors.
  • 223 880 men and women aged 50+ were followed up
  • 3.5% risk of hip fracture (7,724 fractures) and 413 (5·3%) died as a result.
  • Significant disability (and consequent impact on health AND social care system – quantified in the paper)

Once again – same old risk factors….Cigs, lack of sweat etc
Current smoking was the risk factor responsible for 7.5% of the hip fracture burden, physical inactivity – 5·5%, history of diabetes – 2·8%, and low to average BMI 2·0%, 1·4–2·7), low alcohol consumption and high BMI had a protective effect.

Implications

  • hip fractures are an important cause primarily of disability & mortality
  • Many opportunities exist to ameliorate the burden of hip fractures via a focus on treatments that will facilitate a rapid and complete recovery.
  • Primary prevention measures should be strengthened to prevent falls, and individuals should be encouraged to avoid smoking and a sedentary lifestyle.
  • Secondary prevention should also focus on treatment of osteoporosis and coverage of effective interventions at population scale (there’s pretty low coverage of osteoporosis meds and falls is, well, pretty messy….overly focused on “specialist services” not generalist population approach)

Hip fracture
Papadimitriou et al – Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30046-4/fulltext?rss=yes

Cauley – Burden of hip fracture on disability
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30067-1/fulltext

Obesity & overweight
Closer to home Kent et al looked at hospital costs associated with overweight and obesity in a 1.1m women cohort. That’s quite a big study and a lot of person years!

Key points

  • Follow up of 1.1m women in England aged 50–64, recruited between 1996–2001
  • Followed up for c5 years starting in 2006.
  • 1·84 million hospital admissions were recorded in this cohort in that time
  • Every 2 kg/m2 increase in BMI above 20 kg/m2was associated with a 7·4% (7·1–7·6) increase in annual hospital costs.
  • Excess weight was associated with increased costs for all diagnostic categories, except respiratory conditions and fractures.
  • £662 million (14·6%) of the estimated £4·5 billion of total annual hospital costs among all women aged 55–79 years in England was attributed to excess weight
  • of this £517 million (78%) arose from hospital admissions with procedures.
  • £258 million (39%) of the costs attributed to excess weight were due to musculoskeletal admissions, mainly for knee replacement surgeries.
  • This cost looks likely to increase substantially especially with regard to diabetes complications.
  • Many health economists are now focusing on the broad societal costs of being overweight, including early retirement, efficiency at work, and prospects of promotion. These societal costs are now estimated to account for 60% of the total costs of being overweight or obese
  • i.e. The NHS costs quoted above (nb in a small slice of the whole population) is c40% of the total societal cost.
  • In 2014, the McKinsey Institute estimated the economic burden of being overweight or obese at US$2 trillion, matching that of smoking and all armed conflict.

Kent et al – Hospital costs in relation to body-mass index in 1·1 million women in England: a prospective cohort study – The Lancet Public Health
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30062-2/fulltext

James – The costs of overweight
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30068-3/fulltext

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