Public health

Faced with an ageing population, an ever-increasing number of expensive drugs and procedures available, and an unprecedented call on incapacity benefit, the government is determined to focus on sickness prevention rather than cure.

When the NHS was set up, much disease - for example, tuberculosis and rickets - was related to poverty. There was also a high prevalence of industrial injury and occupational disease among the working population. Now some of the biggest challenges we face are linked to lifestyle choices, such as a high-fat diet, lack of exercise, smoking and binge-drinking. This last article in our series looks at the new emphasis on health education and considers the contribution that physiotherapists have to make as the agenda moves further and further away from secondary care. ~ Reports and research by Andrew Cole and Gary Robjent

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What's happening and why?

Public health has probably never had as high a profi le in the NHS as today. Much of the credit for that must go to a ground-breaking report on the future of the NHS produced in 2002 by former NatWest boss Sir Derek Wanless.

Last week, as Frontline went to press, health think-tank the King's Fund published a report by Sir Derek analysing what's happened with some of his recommendations over the past five years. His original report, commissioned by the Treasury, made it starkly clear that health treatment could no longer be divorced from health promotion.

Unless the NHS got a grip on public health issues and the nation became healthier, warned Sir Derek, the total costs of running the service could become astronomical - and possibly unsustainable - by 2020.

The report, together with its follow-up two years later, was one of the main catalysts for the government's Choosing Health white paper in 2004, an ambitious attempt to shift the health services focus from cure to prevention. The major health issues highlighted were smoking, bingedrinking, sexually transmitted diseases and obesity - all lifestyle issues that needed a holistic rather than medical model of care, and demanded innovative approaches extending well beyond traditional NHS boundaries.

One of the most eye-catching recommendations was personal health trainers who would offer people with multiple problems health MoTs' and guide them through the system. The emphasis was on using holistic approaches to change lifestyles.

Unfortunately, implementation coincided with a major reorganisation of primary care trusts and a drastic squeeze on budgets. As a result many trusts redirected money earmarked for public health into meeting more pressing acute sector targets. Despite these problems, signifi cant progress has been made in the last three years. The ban on smoking in public places is probably the most striking. But, according to the Department of Health, the NHS has now met 135 out of 190 commitments made in the white paper and achieved 386 out of 491 actions. This includes appointing 1,200 health trainers a year ahead of target.

Just as important, however, is the development of infrastructure for partnership working across health, social services and other relevant departments, highlighted in previous articles in this series. Administrations in all four home countries have already prioritised public health. And with a strong direction from the Treasury, public health is likely to grow as an area of investment for several generations right across the UK.

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What does it mean for healthcare?

Despite increased affl uence and billions of pounds poured into healthcare, there are worrying signs that as a nation we are becoming less rather than more healthy. The next generation could be the first in over a century to face a lower life expectancy than their parents. That underlines the critical

importance of the public health agenda. And one of its biggest challenges will be obesity, which is now at an all-time high. Obesity in children has trebled since the 1980s and is continuing to rise in the adult population, where over half are now officially overweight or obese. Lack of progress on tackling obesity is one of the areas highlighted by Sir Derek Wanless in his latest report.

No one seems too bothered if you don't meet public health targets. It's certainly not a hanging offence in the same way that missing your access targets would be,' ~ Chris Drinkwater

The effects can be devastating. Obesity is an important risk factor in a number of chronic diseases, including heart disease, stroke, some cancers and type II diabetes. It is currently responsible for 9,000 premature deaths each year and is costing up to £3.7 billion a year in England alone.

Understandably, the health service has a lead role in combating this, but obesity is probably one of the most complex of all public health issues. The benefi ts of stopping cigarette smoking are clear - life expectancy improves more or less overnight - but it is more difficult to sell' the benefits of changing diet and increasing physical activity.

For a start there is less evidence about which approaches work. It is also clear this is not simply a healthcare issue but involves tackling what Chris Drinkwater, NHS Alliance lead on public health, calls the obesogenic environment', which includes leisure habits, family eating patterns and school activity.

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David Stout, director of the Primary Care Trust Network, believes the new drive to promote partnership working and joint needs assessment will be critical to public health success. But he has concerns about health inequalities, which are still growing.

Perhaps the central dilemma is that public health works on a much longer timescale than the rest of healthcare, and most trusts and local authorities are committed to short-term targets.

And even where there are clear public health targets - such as halting the rise in obesity in under 11s by 2010 - they seem to carry less weight. No one seems too bothered if you don't meet public health targets. It's certainly not a hanging offence in the same way that missing your access targets would be,' says Mr Drinkwater

Hopes and concerns

Hopes

  • Huge health benefits
  • Preventing NHS costs becoming unsustainable

Concerns

  • The NHS has a poor track record in turning rhetoric into reality
  • Public health goals are long term; NHS political priorities are short term
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What does physiotherapy have to offer?

Whether it is smoking, obesity, chronic disease or getting people back to work after long-term sickness, physiotherapists would seem to be ideally placed to help deliver the public health agenda.

'If exercise and rehabilitation were pills people would be popping them like no one's business. In reality it's not as easy as that,' ~ Julie Moore.

Central to many public health initiatives these days, of course, is activity and exercise. Regular exercise has been shown to cut heart disease by a third, strokes and type II diabetes by a quarter and hip fractures in older people by a half. And that's where physiotherapists come into their own.

They are, for instance, taking an increasing part in developing and tailoring exercise sessions for older people to help prevent falls and to manage weight. Usually physiotherapists will run classes for those who are frailer or have specific medical problems, while exercise instructors will run the more generic classes under physio supervision.

man eating hamburger in front of tellyPhysiotherapy is also integral to cardiac rehabilitation, which typically involves exercise training, education and counselling, and has been shown to cut cardiac mortality by 27 per cent. However, a recent British Heart Foundation survey revealed that only 40 per cent of patients receive rehabilitation and only 60 per cent of those programmes employ physiotherapists. Disturbingly, uptake is lowest among minority ethnic groups, where the incidence of heart disease is highest. Physiotherapists also have a central role in pulmonary rehabilitation, where it has been shown that increased exercise can significantly improve the quality of life of people with chronic obstructive pulmonary disease. Yet the take-up of such exercise programmes is less than two per cent.

To overcome this, the British Lung Foundation recently introduced community exercise programmes, linked to their Breathe Easy support groups, in 10 pilot sites. The scheme was so successful it is now hoped to roll out the scheme across the country.

Senior physiotherapist Julie Moore was closely involved in setting up the classes. She also runs several pulmonary rehabilitation programmes within Lambeth and Southwark primary care trust. But she remains frustrated by the imbalance between supply and demand. In her trust she has a capacity to see 432 patients a year. But there are around 5,000 people with COPD in the area and, she estimates, possibly another 5,000 who are undiagnosed.

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Even those who do benefit get little support or followup once they have left the programme. All the evidence suggests that without this follow-up patients are only likely to maintain their exercise regime for a year at most. 'If exercise and rehabilitation were pills people would be popping them like no one's business. In reality it's not as easy as that,' says Ms Moore.

One of the chief difficulties for Ms Moore is the need constantly to justify any public health initiatives through measures of immediate, local health gain - often, ironically, expressed in terms of their impact on the acute sector.

Because she is busy running a service, she struggles to pull together these statistics. Moreover, the progress of respiratory disease is notoriously unpredictable. Some of these people do get worse rather than better for all kinds of reasons and that can be incredibly frustrating.

We know that exercise has dramatic effects on the health of an individual but measuring that over a short period of time is so hard. But I keep getting asked, how many bed days has my service saved?'

Most practitioners in rehabilitation would love to extend their work to primary prevention, encouraging people to change their habits and so ensure they don't succumb to these conditions in the first place.

But as Samantha Breen, physiotherapy lead for cardiac rehabilitation in central Manchester, acknowledges, alerting people to the danger of disease before they have experienced it is a tougher proposition. The problem is that something like heart disease or stroke is always going to happen to someone else, not you,' she says .

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On the ground - Glasgow

Physiotherapists are integrally involved in the 19 government-funded Pathways to Work pilots, which over the past four years have been seeking to help those on incapacity benefi t to return to work. One of the most successful schemes is in Glasgow, where an estimated 29 per cent of those who have taken part in the rehabilitation programme are now back at work.

The rehabilitation team consists of 25 physiotherapists, nurses and occupational therapists, all of whom operate as generic rather than specialist practitioners. I like to think that if you came into the offi ce you couldn't spot who was the OT and who the physio,' says programme director Sue Plummer. Team members will still call on the specialist expertise of a particular practitioner where needed. But in general everyone will take on all aspects of the work, including cognitive behavioural therapy, pain management and job preparation.

In the last two years they have offered condition management' - that is, rehabilitation focusing on personal support rather than clinical intervention - to over 2,000 people on incapacity benefit. Clients receive up to 13 one-to-one sessions aimed at equipping them for a return to work.

Over two-thirds of their clients have mental health problems, says Ms Plummer. The other major conditions are cardiovascular and musculoskeletal problems. Many people feel crippled by feelings of worthlessness.

People just want to stay in bed all day and pull the sheets up over their heads. Typically they'll say they don't feel confi dent enough to go back to work. They have lost any skills they had - some of them don't even feel confi dent about using transport. Many are worried about how their physical condition, such as a back problem, will hold up when they go back to work.'

After discussing their problems, the team draws up an action plan to tackle what clients identify as their biggest obstacle to returning to work. But the key throughout is that it is voluntary and based on self-help. Our whole philosophy is to support these people to manage themselves,' says Ms Plummer.

And it seems to be working. A Jobcentre Plus analysis indicates those on the programme are twice as likely to be back at work six months later as those that haven't been through the scheme - and three times as likely still to be employed after a year.

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On the ground - Armagh and Dungannon

A small-scale physiotherapy-run exercise programme in Armagh and Dungannon, Northern Ireland, is helping people with diabetes to keep their condition under control - and reducing their risk of cardiac and respiratory problems.

Under the scheme, which began in 2004, patients who have been newly diagnosed with type II diabetes are referred for a six-week structured exercise programme.

Programme leader Frances Moen says she receives a wide variety of referrals with a huge range of needs, so it is important to ensure each exercise programme is tailored specifi cally to the individual. Most people will take part in a structured exercise programme at the local leisure centre but some may be unable to get to the gym and will need to have a home exercise programme designed for them.

One man, for instance, has an artifi cial hip and so we had to devise an exercise programme for him that didn't involve him using that hip at all,' Ms Moen says. You have to think outside the box.'

And the results have been impressive. In 2005, for example, 30 out of 37 patients showed a signifi cant improvement in their walk tests, a fi gure that increased to 52 out of 63 last year. In addition, more than half showed improved scores on the health, anxiety and depression rating last year.

What the programme can't do is measure the precise impact this has on the diabetes itself, but Ms Moen has no doubt it has an effect. She also notes that exercise helps with cardiovascular fi tness and respiratory problems. One woman with chronic obstructive pulmonary disease was being admitted to hospital once or twice a winter but since she started going to the gym she hasn't been admitted once.'

The number of referrals to the programme is increasing each year, but Ms Moen would love to expand its scope to take in more pre-diabetic health promotion, as well as following up her patients to ensure the changes they make are sustained.

Useful references and resources

Wanless D. Securing Our Future Health: Taking a Long-Term View, Final Report [2002], HM Treasury
Wanless D. Securing Good Health for the Whole Population [2004], HM Treasury
Wanless D et al. Our Future Health Secured? A Review of NHS Funding and Performance [2007], The King's Fund
Choosing Health: Making Healthy Choices Easier [2004], DH
2nd Choosing Health Progress Report [2007], DH
On the State of Public Health: Annual Report of the Chief Medical Offi cer 2006 [2007], DH

Web links

Agile - chartered physiotherapists working with older people www.agile-uk.org  
British Lung Foundation www.lunguk.org
British Heart Foundation www.bhf.org.uk  

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This text on this page was last updated on 19 Sep 2007.