We have all heard the phrase, “an ounce of prevention is better than a pound of cure!”. A phrase first offered as a warning about the risk of fires to the people of Philadelphia by Benjamin Franklin – is often cheerfully offered in everyday conversations. However, when we look at population health, I wonder how far have we moved as a society towards making this idea a reality?
There have been some excellent public health initiatives and campaigns in recent history that have undoubtedly made a big impact on a preventative level to the health and wellbeing of our nation.
Compulsory Seatbelts have made an impact on reducing deaths from road traffic accidents arising from complex head, facio-maxilliary and chest injuries.
Banning smoking in public places has been implemented successfully and smoking cigarettes is now the exception rather than the rule in most social settings. Culturally, as a society we have moved from a position of outrage, debating the human rights and railing against the ‘nanny state’, to accepting and adapting to this legislation in the most part. On reflection, it was incredible that we tolerated for so long the choice people made to smoke in a pub or restaurant, while non-smokers, including children, breathed in their highly toxic second-hand smoke.
Similarly, the public health messaging about getting your 5-a day has found a place in our collective consciousness. Even if many of us don’t always manage to consume 5 portions of fruit and vegetable a day, we know that it is a good way to stay healthy and reduce the risk of certain forms of cancer.
So, there is some evidence that strong, repeatedly broadcast messages, backed up by scientific evidence, and where appropriate, legislation, can make a big contribution towards a reduction in health-harming behaviours and better health-supporting habits at a population level.
However, while we have acted decisively in our country on preventing smoking related illnesses, we have similarly compelling evidence that exposure to childhood adversity leads to a huge range of physical health problems, such as cancer, heart disease and diabetes. Yet I still don’t see consideration of this massive public health imperative cropping up in parliamentary debates, Prime Minister’s questions or featuring on the front page of national newspapers.
It is over 20 years since the seminal paper, ‘Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study‘, was published by Vincent Felitti and colleagues. This paper was ground-breaking, revealing some remarkable findings that had enormous implications for population health policy and concluded, ‘We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.’ However, we have not seen, what is now a vast body of evidence, detailing the causal and proportionate link between the amount of adversity experienced before the age of 18 and poor mental health, poor physical health and negative social outcomes, lead to game-changing investment in preventative strategies at a national or local level.
Sure, there are some pockets of good practice and some large-scale initiatives such as Family Nurse Partnership (FNP) and Troubled Families, but these are not without controversy, and are not available in every area to the same extent. In fact, several local authorities are decommissioning FNP and similar targeted interventions because they are under such immense financial pressure. The universal offer is also facing significant challenge in many areas due to the impact of public health budget cuts being passed on to providers. One Health Visiting service I know of had 29 preventative community-based initiatives in addition to the statutory offer across the county. At the time of writing these community resilience initiatives have all been discontinued due to financial pressures despite the emphasis on the need to ramp up prevention in the ‘Five Year Forward View’ and in the acknowledgement in local Sustainability and Transformation Plans (STPs) that we have to fundamentally transform our approach and stem the flow of demand.