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.
Ideas are worthless without implementation…
I don’t see much evidence of a coherent, well communicated and funded attempt to fundamentally shift our approach towards prevention and tackle the prevalence of childhood adversity across health and social care in England.
We cannot keep doing the same things and expect to see a different outcome…
Acute and community services are under unprecedented pressure; good staff are getting burnt out, disillusioned and are leaving the NHS in record numbers. There are serious recruitment problems in several key areas of the workforce, most notably in nursing and some key branches of medicine such as child psychiatry. If you need to see a clinical psychologist on the NHS, good luck...
We are still fundamentally bound up in a medical model and as a health and social care system we continue to react to the symptoms or behaviours (which are often a person's only ways of coping) and we fail to come close to addressing the cause. Diagnosis or labels are the shorthand the caring professions use to categorise people and their problems. Unfortunately, this categorisation of a person as 'an addict' or as someone who is, 'paranoid and psychotic', prompts the NHS and wider care system to mobilise its resources in response to that diagnosis or label. The system and the professionals that person comes into contact with, assume they know 'what is wrong' with a person and stop asking questions. Once diagnosed or categorised, it is even more unlikely that a person will be asked, 'what happened to you?'
This scenario is playing out for millions of vulnerable people across the many services that support people who need help or are vulnerable. We address the presenting problems, attempt to manage or modify their problematic behaviours and try and treat the symptoms of their illness or dysfunction.
Unfortunately, many of these problematic behaviours and symptoms are the tip of the iceberg. They are, in the case of many health harming behaviours, a person's attempt to cope with emotional or physical pain and distress. Attempting to 'help' a person to abstain from or modify these behaviours without understanding the source of their pain is not only unlikely to be successful, but worse, could be unethical.
Consider the case of obesity. This has become a public health crisis in the UK.
The latest 'Health at a Glance' report by the Organisation for Economic Co-operation and Development indicates that 26.9% of the UK population had a body mass index of 30 and above, in 2015. The OECD’s report, also suggests that obesity in the UK has increased by 92% since the 1990s, while other studies suggest that by 2050 over 50% of the UK population will be obese. Along with smoking, obesity is one of the biggest killers of the modern age, leading to cancers, heart attacks, strokes and diabetes. This epidemic could bankrupt the NHS and adult social care unless there is radical intervention.
Herein lies the problem… If we continue to invest in dealing with the symptoms rather than the underlying causes, we will fail to make a dent in the public health crisis we are facing. We will see more regulation imposed on food and drink manufacturers, more education about healthy eating and exercise as well as a rise in treatment costs for bariatric surgery when those measures fail to turn things around. The reason?
Food is a psychoactive substance, we use it to sooth ourselves as well as to nourish our bodies. For many, food is a self-soothing strategy. Some people 'comfort eat' more than others. It provides a temporary aid to emotional self-regulation, short-term relief, a quick fix. The only problem is it never lasts long. The same can be said of drug use, smoking or reliance on alcohol as a way of coping with emotional pain. The relief never lasts, the pain returns, and the cycle of health harming behaviour continues.
What are the solutions?
The solutions are not rocket science, although maybe at times they feel uncomfortable.
For example, we have to stop focussing disproportionately on the presenting problems or behaviours when we are trying to help people with complex and multiple vulnerabilities.
We need to ask people who seek care and help from services, 'what happened to you?', not 'what is wrong with you?'.
We have to provide training to the workforce across the NHS and other caring organisations so that their assessments include routine enquiry about adversity in childhood. If we, as professionals, don’t ask directly about adversity and abuse, the people we are trying to help will rarely volunteer this information for a variety of understandable reasons.
We know that if we ask, people tell us about their adverse childhood (and adult) experiences and as long as the professional responds appropriately, this can be the start of a life changing shift in perception and recovery. Services can offer the right help and support; the system saves money and people can make sense of why they are struggling right now and move towards recovery.
In San Diego, the Kaiser Permanente organisation introduced routine enquiry in the form of an ACE assessment questionnaire a few years ago. All of their clients have an ACE assessment as part of their health assessment on joining their health insurance plan. Over the course of the last few years they have completed hundreds of thousands of these ACE assessments. No-one complains about being asked these questions and in a recent data mining exercise, they looked at the service utilisation patterns of 130,000 of their patients. They found that in this group, (which represent a 2-year intake into their programme) that compared to the year before they were asked the ACE questions, in the year following, this group used 35% less Doctor's office visits and 11% less Emergency Room Visits. With an annual budget of 4bn dollars, that represents a considerable saving for Kaiser!
I want to leave you with the following conclusions…
Waiting to be told doesn't work!
Ask people what happened to them and they will tell us. We can then help them, and they can help themselves.
More and better therapies aren’t going to solve this!
There is no therapy, drug or surgical intervention that can help us shake this state of dis-ease that predictably follows exposure to toxic stress in childhood. We must not continue to medicalise, criminalise or pathologise problems that have their origin in abusive, neglectful or violent childhood experiences.
The first 1001 days from conception to age 2 are disproportionately important in determining the health and prosperity of our future adult population. Parenting programmes are cost-effective, and evidence-based and can help prevent child maltreatment
Many parents who neglect their children don’t know that they are harming their children. They just have no idea what good looks like. Their experience of being parented is often characterised by adversity and they are repeating those patterns. Parents with young children receiving family support services, when asked about their own experience of adversity in childhood, frequently then reflect on their own children’s lives and sometimes see that they are exposing them to multiple ACES. But then they predictably ask for help! This offers the opportunity to break the intergenerational cycle of adversity and offering parenting programmes is a good place to start. But not only to families who are struggling – why don’t we offer parenting courses to all parents as part of the antenatal and early years offer – universally and for free? We have to shift the status quo and embrace prevention as a priority. We can’t keep doing the same things and expecting a different outcome – that after all, is surely a sign of madness.
Warren Larkin is Consultant Clinical Psychologist, Author and Founding Director of Warren Larkin Associates. He likes to think he is helping to change the world by asking the right questions and challenging the received wisdom. He designs trauma-informed systems, helps professionals ask about ACEs & to respond skilfully to disclosures and talks to anyone that will listen about routine enquiry and ACE science.
In my next piece I am going to cover the upstream interventions that can fundamentally change the population health profile of the nation. In particular I will be focusing on trauma-sensitive schools, because in every class, in every school, in our great nation, there are children who can't learn. They are afraid and inside are worrying about what will happen to them when they get home. 1 in 10 children will experience 4 or more ACEs. 1 in 20 children will be experiencing sexual abuse, 1 in 14 will be experiencing physical abuse and 1 in 5 children will be exposed to domestic abuse. Yet most of the time we wait to see if they say something to a teacher or until there is a sign of abuse that can't be ignored before we intervene to safeguard those children. Most of them say nothing and many end up in mental health services, drug and alcohol services or develop cancer, health disease or obesity later in life. Those exposed to 6 kinds of adversity before age 18 are likely to die 20 years before their peers who have no ACEs to report. What are we going to do to fix this unacceptable and tragic reality?
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