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Terry Maguire is a community pharmacist and vice-chairman
of PharmacyHealthLink
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It has taken 50 years but the truth is finally out: the NHS can be bad for your health. You do not agree? Why, then, in the league of big killers, does iatrogenic disease come an impressive fourth? Some achievement for a service whose mission is to save lives. And then there are health inequalities — the difference in the health of the best off in our society compared with the worse off is nothing short of a national scandal.
Ivan Illich, philosopher, doctor-baiter and one-time priest, was thought
to be barking mad when, in the 1970s, he made this claim in The Lancet.
He suggested a conspiracy by the medical profession and the drug industry
to bring about the “medicalisation of society” for the sole
purpose of profit. Drugs and other medical technologies, he was convinced,
removed personal responsibility for suffering and created dependence
on health professionals resulting, ironically, in worse health.
Doctors and other health care professionals, with their unique body of
knowledge, claim they know better than the rest of us so the contract
is that we hand over to them responsibility for our health. For many,
personal health is the GP’s problem not the individual’s.
Some social research even suggests this contract between the doctor and
his or her patient might be as much to do with ensuring the social and
financial standing of the doctor as it has to do with caring for the
patient.
Today, Illich (who died in 2002) is no longer seen as just another vulgar
Marxist but as someone whose views, while extreme, hold some merit and
might explain the lack of public health gain in recent years. There is
an old and, perhaps, tired argument about whether the NHS is a “sickness
service” or a “health service” but the culture of the
NHS must share some of the blame for the pronounced inequalities in health
in the UK.
Yet the successes of the NHS over the past 50 years cannot be denied.
I have three patients with cystic fibrosis, all in their late 20s and
in relatively good health. Had they been born, as I was, in the 1950s,
none would have lived beyond childhood. But the paradox, as Illich pointed
out, is that such developments run the risk of creating hubris in service
providers. In this context of impressive medical technologies, medicine
as a profession has developed a patrician arrogance that, it is claimed,
strangles individual responsibility for health and robs individuals of
the capacity to do things for themselves. This may seem an extreme view
but it is all too easy to see when you look for it. For example, I have
lost count of the number of continuing professional development meetings
I have attended where the speaker, normally a male doctor, makes fun
of the patient who visits his surgery with a sheaf of paper downloaded
from the internet.
The Government knows about this,
appreciates the long-term dangers and com-missioned Derek Wanless to
come up
with appropriate solutions. Wanless restated the obvious: we need better
support for disease prevention services and we need people to take more
care of their own health. Wanless wants people to “engage” with
services that are truly designed
to support good health.
True patient “empowerment” only exists when patients are
educated, facilitated and supported to make decisions about their own
health.
The Government’s self-care initiative is a key element of its wider
public health policy. It is set to re-engineer significantly the way
NHS services are designed and delivered. More subtly, self-care has the
potential to reverse the balance of power within the patient-doctor relationship
and that will be a good thing.
Self-care is more than a do-it-yourself
approach to health. It instils and articulates public health principles
and philosophies, and it includes avoidance of disease and self-treatment
of common ailments, as well as managing long-term conditions.
Post-Wanless the challenge will be to make self-care happen. This requires
a major change to the culture of the NHS rather than simply creating
a whole raft of new services. The irony is, of course, that the self-care
the Government would dearly wish to establish as a cultural norm is the
very self-care that was practised by everyone before the NHS was established.
In that paradigm, community pharmacy was a key resource in supporting
people to look after themselves — a pharmacist was the poor man’s
physician. And, in the new paradigm, pharmacy must again become a key
player.
Indeed, 85 per cent of what community pharmacists do on a day-to-day
basis could be considered public health, we just do not call it that.
Pharmacists, and the pharmacies we work in, make a major contribution
to the social capital of local communities. Social capital is the level
of support that a community can access when needed as opposed to help
given by health professionals, which is often viewed as being forced
on it. The challenge for pharmacy is to ensure that its services are
actively promoted and used in the proper way by its communities.
Smoking cessation services, emergency hormonal contraception, minor ailments
schemes and obesity clinics all mark the
beginning of a change in the way pharmacy engages with and supports local
communities. But we must ensure that in offering these services we do
not adopt the paternalism currently so inherent in the practice of medicine.
We need to refrain from telling people what to do and listen more. I
find that the biggest challenge is to get pharmacists to stop giving
advice and to start finding out what the client needs to bring about
change. An answer may be to train pharmacists in brief intervention techniques,
such as motivational interviewing.
Some years ago I sought funding to set up a diabetes service. One requirement
for getting money from an innovative public health project (the “Building
the Community Pharmacy Partnership”) was that I needed a community-based
partner. I linked up with the Falls Women’s Association but it
dismissed my idea of a diabetes service. It wanted to address the wider
determinants of health in the community so we agreed on a service to
address obesity. When the time came to prepare a leaflet for the scheme,
the association objected to the words “fat” and “obese” being
used. “Fat” and “obese”, it told me, were
pejorative terms and repelled the people we sought to support. I had
missed this key point. In the end, we used “healthy weight challenge” instead.
During the support
sessions we ran, I also came to understand that the reasons for an individual
becoming obese were complex and many, and not just down to eating too
much or not taking enough exercise.
Some of the 35 women who enrolled on our programme had alcohol problems,
sexual abuse problems and domestic violence issues, and these contributed
to their weight problem (and their increased risk of developing diabetes).
Only by addressing these problems could individuals begin to resolve
their obesity. I am not a trained counsellor and could only act as a
signposting agency when social issues emerged. The initiative turned
out to be an effective service in its primary aim of improving individual
understanding of the role of nutrition and exercise in obesity. Individuals
lost weight and, more importantly, they were able to do it for themselves
and their families.
Ivan Illich was partly right — reactive
paternalistic care, the main offering of the current NHS, is seldom successful
in addressing the behaviours that present the greatest risk of disease.
We need to give people back the right to look after themselves. After
all it is their health, not ours. |
The
Pharmaceutical Journal