Royal Commission on the NHS Chapter 5

Good Health

5.1 Although the promotion of “a comprehensive health service designed to secure improvement… in the prevention” of illness is one of the duties laid on health ministers by the NHS Acts, only a small proportion of NHS resources is devoted to prevention. The NHS has always been primarily a “treating” service. The curative and caring services make the essential contribution to the alleviation of suffering and always will, but we regret that more emphasis has not been placed in the past on the preventive role of the NHS. This must change if there are to be substantial improvements in health in the future. We received a great deal of evidence to support this view, and in Chapter 2 we stated as our first objective for the NHS that it should aim to encourage and assist individuals to remain healthy. In this chapter we examine ways in which this objective may be achieved.


5.2 Prevention of ill health has been classified as primary, secondary or tertiary. Primary prevention is taking measures to prevent disease or injury occurring, immunisation, good obstetric care and discouraging smoking for example.  Secondary prevention measures are concerned with identifying and treating ill health promptly, for example through screening patients at risk. Tertiary prevention is concerned with mitigating the effects of illness or disease which has already occurred and includes rehabilitation and continuing care such as the care and after care of diabetics and terminal care. Health services are for the most part concerned with the second and third categories. In this chapter we deal mainly with primary and, to a lesser extent, secondary prevention.

5.3 To put into perspective what may be accomplished by the NHS, it must be understood that many of the main improvements in the health of the nation have come not from advances in medical treatment but from public health measures, better nutrition and improvements in the economic, social and natural environments. As the Health Education Council’s evidence pointed out:

“The three main components of successful health promotion over the last 100 years were achieved by regulatory procedures affecting the environ­ment, specific programmes addressed to pregnant women, infants and school children, and the general improvement in the level of nutrition.”

The provision of a clean water supply, an efficient sewerage system and better standards of food hygiene in the nineteenth century virtually eliminated cholera and greatly reduced enteric fever which until then had been endemic in the UK. Medical advances made little impact on mortality rates until the introduction of immunisation and the sulpha drugs in the 1930s, and the antibiotics in the 1940s. Since then mortality has declined at a slower rate -although for particular age and sex groups, infants and women between the ages of 35 and 44 for example, the fall has been much sharper. Curative and caring services and related research contribute a great deal to individual treatment and their importance must not be under-rated, but on the basis of past experience a substantial improvement in national and community health is more likely to be achieved by preventive measures.

5.4 We make the point, not to belittle what the NHS has achieved, but to put it in perspective. Mortality statistics do not tell us much about the state of health of the existing population, or the quality of life of the old or chronic The introduction of effective vaccines for polio in the 1950s made only a small difference to the mortality statistics since not many people died from polio, but led to a big reduction in the incidence of disablement in the population. Important  though  the  acute  services  are  for  the  individual, dramatic improvements in the general health of the nation or in mortality will not  be achieved  by simply  spending more and  more  money on  curative medicine. We have therefore considered the case for putting more money and effort into preventive medicine.

5.5 The most obviously preventable conditions are those which can be attributed directly to the way we live. Smoking is an important contributory factor in lung cancer, bronchitis and coronary heart disease, but in 1976 46% of adult men and 38% of adult women smoked cigarettes. Road accidents account for about 6,500 deaths in Britain each year. The  White Paper “Prevention and Health” points out that “deaths and serious injuries to front seat occupants of cars involved in road accidents could almost be halved” if front seat passengers wore seat belts at all times.  Excess blood alcohol contributes massively to road accidents, and alcoholism to other accidents and to social problems. The wrong kinds of food encourages obesity and dental Nutrition influences both health and disease and an increasing interest in diet amongst the general public indicates that educational efforts are likely to be rewarding. Society’s concern about nutrition may be seen in the provision of school   meals.  Reduction in smoking and alcohol related illness, the prevention of road accidents and mitigating their results, improved nutritional policies, should be the prime targets for prevention. But there are other factors which are outside the   control of the individual, and we comment on environmental and occupational health considerations below.

5.6 The first problem of preventing ill-health is lack of detailed and precise knowledge of the causes of many diseases, and therefore of the best means of preventing them. Obviously there is no difficulty of this kind about, for example, the link between smoking and lung cancer – where Britain has particularly high death rates. This is an exceptional case, and in heart disease, for example, there is no such certainty. Risk factors such as smoking, obesity, lack of exercise and high blood fat levels have been identified. The role of diet in heart disease is particularly contentious and similar uncertainties exist about other killing diseases.

5.7 There is also a lack of established fact on which some other preventive measures, particularly screening, might be based. It is a widely held view that early diagnosis and treatment of a disease improves the prospects of cure. Some of those giving evidence to us argued that mass screening – even an annual check-up for everyone in the country – would be desirable and effective in enabling disease to be identified and treated early. There are two important points to be made here. First, it would be quite impracticable to provide regular screening even for major diseases for the whole population; second, there is no evidence that unselective screening of this kind would produce useful results. While screening is not the universal panacea that some people believe, there is a place for it where high risk groups can be identified and treated effectively at acceptable cost. The use of age and sex registers in general practice can make a contribution to screening and health visitors have an important role to play in the developmental screening of children and the One programme which has been shown to be effective is the screening of “at risk” pregnant women for foetal abnormalities. The continued expansion of pre-natal screening and genetic counselling with the support of therapeutic abortion facilities could do much to reduce the number of handicapped children born each year. We recommend the expansion of proven screening programmes,

5.8 The second problem raised by preventive measures is personal freedom. To what lengths should society go, to force each one of us to do things which are good for him? In a free society it is unlikely that we shall be compelled to take exercise or to eat things which are good rather than bad for us except by social pressure. But society can choose to fine those who do not wear seat belts in cars, to fluoridate all drinking water (discussed more fully in Chapter 9), and to tax cigarettes and alcohol punitively. Opponents of such measures argue that they are an unwarrantable intrusion on the freedom of the individual.

5.9 This is a well understood and extensively argued ethical problem, but it is difficult to find common examples of individual action which affect only the individual. There are few of us who could kill ourselves whether by motor­ car or by cigarettes without affecting others. On another level, there is the cost to society of medical treatment. A great deal of regulation of society exists already and is accepted as necessary: on the road it includes, for example, a requirement that people should not drive with more than a certain amount of alcohol in their bloodstream and a host of other regulations designed to protect road users. A balance has to be struck between extending measures of this kind, which benefit the health of the nation, and interfering unreasonably with the liberty of the individual. Yet if the health of the nation is to improve we have little doubt that society should be prepared to be considerably less self-indulgent, and the government to take a stronger line, on restricting activities, like smoking, which are known to be harmful. The William Temple Founda­tion, in its evidence to us, commented on this aspect of community responsibil­ity for health:

“Although the responsibility and potential for each individual to influence his own level of health should not be undervalued, this approach ignores the important perspective that should be part of a community diagnosis. This would include consideration of society’s responsibility for preventing illness amongst its members. It would appear unhelpful to encourage people as individuals to stop smoking, over-indulging in the ‘wrong’ foods, and leading stressful sedentary lives, when there are evidently so many strong influences encouraging, or even ensuring, that people continue to do these harmful things.”

5.10 The third problem is putting prevention into practice. We discuss health education, environmental health measures and occupational health services below, but there is a general point to be made about costs first.

5.11 Preventive services will not necessarily reduce NHS costs. Some preventive measures  are  expensive  in  themselves and  some, for example screening programmes, may increase current demand on the NHS if more cases requiring  treatment  are  Future costs may also rise if prevention increases life expectancy without a significant reduction in indivi­dual morbidity. Calculation of the balance between present and future costs is extremely difficult. But the effects of prevention on NHS costs is only one of the factors to be taken into account when preventive measures are evaluated. The benefits of prevention will include the improved health of the population and reduction in those costs of ill-health which fall outside the NHS.

5.12 There are some preventive measures which certainly do or could reduce NHS costs. Vaccination and immunisation programmes are obvious There has been a disconcerting fall in recent years in the number of children being immunised and efforts must be made to regain the previous high levels. The economic benefits of preventing illness amongst the working  population must not be forgotten. The annual cost of treating smoking-related diseases in England and Wales was estimated in the recent report of the Expenditure Committee at about £85m at 1977 prices and the number of premature deaths at between 50,000 and 80,000 each year. The Department of Environment has estimated that in 1977 road traffic accidents cost the NHS about £44m and imposed considerable costs elsewhere in the economy in loss of output and property damage. We recommend that the wearing of seat belts should be made compulsory for drivers and front seat passengers in motor vehicles.

Health Education

5.13 A great deal of evidence was sent to us urging that more effort and money should be spent on health education. The Health Education Council for England, Wales and Northern Ireland received £3m in 1977/78. It is difficult to calculate the additional value of work undertaken, for example by health professionals and teachers as part of their normal duties, but it is certain that the amount of money devoted to health education represents a very small proportion of the total health and education budgets.

5.14 The aim of health educators is to inform people about risks to health and to increase understanding of factors which will promote good health. Information will not of itself make people lead healthier lives and needs to be reinforced by the example and advice of government, teachers, and health professionals. To change attitudes and behaviour is difficult and although health education has led, for example, to some reduction in the number of smokers there is no clear evidence that without legislation or political commitment, it can improve health on its own. This is not necessarily a reason for limiting expenditure on health education but is an argument for not relying too heavily on it as the saviour of the nation’s health. Existing ways of encouraging people to lead healthier lives are not well developed.   We recommend the continued expansion of health education but some of the increased resources must be spent on developing more effective methods and on monitoring and validating existing and new techniques.

5.15 It is likely to be easier to promote healthy habits at an early age than to change established attitudes and behaviour. We would particularly welcome a considerable strengthening of health education in schools, with teachers, health education officers and health professionals playing a much fuller part than they do at the moment. Health visitors are particularly important in this respect because they are specifically trained to promote health education, but all those who teach health education need to be trained to communicate information about healthy living. Too few in-service training opportunities exist at present. We were not impressed by the account, we received of existing arrangements in schools from the main authorities concerned. We recommend that they should examine seriously their efforts in this field.

5.16 While health visitors and environmental health officers have for long had a clearly established role in the promotion of health, other  health professionals, for example, doctors, dentists, pharmacists and nurses, all have an important part to play. They may be able to advise people at times when, because of personal or family circumstances of illness, they are particularly receptive to advice, and it is important that they encourage patients’ self-help We should like to see health education given greater emphasis in the training and continuing education of health professionals.

5.17 The operational responsibility for health education lies with the area medical officer who plans health education programmes with the assistance of specialist health education staff. But many health authorities have been slow to appoint area health education officers and six areas in England have no health education officers at all. One of the reasons for lack of progress has been a shortage of able, qualified staff, and we were encouraged to hear that the Health Education Council and the Scottish health education bodies are working to meet some of the training gaps. It does not necessarily follow, of course, that because a health authority has no health education officers it makes no health education effort, but health education should be emphasised in the forward planning of health authorities and we so recommend.

5.18 Voluntary bodies have often shown the way to future provision of services by health and other statutory agencies. It is clear that they have also a great deal to offer in promoting self-care and in providing care and support for groups of people suffering from particular illnesses and diseases. We say more about this important role of voluntary bodies and volunteers in Chapter

5.19 Intelligent self-medication and care can undoubtedly reduce demands on health services, and it is essential that society accepts the need for appropriate self-care. However, there are wide variations in individuals’ abilities to care for themselves, and excessive emphasis on self-care could mean that patients were discouraged from using NHS services when they needed That would be contrary to a number of the objectives of the NHS which we suggested in Chapter 2. Valuable work is or can be done by health professionals, especially pharmacists, in enabling people to treat themselves.

5.20 The growing interest of the health departments in health education has been show recently by several useful publications, including “Reducing the Risk: Safer Pregnancy and Child Birth” and “Eating for Health”. We hope that this impetus will not be lost and that further high quality publications will be forthcoming. Another important function of the health departments is to bring pressure on other government agencies. The Expenditure Committee’s Report on Preventive Medicine pointed out that:

“Decisions which may affect health are taken in a number of government departments other than the DHSS; such matters as transport planning, food pricing policies and housing are particularly clear examples of this and fluoridation has implications for the Department of the Environment.”

5.21    Radio and television could have a great deal to offer by providing information to individuals and families about ways to improve and keep their health. For example, it has proved difficult to reach people in social classes IV and V using the more conventional methods of health education. There are welcome signs of collaboration between the Health Education Council and the television companies. However, there is no doubt that television and radio, certainly in their commercial forms, do a great deal of harm by promoting excessive consumption of alcohol, tobacco and sweets, for example – which, except in moderation, are bad for us. As the Society of Community Medicine pointed out to us when commenting on the failure of health education to persuade more than a minority of individuals to alter their way of life:

“the effects of the present cultural backcloth outweigh the influence of health education effort. It follows that the cultural weave and woof as exemplified by plays, films, books, advertising material, etc., must contain strands of positive health”.

No health education programme will make much impression on the public unless it is forcefully presented and widely disseminated. The most effective medium is undoubtedly television. The high cost of using it should be reflected in the funds made available to the Health Education Council and the corresponding bodies in Scotland. We recommend that they are increased for this purpose.

Environmental Health

5.22 As we have already pointed out, it is through public and environmental health measures that the greatest advances in preventing ill-health have been NHS reorganisation did not include the transfer of environmental health services to the NHS, and responsibility for preventing the spread of communi­cable diseases, food hygiene, port health, public health aspects of environmental services and the enforcement of requirements about conditions at work places, remains with district level local authorities. There were few complaints in our evidence that this had caused problems, although the difficulties of co-operating closely with medical staff employed by health authorities may be similar to those experienced by other local authority services, outlined in Chapter 16.

5.23 Although it is clear that the levels of the most serious killing and crippling diseases, for example heart and lung diseases, are largely affected by individual behaviour, there remain many other areas where government action could help to improve our environment. Restrictions on smoking in public places and a more vigorous policy on noise pollution are examples. Local authorities should also ensure that sufficient resources are made available to environmental health services to allow them to maintain their previous high The Society of Community Medicine pointed out that:

“Despite many advances in improvements of environmental control, especially in the more traditional sectors, ie, water and air, there is little evidence that the physical environment continues to improve; rather the reverse with the environment being continually and subtly degraded.”

5.24   Community physicians have a particularly important part to play in environmental health and health education. Their role and future is discussed more fully in Chapter 14 but some comments are appropriate here. At reorganisation the identifiable responsibility that the medical officer of health (MOH) had for a defined population disappeared. The community physician who discharges these responsibilities is less in the public eye than the old MOH, and some of the impetus for the development of services may have been lost. This is not to suggest that the clock should be turned back to before 1974, but to indicate that this is an area of health service activity which must be kept under review.

Occupational Health and Safety

5.25    Occupational health is concerned with “the reactions of workpeople to their working environment, and the prevention of ill-health arising from working conditions”. To this definition others would add that it should also be concerned with the effects of ill-health on work. Except for its own employees the NHS does not carry responsibility for the prevention and control of health hazards at work. The 1974 Health and Safety at Work Act provides a legislative framework for maintaining and improving health and safety, with the onus on the employer “to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees”. The Health and Safety Commission (HSC) and its operational arm, the Health and Safety Executive (HSE), are responsible for promoting and enforcing higher health and safety standards. The Act applies to nearly all employees but, as Crown employers, the NHS is immune from the enforcement provisions. The Health and Safety Commission have asked the government to remove that immunity so that NHS employees receive the full protection of the Act. We support this request. Occupational health for NHS workers is discussed in Chapter 12.

5.26 Our evidence on occupational health concentrated on the relationship between the NHS and occupational health services, some of it recommending that the NHS should establish a comprehensive occupational health service. It was not always clear what was meant by this and there are a number of possible alternatives to the present situation. The first is for the NHS to become responsible for the occupational medicine aspects of occupational Doctors employed in occupational health would be taken into the NHS, their closer contact with the main stream of medicine would be ensured and there would be less duplication of activities by the two services. The NHS could provide a service obviously independent of the possible biases of individual employers; and it could do so on repayment.

5.27 The second possibility would be for the NHS to be made responsible for all health aspects of occupational health, leaving the safety and welfare responsibilities where they are. Unless the Health and Safety at Work Act were revoked such a move would lead to the duplication of the tasks of the HSC and HSE, since new bodies with similar responsibilities would need to be established.

5.28 The third approach would be to transfer overall responsibility for health, safety and welfare from the Department of Employment to the DHSS and NHS. It is far from certain that this would lead to the required integration or to a comprehensive service.

5.29 This is a complicated subject, but it seems to us that the bodies established by the Health and Safety at Work Act should be allowed to continue to develop. While there are obvious links and overlap with the NHS in the health aspects of their work, the safety aspects demand special expertise and knowledge from a variety of professions not all of whom have much connection with the NHS. Doubtless there are deficiencies in the services provided under the 1974 Act at present, but we do not think these would be remedied by a large scale reorganisation. Probably the right way forward is to strengthen the Health and Safety Commission and Executive and to foster the development of links with the NHS. Even if industries and firms provide their own occupational health services there will inevitably be overlap with the NHS; and they are unlikely in the main to be able to carry out the epidemiological studies and the monitoring of health trends which depend on Consideration should therefore be given to the NHS providing, in each region and based on a university department of occupational, social or community medicine, a consultant in occupational medicine.

5.30    We asked one of our members to discuss in greater detail the issues raised here and his paper is reproduced at Appendix F.

Conclusions and Recommendations

5.31 Preventive measures are by no means the exclusive responsibility of the NHS. Nonetheless, in our view a significant improvement in the health of the people of the UK can come through prevention. There are major areas where government action could produce rapid and certain results: a much tougher attitude towards smoking, towards preventing road accidents and mitigating their results, a clear commitment to fluoridation and a programme to combat alcoholism, are among the more obvious examples.

5.32 This must be matched by other measures. More emphasis should be put on health education and on the development and monitoring of its There is room for greater involvement of GPs and other health professionals, and better in-service training for teachers in health education. The imaginative use of radio and television will be important. Much more can be done to emphasise the positive virtues of health and the risks of an unhealthy life style, and this should include environmental and occupational hazards as well as personal behaviour. It is important that local authorities should not let standards of environmental health slip. The NHS needs to face its responsibilities in prevention.

5.33 Occupational health and safety is not a responsibility of the NHS at present though some evidence we received suggested it should become so. This is a complicated field, and one which in many respects has little to do with the central functions of the NHS.

5.34    We recommend that:

  • proven screening programmes should be expanded (paragraph 5.7);
  • the wearing of seat belts should be made compulsory for drivers and front seat passengers in motor vehicles (paragraph 5.12);
  • health education should be expanded, but some of the increased resources must be spent on developing more effective methods and on monitoring and validating existing and new techniques (paragraph 5.14);
  • education authorities should examine seriously existing arrangements for health education in schools (paragraph 5.15);
  • health education should be emphasised in the forward planning of health authorities (paragraph 5.17);
  • funds for the Health Education Council and the corresponding bodies in Scotland should be increased to allow them to make more use of television (paragraph 5.21).