The underlying conditions that make COVID-19 into a killer disease are themselves pandemics. Here, Honorary Reader Martin Yuille and Professor Emeritus Bill Ollier outline the need to tackle these conditions by combining public policy reform with community change and technological innovation.
- Underlying health conditions are the greatest risk factor associated with COVID-19 mortality
- A new approach to public policy based on scientific evidence and reasoning is needed to tackle these conditions
- This new approach would see health improvement becoming the central purpose of every branch of national and local government, rather than it being conflated with healthcare.
After the pandemic, which window of opportunity will open widest for far-reaching innovation and experimentation in public policy reform? If there is one window that cannot be shut back down, it surely relates to public policy in the field of health.
We distinguish ‘health’ from ‘healthcare’; health is a state we all wish to have, while healthcare is an intervention we all wish will end as quickly as possible.
Post-COVID-19, it will not be simply a matter of improvements to stockpiling of PPE, increased provision of ventilators or intensive care beds, or capacity for population-wide testing or large-scale contact tracing. There are deeper issues at play, going right back to basic definitions of ‘health’.
This broader issue of health has to be tackled afresh, because what makes COVID-19 such a problem is that, while it is a mild disease for those who are otherwise healthy, it becomes a killer disease for those with underlying conditions. This is also frequently the case with other respiratory infections like influenza. Continuously improving population health by tackling those underlying conditions is the best defence there can be against the next viral pandemic. That is what public policy now has to put right.
The underlying conditions that make COVID-19 into a killer disease are themselves pandemics. They include chronic conditions like diabetes, heart disease and cancer. Prevention does not mean improving treatment of these conditions, but reducing the risks that we all face of getting them. Those risks are well-known: obesity, for example, was identified by the World Health Organisation (WHO) as a global pandemic years before COVID-19 came along. It affects not only high income but also middle and low income countries. In North Korea, obesity (BMI over 30) affects 6.8% of adults. WHO has coined the term ‘globesity’ to refer to the problem.
If we ‘follow the science’, then continuous improvement of population health requires us to think again about how public policy can be used to combat obesity, insufficient physical exercise, and social isolation. Public policy has, so far, failed. Healthcare policy is not the issue in the first instance. By the time we need healthcare, we have missed the opportunity to prevent ill-health. The direct issues relate to food and agriculture policies; transport, housing and planning policies; and cultural and community policies. The indirect issues include education policies, economic and business policies, and even foreign policy (think of chlorinated chicken or hormone-enriched beef).
Improving population health as a goal in itself and as protection against the next new viral epidemic thus encompasses public policy as a whole, if we are to follow the science. WHO has expressed the need for ‘health in all policies’ so as to fight against common chronic conditions. This would put health on the agenda of every department of national and local government.
However, this does not go far enough. Health should not merely be on the agenda. It has to become the agenda itself. In other words, health has to become the purpose, the organising principle, the raison d’être of government and of governance. If we do not follow the science, we will be left with the consequences of ever-increasing levels of diabetes, heart disease, cancer, depression and anxiety. Much of the £152.9 billion needed in 2018/19 by the NHS goes on treating these conditions. Then there are the non-NHS costs of the consequences of this ill-health. Public Health England has calculated that the financial costs to individuals, employers, the NHS, the government, and to the whole English economy to be between £147 billion and £185 billion per annum. This corresponds to about 11% of GDP for the UK as a whole. Despite all this cost, without change, we shall still be left at the mercy of the next pandemic.
Health is not the ‘absence of disease’: we endorse the argument that it should be defined as the status we each have when our needs are optimally satisfied.
Applying this definition in policy reform, a Deputy Prime Minister (DPM) should have direct responsibility for population health and should have the role of coordinating action on health across all departments. The Department of Health becomes the Department of Healthcare. MHCLG seeks optimal housing provision. BEIS ensures that employers provide optimal rest and exercise for employees – as well as safety at work. And so on.
Part of the DPM’s coordination can be delivered via the National Risk Register that was introduced in 2008 to list, monitor and mitigate significant risks. Flu is on the register. So are emergent infectious diseases. But obesity, for example, is not – despite the recommendation of the Chief Medical Officer. All the modifiable risk factors for the common long-term conditions need to be on the national and community level risk registers. The register is a good tool for defending communities from floods. It needs to defend them also from the pandemic in chronic conditions. Of course, this requires a government that takes risk reduction seriously. The recent depletion of national PPE stockpiles indicates that this cannot be taken for granted.
In addition to such institutional changes in our governance, we also need community and technological change.
Britain’s first-ever Public Health Minister, Tessa Jowell, laid out a vision in 1998 for improving the health of the population that saw stakeholders – including communities – agreeing to work together. Moving from vision to practise is never easy, and the first major attempt at improving population health in 2008 relied not on stakeholder agreements, but on a conventional service approach, with the introduction of the NHS Health Check.
This service has persisted for over a decade but is at risk of becoming solely triage for patients. However, it can still provide a platform for reforms that would promote the health of the population via stakeholder agreements and that would elevate individuals and communities from passive recipients of a service into citizens and organisations who are engaged and involved in their own health and that of others.
One idea is to convert the typical practise nurse who performs health checks into someone who also undertakes community development work. Citizens coming in for checks would be encouraged not only to improve their own health but also to work for their community on such goals. Some citizens would then become health champions. The rapid recruitment of 750,000 volunteer champions of the NHS at the beginning of the COVID-19 pandemic suggests that there are many people who would want actively to aid their fellow citizens’ in preventing disease.
Imagine health champions (recruited at an NHS Health Check and supported by the nurse / community development worker) who are members of football fan clubs. They might undertake to improve their fitness and lose weight alongside their fellow fans at the club (regardless of whether they have had a health check). The club is encouraged to support this because the fans want to bring their families and friends along too. Thus, the health check has become a tool simultaneously for improving health, for community development, and for building a local business.
The technical business of health improvement is ‘risk reduction’. This means I need to know, as quickly and as precisely as possible, that I am being successful in minimising my risk factors for the common long-term conditions. I need regular testing of my ‘risk biomarkers’ with my test results stored safely. These risk biomarkers are simply molecules in our bodies where a change in structure or concentration is robustly associated with decreasing risk of, say, diabetes.
Little research has been done on such risk biomarkers because work on prevention has been so feeble. However, with the right prevention infrastructure in place, the innovation required should be quick and straightforward. Unsurprisingly, this infrastructure is precisely what is needed to prevent a disaster when the next pandemic strikes. It comprises a national health data management system comparable to what was being built up until 2010 by the NHS Connecting for Health project, plus a biobanking system comparable – but larger – than the UK Biobank project started in 2005.
Nearly all governments around the world have decided that they need to say that they are following the science in dealing with COVID-19. From the point of view of the way that public policy rationales change over time, the new reliance on evidence makes a welcome change from reliance on either dogma or fantasy. The challenge for public policy thinkers will often be a need for them to brush up on their knowledge of areas of science that are key to public policy, areas such as epidemiology.
Dr Yuille and Prof Ollier are honorary and emeritus members of The University of Manchester’s Centre for Epidemiology. Their forthcoming book, ‘Saving Sick Britain’, is to be published by Manchester University Press.