Your articles on health inequality this week included excellent coverage of the government’s project to shift the emphasis of healthcare from treatment at the clinic and hospital to prevention through public health initiatives (Downing Street’s radical plan for the NHS: shifting it from treatment to prevention, 29 June). However, one key element is missing from the analysis that has frustrated the implementation of such necessary innovations: the way that undergraduate students are educated and socialised into medicine within longstanding conservative curricula.
Historically, doctors gain an identity that is grounded in the sanctity of the “clinic” (primarily the hospital) as a well-patrolled territory with idiosyncratic rituals and language. Patients are kept on the other side of the fence. Medical education traditionally affords little work-based experience in the first two years, but after that students gain increasing exposure to clinical work. However, this is largely focused on secondary care (hospital and clinic) settings, and on cure rather than prevention.
Medical students soon learn that their professional identity construction depends on strict separation from community-based practices such as social work as they identify with the curative rituals of the clinic. Healthcare as a whole will not be able to focus on prevention, as Wes Streeting wishes, until medical students’ miseducation into the sanctity of clinical cure is addressed. This is a pedagogical challenge that must no longer pass under the radar.
Dr Alan Bleakley
Emeritus professor, Peninsula school of medicine, University of Plymouth
Of course Denis Campbell is right to say that moving the NHS from treatment to prevention is a great idea. The problem is, and has been for years, that finding the money for preventing ill health is apparently impossible while the NHS still has to treat ill health that wasn’t prevented. Treasury rules seem to forbid investing for future savings.
Christina Baron
Former NHS trust chair
Your report (29 June) on “medieval” levels of healthcare inequality affecting the poorest sections of society is borne out by the National Diabetes Foot Care Report 2022 for England. This found that people with diabetes living in the most deprived areas of England are 82% more likely to undergo a major amputation than those in the least deprived. Such a predisposition to major amputation in the circumstances of poverty contributes to a postcode lottery with a 4.8-fold variation in major amputation rates, ranging from 3.5 to 16.8 amputations per 10,000 population with diabetes per year.
People in deprived areas face economic and social barriers to care and restricted referral pathways, resulting in delayed access to specialist care. They are then too late for conventional treatment and require amputation, with all the suffering, costs and life-changing effects these have. Thus the income and home address of people living with diabetes can contribute significantly to whether they lose or keep their legs.
However, it should be possible to prevent most major amputations. Such an aspiration is in keeping with the preventive ethos of the 10-year NHS plan, which it is hoped will facilitate more rapid and equitable access to initial care in the community and prevent amputations in all people living with diabetes.
Prof Michael Edmonds, Jonathan Hunt (patient), Dr Erika Vainieri and Dr Chris Manu
King’s College Hospital, London
The excellent Black report on inequalities in health was commissioned by Labour in 1977 and published in 1980, by which time the Tories were in government and the report was marginalised and ultimately dismissed by them. The report recommended improvements in child benefits, childcare allowances, preschool education, school milk and meals, disablement allowances, housing and working conditions. Nothing new there, then. We know what needs to be done to make the quality of life more equal for all of us. Anyone who lives in or is familiar with those parts of the north (and elsewhere) suffering extreme deprivation knows that things must change. The situation is intolerable. It is a blight on our so-called civilised society.
Val Cooper
London
The ministerial U-turn on planned health-related benefit reforms included a welcome pledge to “listen”. They would do well to study the link between deprivation and the “lifestyle diseases” arising from obesity, smoking and excessive alcohol consumption. As well as explaining the 11-year life expectancy gap between the most and least deprived parts of the country, it is a vital but often overlooked factor in the debate over health and disability benefits.
My research reveals that people in the poorest communities typically experience poor health up to 21 years earlier than those in richer areas. In Blackpool, for instance, “healthy life expectancy” is just 53.5 years, compared to 74.7 years in Rutland. People in Blackpool are therefore far more likely to leave the workforce before state pension age – and therefore claim health and disability benefits – than those in Rutland.
The government must pursue a longer-term approach to curb the rising welfare costs of poor health and disability. We need a comprehensive public health strategy to tackle the root causes of premature poor health. For too long successive governments have shied away from bold actions around smoking, obesity and alcohol to significantly improve public health.
Prof Les Mayhew
City St George’s, University of London
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