‘Sickness and cure versus wellness and health’ was the title of the big debate on prevention at this year’s NIPC Prevention Conference. Experts gave their perspectives on the challenges facing effective prevention – and there are many. 

The debate focused on a number of areas, including the division of resources and efforts between treatment and prevention, and the need for direct and radical action in order to redress the balance between acute care and effective prevention. Key deficits include health inequalities and lack of proper data and information systems in Ireland.

Contributions from the floor made for a stimulating session, which was chaired by RTÉ Current Affairs Department political correspondent Katie Hannon.

Not a case of ‘either-or’

Margaret Barry, professor of health promotion and public health at NUI Galway said as regards cure versus prevention, it was not a case of ‘either-or’. A modern health service needed to include the best treatment and rehabilitation, but it also needed investment in health promotion and prevention.

She said the current health system will ultimately be overwhelmed by the growing incidence of non-communicable disease. Therefore, urgent intervention was required at a population level to bring about big shifts in terms of reducing modifiable risk factors.

“It’s also important to realise that while promoting healthy lifestyle is very important, lifestyles are rooted in the environment in which we live. So we also have to promote healthy environments, and that means we have to take action way beyond the health services.”

Pivotal role of general practice

Andrew Murphy, professor of general practice at NUI Galway, pointed to the pivotal role of general practice in the health system. NUI Galway research, he said, showed that secondary prevention in general practice for CVD reduced overall mortality by 20%.

Prof Murphy said great potential existed but there were difficulties in general practice in terms of providing an effective preventive service. “At the moment general practice accounts for about 2% of the overall healthcare budget.” 

He also referred to workload and manpower pressures in general practice set against the expectation that GPs must perform more chronic disease care and prevention. 

Prof Murphy also pointed to the need to deal with multimorbidity and to move away from the single-disease focus in the system. 

The role of insurance companies

Former Department of Health Secretary General and current chair of the Heartbeat Trust Dr Ambrose McLoughlin said it was worth highlighting that over 40% of healthcare in Ireland took place in the private sector. 

“It is extremely disappointing, therefore, that health insurers are not contributing in a significant way to the prevention and protection of their members from chronic disease.” He said it would be wonderful if insurance companies could fund the roll-out of programmes like Croi MyAction across the country. 

Dr McLoughlin stressed the need for a functioning primary care system, and a wider scope of practice for other professionals including pharmacists and specialist nurses. In order to tackle the manpower issues in the service, conventional solutions would not suffice. 

“We will have to look at what type of auxiliary personnel we introduce to the primary and community setting under GPs. We also need to invest heavily in rapid turnaround diagnostics so that GPs can be empowered to make early interventions and supports.” 

He also stressed the need to embrace new technologies to improve diagnostics as well as virtual consultations to help cut outpatient waiting times. 

Self-management supports

Carmel Mullaney, public health specialist with the HSE, outlined her work on a national framework for self-management supports for people with chronic conditions including CVD. She highlighted the need for patients to become involved in prevention and self-management support, as the methods of care delivery are reformed. The emphasis will be on helping people to live well with their chronic condition.

Use of taxation and regulation

A key component of effective prevention was in the use of taxation and regulation by governments, according to New Zealand cardiovascular epidemiologist Prof Rod Jackson. “In new Zealand, we have regulated and taxed the hell out of the tobacco industry, we now need to do the same with the food industry. We need to tax sugar… we need to take this seriously. Obesity is ultimately a political issue.”

A lifestyle plan

Less than half of all coronary patients in Europe can get access to comprehensive lifestyle and risk factor management programmes to reduce their overall CVD risk, according to World Health Federation president-elect Prof David Wood. He said we need to be radical in our thinking about the delivery of preventive care.

Science and politics

Ambrose McLoughlin pointed out that it is very difficult to get a political system to accept science and evidence. He said policy is essentially driven by a flawed political structure. However, he praised the roles of former health ministers Michael Martin and James Reilly in taking on the tobacco industry.

Dr McLoughlin said in his time in the Department he favoured policies such as sugar and fat taxes and increased alcohol and tobacco taxes, but the lobby groups were very influential and there were worries about job losses. He pointed out that roughly 40% of the current health budget was spent on the problems resulting from tobacco, obesity and other healthcare-associated lifestyle issues.

Dr McLoughlin said a key concern too was that, while the middle-classes were getting the prevention message, the children of people in lower income groups were going to carry forward the burden of chronic disease.

Referring to criticism in some quarters of the government’s latest obesity strategy, Prof Jackson argued that even a relatively bad obesity plan is a good one, as it is trying to recognise and tackle the problem. He pointed out too that obesity/overweight levels in Ireland were beginning to drop, so positive things were finally happening.

‘Fire-fighting’ provisions

Irish cardiologist Dr Susan Connolly, now working at Imperial College, London, pointed out that the HSE had national leads for acute coronary syndrome and heart failure. These were essentially ‘fire-fighting’ provisions. “Where is the national clinical lead for prevention?”, she asked.

“We have the money (to effectively fund prevention). We just need to redirect it and somebody needs to speak up and tell the government to do it.”

Radical thinking needed

Prof Wood said radical thinking was needed on prevention. In this context, he said “we don’t need the cardiologists, who are doing an absolutely superb job in specialised centres; we don’t need the GPs, who have a different and very important role to play. What we need is a third way, and that’s exemplified by the Croi centre, which is run by nurses, dietitians, physical activity specialists, etc. These are the people with the necessary skills to deliver the preventive healthcare that is required by patients with cardiovascular disease: those at high risk, those with diabetes, etc. Why don’t we look at a third way of delivering healthcare outside hospitals and general practice?”

Prof Wood said there was an over-emphasis on intervention in cardiology. “There are very few cardiologists whose primary interest is preventive cardiology.” He also questioned whether all GPs have the necessary skillset for effective preventive care.

Prof Jackson said while he largely agreed with the ‘third way’ approach, there was a problem. “You don’t have the information. Your information systems are Third World.”

He pointed out that Ireland, unlike his home country of New Zealand, has no unique patient identifier which effectively means “you don’t know whether or not you are doing a good job.” In one of his presentations to the NIPC conference, Prof Jackson outlined how the availability of a unique patient identifier in New Zealand could be used for the benefit of population-based CVD prevention.

Dr McLoughlin said plans were in place to introduce a unique patient identifier in Ireland, but that it will take some time to introduce it. He said he would be in favour of exploring the option of Prof Woods’ ‘third way’, but he said one big deficit was that we have not developed the level of involvement by GPs in our healthcare system that is essential, and we need to develop the other healthcare professions. 

He pointed out that there are only 600 nurse prescribers in Ireland, when we should have 6,000.

Prof Murphy said a problem in adopting an integrated approach to prevention in Ireland was lack of trust. “Doctors are not trusted by the Department of Health and I think at times by the HSE. GPs at times are not trusted by their hospital colleagues and vice versa.”

Inequalities

Speaking from the floor, public health specialist Diarmuid O’Donovan pointed to glaring health inequalities in Ireland. While smoking rates in general had fallen to below 20%, over 30% of the population living in the most deprived areas still smoked, and there were other inequality issue such as access. He said we have a deep problem with health inequality and all the other issues around prevention are not going to be addressed until inequality is tackled.

Prof Murphy said there is much evidence to show that introducing high-quality primary care to deprived areas reduces morbidity and mortality. Unfortunately, there were deficits in terms of supporting primary care teams in these areas.

Community care

Dr Sean Dinneen, national clinical lead for diabetes, told the debate that key deficits in prevention include deficiencies in health informatics – we do not, for example know how many people in Ireland actually have diabetes, which is ‘shocking’- and the lack of a GP contract that focuses on prevention rather than sickness.

Brid Gavin O’Connell, data manager at University Hospital Galway, stressed the need to give ownership for their health back to the individual. “We still have to deal with the sick people we have now, but as regards prevention, we need to get in and educate children from a very early age.”

Consultant cardiologist Dr Jim Crowley said hospital cardiologists feel the work they do is important. However, there needed to be a bigger emphasis on primary care and managing patients in the community. He queried why community-based prevention programmes have not been developed and expanded. “To me this is a mindset issue. People don’t recognise that this is what needs to be done.”