Fixing the NHS with public health and public engagement

China’s covid-19 pandemic is the starkest example of the power and the danger of autocracies. Through iron rule and absolute implementation of its zero covid strategy, China kept death and ill health from covid at low levels. But the statistical success of China’s approach became its blind spot. Unlike other countries, with differing levels of covid measures, China did not optimise the exit strategy: to optimise vaccination levels in its population and then gradually open up society. Vaccination coverage was suboptimal and the comparative effectiveness of its domestically produced vaccine is questioned.

China became trapped, unable to ease restrictions and unable to make progress with its vaccination strategy. When public pressure became too great to prolong restrictions even further, SARS-Cov-2 was unleashed again in a society with little or no vaccination-induced or natural immunity. Now, China has effectively stopped counting cases. Its reporting of covid-19 deaths is unreliable, with some modelling studies predicting over 1 million deaths in 2023, and this after two years of oppressive restrictions.

Whilst long term, consistent policy making can bring benefits, autocracies are bad for health. Miles Balfe identifies five challenges that autocracies pose to human health and medical science, and these include a corrosive impact on mental health and wellbeing, subversion of health professions, and perpetuating health inequalities. ¹ The challenge for democracies, says Balfe, is to prevent their own health systems from becoming reliant on autocracies for resources.

Democracies, of course, aren’t immune to health crises, as current events in the NHS demonstrate. Immediate solutions are required, to address the workforce crisis and to ease the pressure on primary and emergency departments in particular, but the chronic problems of the NHS require long term strategies and plans, especially to improve baseline population health through primary care and public health, deliver the long promised investment in and integration of social care, and address the wider determinants of health. The ideal, therefore, is a democracy with consistent long term policy making for health.

John Ashton reminds us that when banker Derek Wanless was asked to consider the case for increasing UK health funding to European levels, he concluded that the only viable model was a complete system transformation rooted in public health and full public engagement, bringing with it a focus on prevention and interventions outside the health system. ² Such a transformation is politically difficult but necessary.

Changing clinical practice is hard too, as this month’s paper reveals an absence of progress in switching to low carbon inhalers. ³ Something as intuitive as using patient-reported outcomes to reduce pressure on outpatient services comes with challenges according to the evidence. ⁴

Indeed, in times of trouble, the skills required to appraise evidence, especially systematic reviews of the evidence, become essential to seeing our way through the fog. ⁵ And this should be another advantage of democracies that, unlike autocracies, science does not become “subservient to the political goals of the regime.”