Disentangling the burden of disease in the UK: what now?
Authors: Ellen Nolte
Journal: The Lancet (2018)

"I wouldn't be here today if it were not for the NHS" was Professor Steven Hawking's response1Hawking S "I would not have survived": Stephen Hawking lived long life thanks to NHS.The Guardian. March 14, 2018; https://www.theguardian.com/science/2018/mar/14/i-would-not-have-survived-nhs-enabled-stephen-hawking-to-live-long-lifeDate accessed: September 19, 2018Google Scholar to an American newspaper that used him as an example to highlight the deficiencies of the UK National Health Service (NHS) by writing, "People such as scientist Stephen Hawking wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless".2Investor's Business DailyHow house bill runs over grandma.https://cdn.factcheck.org/UploadedFiles/IBDArticlesaspx.htmDate: 2009Date accessed: September 19, 2018Google Scholar Since the NHS is celebrating its 70th anniversary, it is timely to take stock of what has been achieved thus far in terms of population health. Over the past 150 years or so, people in the UK have seen tremendous increases in the number of years they could expect to live. In 1871, the average newborn girl would live about 45 years (vs 41 years for boys); by 2016, this life expectancy had almost doubled to 83 years (vs 79 years for boys).3Office for National StatisticsHow has life expectancy changed over time?.https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/howhaslifeexpectancychangedovertime/2015-09-09Date: 2015Date accessed: September 19, 2018Google Scholar Much of this increase in life expectancy was, at least initially, due to improvements in public health, such as the provision of clean drinking water, safe sewage disposal, and improved food safety. Advances in medicine and health care played an increasingly important part too, raising—at the time of the creation of the NHS in 1948— hopes that all diseases could be cured.4Snow S The NHS at 70: the story of our lives.Lancet. 2018; 392: 22-23Summary Full Text Full Text PDF Scopus (2) Google Scholar Indeed, as new interventions became progressively available to treat common conditions, there were remarkable reductions in death rates from conditions that were potentially amenable to health care,5Nolte E McKee M In amenable mortality—deaths avoidable through health care—progress in the U.S. lags that of three European countries.Health Affairs. 2012; 31: 2114-2122Crossref PubMed Scopus (62) Google Scholar including heart disease6Unal B Critchley JA Capewell S Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000.Circulation. 2004; 109: 1101-1107Crossref PubMed Scopus (547) Google Scholar and treatable cancers.7Rachet B Maringe C Nur U et al.Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England.Lancet Oncol. 2009; 10: 351-369Summary Full Text Full Text PDF PubMed Scopus (146) Google Scholar However, as people live longer, an increasing number are living with often multiple, long-term conditions. As the UK analysis of the Global Burden of Disease Study 2016 by Nicholas Steel and colleagues8Steel N Ford JA Newton JN et al.Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2018; (published online Oct 24.)http://dx.doi.org/10.1016/S0140-6736(18)32207-4Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar in The Lancet shows, the number of years lived with disability now surpasses the number of years of life lost. The study provides important insights into the patterns of disease burden across the devolved nations of the UK, across English local authorities, and over time. Some findings are perhaps not surprising; the mortality burden has remained highest in Scotland from 1990 to 2016,9Hanlon P Lawder RS Buchanan D et al.Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a "Scottish Effect".Public Health. 2005; 27: 199-204Crossref Scopus (94) Google Scholar and in the most deprived local authorities compared with the least deprived, by over two times. However, Steel and colleagues add granularity by providing detail down to the local level that, as the authors note, "can support various local, regional, and national actions", including the development of integrated care systems. Here is where the challenge lies. Over half of the mortality burden is attributable to behavioural risk factors, such as tobacco use, poor diet, alcohol and drug use, and low physical activity, and to environmental factors, such as air pollution. The authors highlight the key role that health services should have by prioritising primary prevention. Indeed, one of the core functions of the proposed integrated care systems in England is to place greater emphasis on population health and preventing ill health.10NHS EnglandBreaking down barriers to better health and care.https://www.england.nhs.uk/wp-content/uploads/2018/06/breaking-down-barriers.pdfDate: 2018Date accessed: September 19, 2018Google Scholar Yet, as Steel and colleagues also acknowledge, much of the need for action lies outside the immediate control of the health service. Thus, an effective strategy needs to consider the wider context within which people live and efforts should go beyond targeting the individual, taking greater account of the organisational and system levels in particular. Strategies also need to go beyond the health-care context to fully consider the broader influences that affect people's lives. As Rutter and colleagues11Rutter H Savona N Glonti K et al.The need for a complex systems model of evidence for public health.Lancet. 2017; 390: 2602-2604Summary Full Text Full Text PDF PubMed Scopus (314) Google Scholar have highlighted, the achievement of meaningful effects on complex multi-causal problems (eg, obesity) requires a multifaceted approach that cannot solely rely on a series of single, unlinked interventions that require the individual to act (for example, making healthy choices on the basis of traffic light labelling of food or taking up exercise on prescription). Such interventions tend to have low reach and widen health inequalities. There is a need for a wider policy framework that is mindful of the potential tensions and unintended consequences of policies that are not consistent, recognises the influence of powerful corporate actors in undermining public health policies that seek to promote health,12McKee M Stuckler D Revisiting the corporate and commercial determinants of health.Am J Public Health. 2018; 108: 1167-1170Crossref PubMed Scopus (68) Google Scholar and creates a policy environment that provides the means for those who are asked to implement change to acquire the capacity and competence to do so. I declare no competing interests. Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016These estimates at local, regional, and national level will allow policy makers to match resources and priorities to levels of burden and risk factors. Improvement in YLLs and life expectancy slowed notably after 2010, particularly in cardiovascular disease and cancer, and targeted actions are needed if the rate of improvement is to recover. A targeted policy response is also required to address the increasing proportion of burden due to morbidity, such as musculoskeletal problems and depression. Full-Text PDF Open Access