Every year, about 20 people in Guernsey and Alderney under the age of 75 die of liver disease. On average, 19 of those deaths (95%) are thought to be preventable.
Likewise, around 35 people die of respiratory causes before their 75th birthday, and 22 of those deaths (63%) could have been avoided. There are about 112 deaths relating to cardiovascular disease (including heart disease and stroke) among under 75s each year, with 69 (62%) thought to be avoidable; and 218 cancer deaths, of which about 128 (59%) might have been prevented.
These figures come from p63 of the Guernsey and Alderney Health Profile 2010-12 (HSC hopes to publish a newer edition late this year or early next). They are based on the concept of “preventable mortality” – which is also used in the UK as a measurement of the population’s health. “Preventable mortality” is the number of deaths among people aged under 75 from diseases which could have been avoided if people made healthier lifestyle choices, and if the health system caught signs and symptoms early enough. (There is a separate statistic – amenable mortality – which relates to the number of deaths caused by lack of access to, or poor quality of, healthcare.) These figures will only ever be estimates, but they are based on the best scientific knowledge we have about what causes disease, what can be done to change the course of disease, and how effective early interventions can be.
One of the main ways that the number of preventable deaths can be reduced is by improving the general health of the population. There are a number of well-known lifestyle factors which damage people’s health in the long run: smoking, drinking, eating an unhealthy diet, and being overweight or inactive, in particular. (The risks of falling ill are also not evenly distributed: from the UK, we know that people who are poorer, and people with mental health conditions or disabilities, are more at risk of early death; and, likewise, men are more likely to die from preventable causes than women.) In Guernsey, just one of these lifestyle factors – smoking – is thought to be responsible for 1 in 3 deaths from cancer and respiratory disease, and 1 in 10 deaths from cardiovascular disease (p5).
It goes without saying that the death statistics are just the tip of the iceberg. There are many more people living with ill-health as a result of these risk factors in their lifestyles. (Alzheimer’s Association points out that “what’s good for your heart is good for your head” – capturing the link between healthy lifestyle choices and the risk of dementia.) The challenge for the new Committee for Health and Social Care is clear: 1 in 5 deaths happen too soon, as a result of factors which could arguably have been prevented; and many more islanders suffer from poor health due to these same factors. Successive political Health boards have recognised the importance of prevention – as early as the 2007 Government Business Plan (and probably earlier) it was one of the Priority Commitments; that was repeated most recently in the 2011 and 2013 updates of the 2020 Vision for Health and Social Care. I am confident that, for my new Committee too, preventing the causes of ill-health; promoting good health and wellbeing; and reducing inequalities in health across the population will continue to be recognised as important priorities for public policy on health.
Of course, prevention is a long-term game. The lifestyle choices people make now can affect their health status in twenty or fifty years’ time. The decisions my Committee makes this term will perhaps do little to change that figure of 97 preventable deaths a year before the next Election. If we invest in prevention, we’re investing in the health of a generation, and we have to see it through, patiently but persistently – even if the results are a long way off.
Prevention was always bound to be near the top of my mind, as a member of the new Health and Social Care Committee, getting to grips with our very broad mandate. But it was brought even nearer the top by the recent announcement my Committee has had to make, that bowel cancer screening locally is temporarily suspended.
There has been a lot of misinformation flying around about that. For the avoidance of doubt, HSC is under a States Resolution to provide bowel cancer screening using an approach called flexible sigmoidoscopy, which relies on a qualified health professional carrying out an investigation of the bowel (and potentially removing polyps, if they are found). HSC staff have been trying to get cover for this role for the past few months, but we are having no success in recruitment (in what we understand to be quite a difficult market to recruit in, UK-wide). While we look for alternative solutions, we decided it was best to write to people who were expecting screening appointments, to let them know that the service was currently unavailable. This has been misunderstood by some as a decision to cancel the screening programme – which couldn’t be further from the truth. (If you have been directly affected by the current situation, by the way, please get in touch: I’ll do what I can to connect you with the advice, support or answers to questions you may need.)
To explain why we wouldn’t pull the service altogether, we need to go back to the stats I began with. Cancers make up 4 in 9 preventable deaths in Guernsey (p63) – so they are obviously a key focus for any policy to promote better health. But not every cancer can be handled the same way. Lung cancer – which is the single biggest cancer killer in Guernsey (p61) – is notoriously difficult to detect early, because there are few distinctive symptoms. The NHS’s recently relaunched “Be Clear on Cancer” campaign is designed to try and increase early detection of lung cancer. But there is no effective screening test at present. On the other hand, over 80% of lung cancer cases can be linked to smoking – meaning that ongoing, targeted work to reduce smoking levels and exposure to second-hand smoke could continue to have really positive health benefits for Guernsey people.
Bowel cancer is not like lung cancer. There are effective screening tests: in the UK, screening (which is generally done by a stool test) is estimated to reduce a person’s chances of dying from bowel cancer by 16% (to put that in context, 1 in 14 men and 1 in 19 women may get bowel cancer in the course of their lifetime, with nearly 60% of people surviving their disease for at least 10 years). There are also lifestyle risk factors which can be tackled – a diet high in red and processed meats is thought to be responsible for around 1 in 5 bowel cancers; smoking, alcohol consumption, overweight and inactivity are other, familiar causes.
But bowel cancer screening is nowadays, without question, part of the armoury that any decent health system should have against mortality from preventable causes. Of course it is unfortunate that the States has micromanaged the shape of HSC’s screening programme down to the age groups to be screened and the technique to be used – this makes it much harder for us to adapt to resource issues (as we’re currently trying to do) or take on board new evidence (as the UK’s bowel cancer screening program has done several times in its ten-year history) without it becoming a complicated policy issue – but this is a consequence of its chequered political history and the States’ own prioritisation process, which we just have to chalk up to experience and get on with.
However, something got lost, locally, over the past few years, as bowel cancer screening became an increasingly contentious political issue. When it first appeared in States’ reports, it was as one of a number of preventive health measures. In 2009, it was put forward together with a proposed Obesity Strategy, as an opportunity to increase prevention. It was as things started to go wrong that the wider conversation about prevention fell away, and the focus homed in on bowel cancer screening as a single service area.
I am cautiously hopeful that, when we have fixed the current issue with our bowel cancer screening service, the new Committee can move the policy conversation back to a much broader discussion about how we prevent ill health and premature mortality. Bowel cancer screening is part of our basket of tools; so is breast cancer screening; so is cervical screening and the HPV vaccination against cervical cancer (all of which is already offered locally, by HSC or by GPs). So, too, are the areas of work in which we tackle lifestyle risk factors which are responsible for so much preventable loss of life – through strategies for Tobacco Control, Drugs and Alcohol, Sexual Health and Healthy Weight. Last week’s “Be Active” conference, focusing on promoting more active lifestyles among young people, adds yet another element to this work.
For HSC, the overall challenge is to continue to develop our understanding of how poor health and early death can be avoided through healthier lifestyle choices and early detection of signs and symptoms. We should try to learn from what’s working elsewhere and, where new techniques emerge, we should evaluate them carefully and determine if they should be adopted locally. We should seek to understand how health inequalities can develop because of people’s specific circumstances – e.g. the relationship between mental health and smoking – so that we can target our efforts appropriately, to remove barriers to good health for everyone. And we should, of course, continue to monitor the data about population health outcomes so that we can see any trends in the level and nature of preventable mortality, and adjust our approach to target them. All this needs to be done in a resource-constrained environment, which means we may often need to be imaginative in terms of how we work – including through effective joint work with our partners in the wider community.
The value of prevention, as a public policy intervention, can be a tough case to argue – because there’s often a gap of years between the action and the results, and because one always has to deal in what-ifs: “What if we hadn’t screened, or run that smoking awareness campaign? How sick would people be now?” Initiatives such as tobacco control, despite their demonstrable effectiveness worldwide, tend to invite pushback from people who resent the “nanny state” – although the same people, being advocates of small government, might recognise that money spent now on tobacco control is serious cost avoided on treatments for cancer and respiratory diseases in future. But, in any case, those 1 in 5 deaths that happen too soon are worth fighting for, and I hope this States will work with HSC in delivering an agenda that keeps prevention & the promotion of good health and wellbeing at the heart of health and social care policy for the island.