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At the heart of general practice since 1960

‘Preventing disease will reduce GPs’ workload’

The head of Public Health England speaks to Caroline Price about plans for GPs to take the lead in averting ill health

Ducan Selbie big interview

Duncan Selbie is visibly rattled. The chief executive of Public Health England has just endured a grilling from Pulse and has reluctantly agreed to pose for his photograph.

But perhaps his slightly grumpy demeanour is justified. Mr Selbie is charged with turning a health service traditionally not good at preventing illness into the lean, healthy-living promoting machine envisaged in NHS England’s Five Year Forward View. It is a big job.

But PHE’s approach has not gone down well with most GPs. Plans for practices to screen millions under the Diabetes Prevention Programme baffled a profession already struggling to keep up with the day job.

And the NHS Health Checks scheme has been criticised by MPs, with the RCGP calling for it to be suspended.

But when confronted with these criticisms Mr Selbie is resolute. GPs are at the centre of his plans, he insists, and will benefit in the long run.

 

A recent PHE study showed diet is now a bigger risk factor in terms of illness than smoking. What are your plans to tackle this?

I used to be chief executive of an acute teaching hospital and we were just dealing with what came through the door. [But] now I’m concerned with what we can do to prevent that. The object of the Diabetes Prevention Programme is to see if we can slow down the conversion rate of the people who are pre-diabetic. Evidence suggests this programme could avoid almost a quarter of those going on to develop type 2 diabetes.

This scheme has been criticised by experts who say it’s too narrow, the benefits are overestimated and it could lead to overmedicalisation.

If we were only doing that, then I would share that concern. When you look at the evidence, it shows this programme can make a difference. We’re piloting this in seven parts of the country and the object is to find out how best to implement it. There are specific populations we do want to reach and we want to learn how we can do that over the next 12 to 18 months. General practice is crucial to that. I’m confident GPs – as they always have done – will follow best practice, so we hope they’ll be very cautious about their overmedicalisation concerns.

But what about introducing a tax on sugary food and drinks?

You’re making a great point. Diet is hugely important. We recommended back in the summer that the proportion of our nutritional intake from sugar should be halved, to 5%. This is a monumental moment for the Government, which has accepted this as a new standard. Alongside this, PHE has conducted a meta-analysis of what works, looking at reformulation of food, advertising, marketing, price, availability and accessibility. We have submitted this evidence to the Government and they are considering it and have committed to an obesity strategy by the end of this year.

So will there be a 20% tax on sugary drinks?

I’m not going to say yes, because I think the Government is entitled to a period of reflection. Evidence suggests the most important [approach] is reformulation of food. There are countries that have looked into price but there’s little published evidence about its effect.

The RCGP recently called for the NHS Health Checks programme to be stopped until you have evidence it works. Will you consider this?

We know that two-thirds of deaths in under-75s are amenable to prevention. And the programme is focused on the population, aged 40 to 75, at greatest risk of early avoidable death. In the past year, almost 1.5 million have taken this up.

There are concerns the scheme is mainly reaching the ‘worried well’. If so, is GPs’ time not being diverted from those most at risk?

You suggest NHS Health Checks are not closing the gaps on inequality; our evidence suggests it is. There will always be a range of views. [But] the programme is made up of a range of tests, each of which has been approved by NICE. The only thing that hasn’t yet been proven is, when we bundle them up in this way, do they make an even greater difference when done systematically and with a focus on those aged 40 to 75? Why? Because it’s never been done before.

We have a research strategy for the programme and, of course, if real evidence came through – not just a view or an opinion – then we would rethink the programme.

What about the £200m of cuts in public health funding; will the front line be affected?

I think there is enough money, but it’s how we choose to spend it. I would rather the cut wasn’t happening, but I have a bigger picture: the £103bn that local government and the NHS has and how we can use that money to better effect. The discussion on diabetes is a good example. We can save the NHS money, but more importantly we can save the NHS and general practice some workload by trying to avoid things in the first place.

GPs are concerned about targets to cut antibiotics prescribing, when they’re not the main problem. How do you see GPs’ role in this?

General practice has an important part to play. It’s in all of our interest, not just GPs’, that we have antibiotics to prescribe that work.

Is there a plan to publish individual prescribing data?

No, only at practice level. It’s about how you make sure the best information, evidence and guidance are there. We’ve done an evaluation with the chief medical officer on high-end prescribing and early results suggest just bringing this to GPs’ attention has an impact.

What about contractual targets?

The objective is to reduce the overall rate of prescribing, particularly of broad-spectrum antibiotics, and to reduce variation. A cold in Newcastle is no different to a cold in Southend, yet we have variations. Without being hysterical about it, getting information out and allowing GPs to compare is sensible. To incentivise good clinical practice to reduce prescription of broad-spectrum antibiotics, what’s not to like about that?

Career

1980 - Joined the NHS

2003 to 2007 - Chief executive, South West London and St George’s NHS Trust; chief executive, South East London Strategic Health Authority

2007-2012 - Chief executive of Brighton and Sussex University Hospitals NHS Trust

Director general of programmes and performance for the NHS and subsequently the first director general of commissioning

2013 to present - Chief executive, Public Health England

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Readers' comments (11)

  • Absolute nonsense. Preventing disease and DEATH might reduce workload but preventing disease just ahifts the workload further down the tracks where it is more complex. At the outset of the NHS it was thought that it would pay for itself because everybody would beCME so healthy and now look what we have got.

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  • Preventing death??

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  • In order to prevent "preventable" disease, you have to provide health promotion, treat risk factors and monitor conditions which increases clinical workload. By preventing early death from "preventable" disease, patients live longer and morbidity in the very elderly increases i.e. dementia, frailty and there are just more patients which also increases clinical workload. I see several flaws in the argument put forward by PHE. Clearly, I am not saying we shouldn't push health promotion but to say preventing disease reduces overall gp workload is a nonsense.

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  • NHS England - new policy once private companies come in - 'Let poor and old people die - it will reduce workload'.

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  • Simplistic nonsense
    I note this man is a manager not a doctor
    Please supply evidence this will be effective
    Lastly the available manpower is totally inadequate
    Another piece of delusion from the utterly incompetent English nhs out of touch bureaucracy

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  • A good illustration of a major problem with the NHS; managers telling doctors what to do, rather than asking us what would help.

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  • The fundamental difficulty is that the man doesn't seem to be aware that we are GPs first and foremost and he is talking about public health - different speciality and not the one I chose. PH is not my primary role and I am sort of busy in my more than full time GP role. He needs to sort out PH to run these screening programmes given that we have no more time and are not being asked to drop anything. The fact that GPs can do most things does not mean that we should, especially when it reduces the time we have available for our own work.

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  • So now it is the GP's fault for not preventing people from getting disease? Interesting!
    What happened to self responsibility or the government's fault for not running adequate health promotions.
    Also when would Gps get time to do this? Do they speak to patients coming into the surgery or do they get a megaphone and tell them what to do outside? What of the many subjects do they talk about, smoking, foods, alchol, drugs etc...
    Would they get paid for this?... thought not!

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  • The financial 'money saving' myth at the heart of all of this is that people dying from a 'preventable illness ' go on to live for ever.

    You prevent cardiovascular disease. You save £xxx in cardiovascular treatments in a 65 year old man (angiograms and A&E attendances) and £xxx in heart ache for the family that would have been left behind. Job done? Give the accountant and public health manager a pat on the back.

    No , what happens is that 65 year old man lives on to develop osteoarthritis of his hips and/knees. He gets forgetful and falls over and ends in A&E three times a year by the time he reaches 80 because he isn't really coping at home. He lives on to be old and dependant and expensive to look after.

    The reason the country can't afford the NHS it wants is precisely because we are preventing preventable disease. The idea that preventing diseases like this saves money and reduces GP work load is absolute intellectually absurd clap-trap.

    Of cause it's desirable to reduce illness and prevent disease. But to argue the reason we are doing this is because is saves money is stupid. It doesn't save any money at all...over the long run it costs, and it cost big style. This guy might be an ace at managing short term budgets and charing meetings within the bureaucracy of the NHS machine but he seems not to understand you can't cure old age, ill health and eventual death. It's an absolute certainty for every single one of us. The absence of this in his argument, I'm afraid, makes him a fool on a pretty fundamental level.

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  • Blimey.
    Do people still think this?

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