Monday, 18 June 2012

Individual choices in public health

My wife and I safely navigated a local NCT course this weekend. I think she was rather looking forward to it. I approached it with rather more trepidation. I would recommend something like an NCT course to any couple expecting their first baby: among other things, it is a really good way of framing your personal discussions about how you as a couple would like your labour and early weeks of parenthood to run. It is of course, a really good way of meeting other couples in the area.

Where is it less recommended is as a source of good information. My fist is a little sore this morning from the moments I was obliged to chew on it, for fear of opening my mouth and starting an argument. Anyone who goes to an NCT class willingly signs up for a certain type of experience, and it would be unfair of me to accuse the class of failing to deliver on its promise. It was, in fact, unerringly on message with what I had been told to expect.

But as a case study in human and social behaviour, an NCT class provides some interesting insight. As a way of framing a discussion about patient-centred care, it is brilliant. I found it very difficult to hold my tongue during the discussion about vaccination.

it occurred to me during the discussion of the merits of single jabs over the MMR that this issue is a little like religion: people often have views that they are comfortable with, and from which they do not want to be budged. It is often futile to have exchanges of view about religion because the starting points of two people who disagree often have very little overlap. The same is perhaps true of people’s views on vaccination. It is perhaps true of my view on vaccination.

It still suprises me how the impact of Andrew Wakefield’s discredited work on 12 children with autism continues to trump the safety record of a vaccine that has been used hundreds of millions of times across Europe, protecting both children and populations from harmful infectious diseases. That statement no doubt speaks volumes about how we assess risk both as individuals, and as a population.

What however, took me by surprise (perhaps naively) was the clear assumption by some people in the room that medical intervention in pregnancy and labour was aimed at something other than the health of the mother and the baby. It was clear to me that the motives of hospital midwives and doctors were somehow distrusted.

However, there were a couple of issues that made me think. During labour and in the early days of a baby’s life, you are offered a couple of interventions that on an individual basis might be considered overkill. For example, babies are often given a vitamin K injection to offset the relatively rare risk of haemorrhagic disease of the newborn. The risk of bleeding complications is low, but the effects when they do happen can be high. Therefore, one’s perception of whether it is worth doing is influenced often by one’s perceptions of the risks of having the injection when compared to the benefits of having the vitamin K.

When judged purely on an individual basis, I imagine that many people come down on the side of not having it. However, the decision to offer all babies this medication is a decision that is also based on benefitting whole populations.

And this creates a tension that one does not often see acknowledged. The NHS is charged with offering a comprehensive health service for everyone. This means that some of the decisions regarding treatment, screening and vaccination are heavily influenced by the benefit at the population level, at the expense, perhaps of the individual experience.

If we know that vitamin K deficiency affects 1 in 100 births, by giving everyone the injection, we are subjecting 99 in 100 babies to an injection that they don’t need. But it is either too costly, or not possible to work out which baby in every hundred needs the injection. So do we as a society fall on the side of public health, or individual utility. There is inevitably some value judgement in this.

And I imagine that this sense of conflict is heightened in couple who are trying to decide how they want their pregancy to run. Particularly the kind of couples who go to NCT classes, and particularly couples who respond to the loss of control that that the imminent arrival of a baby represents by trying to wrestle control over as many aspects of the process as they possibly can.

There are times when the delivery of effective population based care is at conflict with the delivery of patient-centred care. And we need to be honest about that.

I used to deliver a talk to patient and carers about stroke care in London. As part of the rearrangement of stroke services in London, patients are now taken to one of a number of hyperacute stroke units, which offer 24 hours expert assessment and treatment. They will usually return to their local hospital after a couple of days, but the experience of going to a hospital that is not their local one can be both disorientating and inconvenient. But my experience suggests that taking the time to explain that organising services in this way means that we can offer a better level of care to everyone is something that most people get.

And so, perhaps, we need to be honest and emphasise that sometimes that we will be offered therapies which may not offer us any personal utility, but if effectively delivered to whole populations will render huge benefits for everyone. Vaccination is a good example of this. And is a good example of the reality that we are not just individuals, or family units, but rather members of a wider community, and sometimes, there are things that we can do to benefit the population that we belong to.

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