Health is complex, the solutions are long term

Demands on healthcare systems don’t have one solution. The answer isn’t just to be found in a viable workforce plan (doi:10.1136/bmj.p1285) or only in building new infrastructure and refurbishing existing facilities (doi:10.1136/bmj.p1259).12 It isn’t simply about solving the retention crisis (doi:10.1136/bmj.p1272) or cultural change in healthcare (doi:10.1136/bmj.p1258).34 Fair pay on its own won’t solve the problem (doi:10.1136/bmj.p1287), and salvation doesn’t rely merely on a fulfilling hobby such as spoon carving (doi:10.1136/bmj.p977).56 The complexities are obvious, the solutions many, familiar, and interconnected, but joining the dots seems beyond us.

Two principles can help guide our thinking: a focus on prevention (doi:10.1136/bmj.p1232) and avoiding low value and inappropriate care.7 Neither is new or revolutionary. Yet they are easily discarded from short term policy agendas. The real challenge, therefore, is how to re-establish long term thinking in policy making.

The debate on folic acid fortification of food to prevent neural tube defects in babies, for example, hasn’t progressed in more than two decades (doi:10.1136/bmj.p1158).8 The worrying rise in perinatal suicides requires better funded services and support for women and young families to prevent deaths (doi:10.1136/bmj-2023-075414).9 And are the mandatory school inspections that harm the mental health of teaching staff even necessary (doi:10.1136/bmj.p1147)?10 The same applies to overzealous and discriminatory processes implemented by medical regulatory bodies such as the General Medical Council, despite claims of improvement by its chief executive (doi:10.1136/bmj.p1295 doi:10.1136/bmj.p1252).1112

The prevention principle would urge us to support a ban on vaping (doi:10.1136/bmj.p1266) and consider new options for reducing the number of days people experience migraines (doi:10.1136/bmj.p1249).1314 It would also induce bewilderment at the decision to wind down the UK’s world leading covid surveillance network when covid-19 is still with us and future pandemics are inevitable (doi:10.1136/bmj.p1157).15 It would not, however, lend support to a non-evidence based screening programme for haemochromatosis (doi:10.1136/bmj.p1264).16

The first steps of an “avoid, reduce, reuse, recycle, research, rethink” framework (doi:10.1136/bmj-2021-069044) focus on better clinical practice that avoids low value care and inappropriate admissions and minimises blood tests and other interventions.17 This latest article in our series on achieving net zero and environmental sustainability in clinical practice examines critical care. The challenge isn’t entirely a clinical one, because achieving net zero will depend on commitment across healthcare professions, engineering, waste management, hospital leadership, and beyond.

A research paper assessing the value of routine monitoring of people being treated with methotrexate finds that frequency of monitoring should be adjusted according to risk, reducing the burden of work on clinical staff and making life more manageable for patients (doi:10.1136/bmj-2022-074678 doi:10.1136/bmj.p1120).1819 The difficulty here is one of getting research into practice, a timescale of 17 years by some estimates.

The covid pandemic has shown how clinical innovation and new thinking can be adopted much more rapidly. But these are advances in the “last mile” of care in an emergency. Improving the population’s health and matching demand with capacity are a marathon—every day. It is this thinking, a long distance consensus on health and wellbeing at arm’s length from the political cycle, that is absent from policy making and a test of every nation’s priorities.