Description
Risk can mean different things to different people. The World Health Organisation identifies risk to health as the probability of adverse outcome or a factor that raises this probability.1 The number of risk factors to health are countless, but no risk occurs in isolation and many are rooted in a complex chain of events spanning over many years. Any combination of risks factors can increase the threat to individual or population health. However, a majority of risks to health are preventable. Indeed, once occurred many are reversible, if identified and promptly managed, through behavioural or pharmacological interventions. Even a marginal reduction in the level of population-wide risk will have a great impact on health. For example the reduction in salt intake and its link to decrease
diastolic blood pressure or passive smoking and respiratory disease, and not to mention the correlation between fat intake and coronary heart events.
Studies have shown that the main personal, biological and behavioural risk factors to individuals are unsafe sex, smoking tobacco, drug misuse, obesity, high blood pressure, hyperglycaemias, high blood cholesterol level and alcohol misuse.2 In this issue of Public Health Medicine research findings by Simay et al from Hungary3 and Salmasi and Dancy from North London4 have re-iterated that systolic blood pressure and fasting blood glucose are considerably increase the cardiovascular risk and they are frequently present, unidentified, in people who perceived as healthy. The authors state that failure to identify glucose intolerance results in a serious underestimation of cardiovascular risk and deny patients of primary preventative measures based on risk assessment. These findings are not new but are based the authors practical experience coming from different populations and geographic areas. The question is how should we apply these knowledge sets? Are health systems worldwide robust enough to conduct such individual risk assessment? And are they convenient to those patients and individuals deemed to be healthy? With few known exceptions, I believe we are not. Cost-effective and acceptable processes of such risk assessments can only be carried out in primary care settings by competent practitioners. In the UK, for example, General Practitioners5 are rewarded with generous financial incentives to identify risks for those people registered with them using the Quality Outcomes Framework (QOF).6 This is simply because, in the UK, primary care is the backbone of the National Health Service and provides a highly cost-effective service.7 However, what is the status of primary care systems worldwide? Gauging from my international visits and the articles submitted to this journal, primary care is sadly under developed in a majority of countries around the world. In most cases health systems are hospital based (emphasising reactive rather than proactive approaches) and primary care services are provided by doctors with no or limited, post-qualification training in family medicine.
With a paradigm shift in population demographics and disease, the trend of chronic conditions is rising significantly. The WHO estimates that by the year 2020, 60% of all illnesses will be non-communicable in nature.7 The majority of these diseases are preventable and are best managed in primary care settings. Many governments, while aware of the scale and magnitude of the problem, choose not to act. Knowing is not enough. We must apply. And we must do it now.
References:
1. World Health organisation. Reducing risks, promoting healthy life. The World Health Report 2002. Geneva: WHO, 2003
2. Rawaf S. Health in Wandsworth 04. London, WPCT, 2005
(www.wandsworth-pct.nhs.uk).
3. Simay A, Jancso Z, Ilyes I. Relationship between systolic blood pressure, fasting blood glucose and cardiovascular risk assessed in Hungarian family practice. Public Health Medicine 2006; 6:45-51.
4. Salmasi AM, Dancy M. Glucose intolerance: the occult danger in systematic hypertension. Public Health Medicine 2006; 6:52-57.
5. General Practitioners in the UK are doctors specialised in Family Medicine after a three years higher specialist medical training in general practice following 5 years medical school and two years foundation training. (http://www.rcgp.org.uk/pdf/ISS_INFO_Careers07.pdf)
6. The Quality and Outcomes Framework (QOF) is a component of the new General Medical Services contract for general practices, introduced from 1 April 2004 in the UK. The QOF rewards practices for the provision of quality care, and helps to fund further improvements in the delivery of clinical care. (http://www.ic.nhs.uk/services/qof)
7. World Health Organisation. Preventing Chronic Diseases a vital investment. Geneva: WHO, 2005. (http://www.who.int/chp/chronic_disease_report/en/)
