An invitation to morbidity

We have never been healthier. We live longer than ever, and, on all objective measures, have better health than in any previous period. At the last census 85 per cent of us said we were in good or fairly good health. True, living longer can bring problems in its wake, but even in later life the majority of us are able to function well.

Recently, however, the UK Department of Health (DoH) has argued that 60 per cent of adults in Britain now live with a long term health condition. New initiatives emphasising self-care as a way of tackling the problem have been put forward. A national ‘Expert Patient Programme’ is being implemented throughout the National Health Service (NHS), based on a ‘lay led self-management’ course, devised by Kate Lorig at Stanford University in the USA.

There is much to be commended in raising the profile of those who live with chronic conditions. In the past their problems have rarely made the headlines, or been at the forefront of service development. Even so, there are real difficulties in making chronic illness the centre of attention, not least in deciding what is meant by the term.

DoH’s statement that the majority of adults have a chronic condition raises concerns. Such estimates are based on surveys where individuals are asked ‘do you have any long standing illness, disability or infirmity?’. Obviously this can mean many and various things. I am typing this wearing glasses. Should I answer yes, if asked such a question? My feet are giving me more trouble, as I get older. Yes, here, too? Usually such surveys go on to ask whether the condition is ‘limiting’ in any way. This reduces the figures considerably.

In February 2004 the Institute of Ideas held a London conference on ‘Health: An Unhealthy Obsession?’ (1). At the conference I argued that overstating the extent of chronic illness feeds into our obsessional culture. It acts as an ‘invitation to morbidity’ where we focus increasingly on our bodily ills, and less on pursuing our valued goals. Even though the intentions of the DoH are to help those with chronic disorders, estimates of this kind run the risk of doing the opposite. They can detract from the real needs of the more seriously ill, in favour of the worried well and the mildly affected.

Policies on self-care are not all that they are made out to be. The DoH claims that self-management programmes of the sort it is advocating are ‘evidence based’. That is, that research shows that self-management courses can produce lasting benefits. This is misleading. All the evidence I have seen shows that some short-term gains may accrue, but there is no persuasive evidence of long-term ‘health outcomes’. And it is the long term that really matters.

It is not difficult to understand why short-term benefits are found in such studies. Attending a self-care course may well help combat isolation and improve self-confidence in the short run. I sometimes think that even well-run coffee mornings for the chronically ill would work just as well. Reviews have shown that many different programmes have short-term effects. However, other factors such as family demands and the illness itself are likely to reassert their influence as time passes.

At present the government hopes that supporting self-care will reduce the use of services. This is unlikely. It would be much better to develop pluralistic policies aimed at those most in need, and work with what people already do to maintain their health. Top down, one size fits all approaches should be avoided.

Mike Bury is Emeritus Professor of Sociology, University of London. He has served on a variety of professional bodies, including the Medical Research Council and the Health Development Agency. His most recent book, Health and Illness, is published by Polity Press.

(1) See Health: an unhealthy obsession? on the Institute of Ideas website