Looking back and looking forward

Looking back and looking forward

p r i m a r y c a r e d i a b e t e s 2 ( 2 0 0 8 ) 163–164 available at www.sciencedirect.com journal homepage: http://www.intl.elsevierhealth.com/...

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p r i m a r y c a r e d i a b e t e s 2 ( 2 0 0 8 ) 163–164

available at www.sciencedirect.com

journal homepage: http://www.intl.elsevierhealth.com/journals/pcd/

Editorial

Looking back and looking forward

July of this year saw the celebration of the 60th anniversary of the British NHS. Although not the first socialised health service in the world (New Zealand may have claim to that), it is the longest surviving and, arguably, the most comprehensive. From cradle (or from conception) to the grave; prevention, diagnosis, rehabilitation and care; free at the point of delivery; for each according to need rather than ability to pay—such were the principles of the service when it was first conceived. To an extent these principles have been adhered to but, over the 60 years the service has had to endure extensive and increasingly frequent administrative upheavals. It has been the darling (and probably, sometimes, the bane) of successive political administrations. Its recent issues continue to generate controversy – geographically variable provision in what should be a national service; whether private finance of costly new treatments should be allowed (as “top-ups”) without the requirement to pay for the entire cost of the programme – such, and more, are the current debates. Being born in August 1948, I can claim to be one of “Bevan’s babies”. My mother and, unknowingly, I were two of the new service’s first beneficiaries. (These “Bevan’s babies” are not to be confused with “Bevin’s boys”—young men sent to work in the wartime coal mines instead of being conscripted into the army and named after a different politician.) Aneurin Bevan was the minister charged with the introduction of the service. His ideas and, indeed, the man himself were brutally criticized by many in our profession who, pleading the likely curtailment of clinical freedom were adamantly against the NHS’s introduction. (Their greatest fear was, undoubtedly, the curtailment of their income and was dressed up as concern for their clinical freedom—just as some of the fears expressed about confidentiality, today, may, at least in part, be fears about clinical scrutiny.) Someone who made a more lasting impression on the early days of the NHS than I did contributes a guest editorial in this issue. Julian Tudor Hart, while a general practitioner in the Welsh valley settlement of Glyncorrwg, transformed the field of general practice, not only in that locality but also throughout the country. Indeed, he has inspired cohorts of general practitioners, other primary care workers and the specialty of public health throughout the world. Forthright, plain speaking

and passionate in his politics, he showed, by comparison with neighbouring practice populations, that his new way of delivering and organizing care produced tangible health benefits in his community, relatively deprived then, as now. He and others including our current Minister of Health and Social Care and the former Minister (GP in one of those neighbouring practices) celebrated the 60th anniversary in Julian’s house and garden—an apt way to celebrate, given his and his colleagues contribution to the field. One of the other contributions to this issue – that of Solomon et al. – looks to the more recent past, the International Diabetes Federation (IDF)’s year of the foot (2005). This was the first year in which IDF sought to prolong the international spot light on its chosen theme throughout the year, rather than merely in the build-up to World Diabetes Day (14 November). (By the way, 14 November was initially chosen because it was the birth date of Frederick Banting—not a lot of people know that.) Solomon et al. continue the emphasis on foot care—a field in which simple, low cost education and interventions have been shown to be cost-saving (not merely cost effective). Asking patients to remove their socks in the consultation is a great start. In the build-up to this IDF theme for 2005, it was brought to our attention, during a meeting in Chennai, India, that the Indian Times newspaper carried, on the day the conference opened, the story of a poor market stall holder with neglected diabetes who developed chronic foot ulceration. The smell of his infected foot drove people away from his fruit stall, his family slid further into poverty and he was told, wrongly, by a physician that an amputation could only be obtained with a large number of rupees changing hands—rupees which he could never, in a million years, hope to own. The point of the newspaper article was that, faced with this seemingly impossible quandary, he amputated his foot by allowing a train to pass over it. True or not, even if exaggerated for effect, the story epitomizes the profound distress that diabetic complications than cause, in a country in which good health care is, or at least is believed to be, out of the reach of those on low incomes. Looking to the future, we have a report (Jenum et al.) which features the national plan for diabetes in Norway. We have some indication (from Agban et al.) of a reduction in

1751-9918/$ – see front matter © 2008 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe. doi:10.1016/j.pcd.2008.10.002

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p r i m a r y c a r e d i a b e t e s 2 ( 2 0 0 8 ) 163–164

the health disparities between Maori and Pacific Islanders in New Zealand, compared with New Zealanders of European origin (though, predictably, the authors describe significant improvements, over two years, in blood pressure and lipid concentrations though not in blood glucose control). An important topic for the future, reported upon by Anderssen et al., is individuals’ reactions to being labelled “pre-diabetic”. Are we making healthy people sick by conferring this label upon them? Optimistically, they are “seeing possibilities in an uncertain future”. These articles, together with a report on the evidence relating to the identification of LADA (latent

autoimmune diabetes in adults) without the need for glutamic acid decarboxylase (GAD) antibody testing (Lutgens et al.), the review of self-management of blood glucose in type 2 diabetes (author?) and a focus on rennin angiotensin blockade (Bilous) make up this issue—looking back and looking forward. Rhys Williams School of Medicine, Swansea University, Swansea SA2 8PP, UK E-mail address: [email protected] Published on line 12 November 2008