Rob Lawson went into medicine "expecting to make people well and keep people well".
Instead the GP, who retired from the NHS 12 years ago aged 60, found that he was "just dealing with disease".
"I began realising quite early on that I wasn't really meeting the demands of our patients in terms of that preventative bit," said Dr Lawson, who lives 22 miles from Edinburgh, in East Linton.
"It was all disease-focused, and drug-focused. I don't think the NHS has ever really considered prevention to be something terribly important, except in the context of vaccinations and immunisations."
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When the NHS was formed in 1948, infectious diseases such as tuberculosis, polio and measles were still the leading causes of death in Britain.
The mass rollout of free vaccinations transformed population health.
More than 70 years later, the heaviest burden of avoidable mortality comes not from viruses or bacteria but from the unhealthy lifestyles that we inflict on ourselves, and that our environment encourages: obesity, lack of exercise, excess alcohol consumption, diets swamped by ultraprocessed foods and lack of fresh fruit, vegetables, and other sources of fibre.
The vision that universal healthcare would inevitably foster better population health, and thus reduce the real-terms cost of the NHS over time, has been upended by the unexpected and rising toll of non-communicable diseases (NCDs) such as Type 2 diabetes.
"When the NHS started out, we had infectious diseases as the principal killers," said Dr Lawson.
"Gradually, the non-communicable diseases have overtaken the infectious diseases. It's what you call the epidemiological crossover point.
"We passed that some while back but some countries are still approaching it.
"In 2021, there were 670,000 deaths in the UK.
"The statistics vary, but some people say up to 90% of these are caused by non-communicable diseases, others say between 70-90%, but between 40-70% of those are avoidable.
"There's a lot of people dying prematurely who don't deserve to die early, and the largest element behind that is the way we live our lives - or can live our lives.
"Tackle the upstream causes - environmental, socioeconomic and cultural - address them, address poverty, and you begin to tackle the problem that is sucking up all our money and costing £11 billion a year on the NHS for dealing with lifestyle-related conditions."
The way lifestyle and inequality intersect to to create the current challenges facing the NHS will be among the talking points as experts from around the globe converge in Newcastle later this week for a three-day conference by the British Society of Lifestyle Medicine (BSLM) - the East Lothian based charity co-founded by Dr Lawson in 2016 along with Edinburgh-based surgeon, Laurence Stewart, and Michael Boyle, a GP in Sheffield.
Its membership has soared in recent years, signalling a growing appetite among doctors and healthcare professionals for a new approach.
It also comes days after a damning report by independent peer Lord Darzi - commissioned by the new Labour Government to examine NHS England - warned that healthcare reform must include a much greater emphasis on preventing people becoming ill in the first place.
This is at the core of lifestyle medicine - a concept first coined in the 1980s by US epidemiologist Ernst Wynder, but which Dr Lawson says was initially "sidelined as some sort of alternative treatment".
Today, its six pillars - healthy eating (meaning a diet rich in fruits, vegetables and whole grains); physical activity; stress reduction; social connectedness; getting enough sleep; and minimising exposure to harmful substances (tobacco, alcohol, environmental pollutants, the effects of polypharmacy) are not just common sense principles for a good life, but strongly evidence-based.
Never in the history of medicine has there been more scientific literature backing up the harmful physiological effects of everything from loneliness to lack of fibre or exercise, yet comparatively little is being done to promote healthy lifestyles.
The BSLM has been working to change that, partly by training GPs to do things differently.
This can include running group consultations - where patients with the same condition are brought together for moral support as well as more face-to-face time overall with the doctor - or by guiding patients off medication through lifestyle changes that reverse diabetes or bring down blood pressure.
"The results are extraordinary," said Dr Lawson.
"The patients love it, and the doctors are happier.
"There's one practice in a rural deprived area which had to close, but an individual who had come up to Scotland - a person trained in the lifestyle medicine approach - decided to negotiate with the local health board to deliver half an hour consultations for each patient.
"To its credit, the health board agreed. Now that practice has grown to nine doctors.
"A phonecall came from the local A&E department saying 'what's happening, because we're not getting any of your patients anymore?'.
"And of course it cost the NHS less because there was no need to get locum cover, which was costing a huge amount.
"That's just one little example which is embryonic, but it's one we'll be watching very carefully."
She said: "We know that enhancing our lifestyle can be really beneficial in terms of preventing disease, but it can actually be very beneficial in terms of reversing disease as well.
"That's a real passion of mine as a GP.
"If I diagnose someone with hypertension, I don't just stick them on drugs - I try to find out why they've got hypertension in the first place.
"That involves taking a full lifestyle history and then working out how to improve their lifestyle to reverse that hypertension.
"For me, it's about getting them off the drugs.
"We are run on 15 minute appointments for face-to-face now, but if I do diagnose somebody with a condition that needs a bit of work or effort on the lifestyle front, I tend to book them a series of appointments.
"We don't feel inundated in the way that a lot of practices have been and that may be multifactorial, but I do think our preventative approach has had a knock on effect...I'm seeing a lot of patients who are leading much healthier lives and are much healthier as a result.
"One of my colleagues is very into diabetic medicine.
"He and I have been working to try to reverse a lot of our diabetics [and] once you start reversing disease you start seeing the impact that that disease has, both on the patient and the practice.
"Whilst someone's diabetes is poorly controlled they're more likely to get infections, to have hospitalisations, to have complications of their disease, so if you reverse their disease the side effect is that they then don't require as much treatment or hospital appointments or GP appointments."
She said: "That has the knock on effect of enhancing their immune system and reducing not just the disease they're presenting with, but also the likelihood of further diseases in all systems of the body."
She has cured patients of repeated urinary tract infections, not with pills, by advising them to increase their intake of fruit and vegetables while cutting down on ultraprocessed foods loaded with emulsifiers which "supercharge the bacteria that cause UTI".
It drives her "completely insane", adds Dr Fraser, that patients given antibiotics to treat infections - but which also deplete the microbiome, leaving them more vulnerable to other infections - are not advised how "to rehabilitate their gut".
She said: "You need to consider getting enough sleep, making sure you are getting out and exercising, that you're enhancing your diet, that you're feeding all the right micro-organisms in your gut, and you need to make sure that you're not doing things that harm you, like eating ultraprocessed foods and alcohol...yet the vast majority of doctors out there have no teaching in this and no real understanding of its importance."
Dr Callum Leese, a newly-qualified GP in Aberfeldy, has been pouring his enthusiasm for lifestyle medicine into a quest to make the Perthshire enclave 'Scotland's healthiest town'.
"It appeals to people's sense of how life should be lived, because it feels like common sense," said Dr Leese, who has been working with other healthcare colleagues to organise events ranging from community ceilidhs to "feasts" of healthy local produce that bring people together and promote wellness.
His surgery has a video running on-loop where real patients from the community talk about how lifestyle changes have transformed their health.
"The hardest part is reaching the people who really need it," said Dr Leese.
"That's the biggest challenge with lifestyle medicine as a whole - it's very easy to reach people who are health literate and fit and healthy anyway, who understand it.
"Those people are really easy to reach.
"The people who can benefit the most are the hardest to reach. That's the same in Aberfeldy."
Dr Leese has also spent time researching how our environment dictates our lifestyle, with Copenhagen as a case study.
In the Danish capital, he notes, "everyone cycles because its easier to cycle".
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The health benefits of living in areas with plenty of green space are clear, he adds, but fixing it "is complicated".
He said: "An uplift in green space near your home is associated with increased physical activity, and the benefits or being in nature.
"The flipside of that is that if your house is within 100 metres of green spaces it's something like £2,500 more expensive than if they were more than 500 metres away.
"So if you put green space into parts of Glasgow, it raises the house prices and possibly displaces poorer people."
In Aberdeen, Dr Julie Gray describes lifestyle medicine as a "breath of fresh air".
The GP was six years into her career and feeling "jaded" by the toll of lifestyle-related disease on her patients when she first heard about the BSLM in 2016, but admits encountering scepticism from older GP colleagues.
As they retired, her younger colleagues have been more open to embracing a different approach.
They are already seeing the effects.
She said: "I have a number of case studies of patients who I have seen benefit from it - reversing their diabetes, improving their blood pressure and coming off tablets, losing weight and ending up off chronic pain medication.
"There's been so many patients who feel like it's a light at the end of the tunnel - that there's something they can do to reverse their chronic disease instead of taking medicines to paper over the cracks.
"We are in a situation now where the NHS is absolutely crippled. The large majority of the resources go into chronic disease management.
"Something like 75-80% of primary care consultations are related to chronic diseases.
"Instead of giving out more and more medicines, whilst people are still suffering, we should be thinking 'how do we prevent it?'
"We need to improve people's quality of life - not just extend it."
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