The iceberg of illness1 is an important concept in understanding the relation between health and illness and one that healthcare systems ignore, Titanic-like, at their peril. The pyramidal iceberg has health at its base and tertiary care at its apex; as individuals develop symptoms they pass upwards through self care, primary care, and secondary care, with specialised services encountering an ever more highly selected patient population. We know surprisingly little about what prompts movement across these interfaces, particularly that between self care and primary care. Initiatives within the NHS to make access to services easier could have profound effects, yet the necessary research is only just being defined.
The movement of patients from self care to primary care and from primary to secondary care determines workload for health services, and relatively small changes at the base of the pyramid can have substantial impacts on demand at higher levels. For example,