Future imperfect…the government’s prevention vision

Prevention is here to stay for the NHS and health going forward. If one can believe the hype. If we can work out what we mean by it. And not in any form some of us would recognize. Oh, and except most preventive services have been cut, and are about to be cut again.

Last week the Government published Prevention is better than cure: our vision to help you live well for longer  setting out its vision for how it plans to “revolutionise the current approach to prevention, and includes a major focus on the role of primary and community care services in achieving this. “

Speaking in Parliament Matt Hancock the Secretary of State averred that “prevention” will be an “integral” part of the forthcoming NHS Long Term Plan, and set out the Government’s commitment to publishing a Green Paper ‘in the first half of next year’ to outline their plan in further detail. Promising. Exciting even.  It’s great that the Government has agreed to focus on prevention.  What’s not to like? Well, let’s dig into the detail.

Prevention done well is vital if we are to keep our population healthy, our economy competitive and our public services financially sustainable. In fact, if we had heeded the advice of Derek Wanless in 2003 we might not be throwing ever increasing step change sums of money at the NHS every five years without any concomitant increase in productivity or heath outcomes.

No amount of healthcare will end the burgeoning epidemic of non-communicable diseases

No amount of health services will give us a healthy population. Government’s just realised that, right? Well, only in part. Against this background, let’s look at a series of statements by the respected Health Foundation (yeah I know, I’m biased, I’m one of their Generation Q Fellows.)

  • The Foundation’s David Finch, writing in Public Finance in July 2018 pointed out that Health Investment needs long term funding, and public health within this. This message didn’t seem to get through to the new vision.
  • In October the Health Foundation published an analysis of the funding gap for Public Health which concluded, among other things, that
    • “Based on current spending plans, a reduction of almost a quarter in spending per person is expected between 2014/15 and 2019/20. There will have been a £700m real-terms reduction in the public health grant in that period.
    • These funding cuts come at a time when demand is increasing and key indicators of health are causing concern. Mortality improvements have slowed and there are large inequalities in health outcomes between local areas.
    • An extra £3.2bn of funding per year is required for the public health grant to be locally distributed according to an independent calculation by the Advisory Committee on Resource Allocation (ACRA), while restoring real-terms losses and preventing any local area experiencing a reduction”

The Health foundation concludes that “at a minimum, the government should reverse real-term cuts and allow additional investment in the most-deprived areas by providing an additional £1.3bn in 2019/20. The remaining £1.9bn should then be allocated in phased budget increases by 2023/24, with further adjustments for inflation.”

The Government’s vision in this light- the failed doctrine of personal responsibility

The goverment’s  paper sets great store by everyone taking personal responsibility for their health. This has never worked as a population strategy. Why? Because for many of us it’s just too damn difficult. What we know is that policies which rely on people who know what’s required and can do it, widen inequalites. Most other countries of any length of experience have abandoned this approach. Yet here successive governments of all complexions have adopted even if only in part this strategy which triumphs hope over experience.

Our burgeoning epidemics of things like frailty, diabetes, heart diseases and cancers are not driven just by willpower, as if every succeeding generation since 1948 has worsened its diet because we’ve got progressively less good at self-discipline. This is driven by a complex mix of social and environmental factors like poverty, access, advertising, food formulation, inactivity being the default option for many, and an assumption that the NHS will just fix whatever is wrong with us regardless of the cost.

We need a strong and functioning NHS. But we also need prevention to be truly effective. The great danger here is inventing a style of public health based largely in the NHS which is entirely clinically focused, entirely about reducing health damage already done, not preventing it happening, and entirely based on the false counsel that individual behaviour change will solve everything .

This will not solve the massive wave of avoidable disease, disability and misery coming at us. It has its place, but by itself it is a recipe for pouring ever more money into healthcare, not solving the problem at the source.

Could we make this work?

Let’s be glass half full. We could make this work. There is recognition in the paper that the NHS cannot do this by itself, and that is a great hook.

The opportunity of a Green Paper on prevention is an opportunity for local authorities, the voluntary sector and employers to rise to the occasion and show what we can contribute. We could learn the lesson that health policy in France, Canada, New Zealand, Australia, Italy and Spain have learned that prevention needs systemic action, and when you do that it works. The opposite possibility is the NHS runs a massive pile of clinically modelled “prevention services” too late to make the difference needed and at greater cost than local authorities would deliver.

A nation with no prevention infrastructure left:  buying healthcare is not the answer

What does a world with ten years of cuts to local government services like libraries, social groups and transport look like? A world with ever increasing mental health prescription because of loneliness. We cannot prescribe our way out of this.

Services are important, absolutely. And so is behaviour change. But we need balance in our strategy. The rhetoric that everything is socially determined risks being a counsel of despair, while the wagging finger of individual responsibility runs up massive bill for yet more healthcare we will have to settle in the future.

What can what’s left of the non-NHS sector bring?

So what can we bring? Well, in short, this policy needs a strong injection of local government. And such a strong injection, if accompanied with some investment, could really produce results. The Green Paper is our opportunity. And there are several key contributions. I will choose just two:

First, services. The NHS is not as good at delivering national preventive services as local government. To take one example, the National Diabetes Prevention Service has delivered an average weight loss of 7lbs in weight per person (3.3kgs) in a timescale almost three times as long and at a cost per head far greater than programmes like Wigan manage. Local authorities have skills they can offer here. Enablement work in Social Care and so much more has a contribution to this.

Second, wider determinants. Our health is not just about our behaviour, it’s also about the conditions for health – good quality environment, educational outcomes and more. The kinds of things local authorities excel at. If we accept that things like food choice and skills, for example, are barriers to healthy lives, then local government comes into its own. If we don’t accept that then are saying that poorer people who smoke more, risk greater overweight, get more cancer and die earlier just have less willpower. That flies in the face of the evidence. The NHS needs local government to act on wider determinants.

And the plan implicitly acknowledges that where it says we need policy action to reduce salt levels and childhood obesity. I wouldn’t be so unkind as to say these measures are an admission that the principle of individual responsibility breaks down before we are halfway through a document which enshrines just that principle.

There is another opportunity in the explicit recognition that the NHS cannot deliver most of this alone. There is at least a glimmer of recognition that the overwhelming experience of most countries is that individualising prevention to behaviour is just one piece of the jigsaw which makes up good health.

The paper doesn’t make clear where the money will come from or how it will be delivered. But it’s got “needs local government” written all over it.


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