The five year forward view articulated the need for a ‘radical upgrade in public health and prevention’ – but government policy has not delivered. Public health budgets have been cut by £200 million in recent years. And as shown by the King’s Fund, there is more to come. Charlotte Paddison asks if spending less on public health likely to store up problems for the NHS in the future? And what exactly needs to be done to turn things around?
Measuring our success so far
Success or failure in delivering a positive vision for public health manifests itself in the health of our population. The evidence is somewhat bleak.
More than one in four adults in the UK (26%) are obese. If current trends persist, by 2034 one in ten people will develop type 2 diabetes. One in five children in reception in England are now obese or overweight, with children in the most deprived areas twice as likely to be obese than children in least deprived areas.
This is bad news for individuals. It is also bad news for the long-term financial sustainability of the NHS. Obesity – which increases your risk of diabetes and cancer – costs the NHS £5.1bn a year.
Prevention is also important in mental health. Almost one quarter (23%) of children and teenagers experience difficulty accessing mental health services, particularly early intervention and mental health prevention. Between 2010 and 2015 the number of A&E attendances due to psychiatric conditions or self-harm among young people more than doubled. Prevention and early intervention is key given that over half of all mental ill health starts before the age of fourteen years, and seventy-five per cent has developed by the age of eighteen.
Public health: A good return on investment?
The short answer (spoiler alert) – seems to be yes.
Evidence shows public health interventions offer good pay-back both in terms of better health and wellbeing, and NHS finances. For every £1 spent, the monetary value of the benefit from public health interventions has been estimated to be around £14.
Investing to improve the population’s health makes economic sense. It is estimated that, in the UK, people being overweight or obese costs the NHS £5.1 billion, smoking costs £3.3 billion, alcohol costs £3.5 billion, and physical inactivity costs £0.9 billion (2006/07 figures). These drivers of demand on our health system are amenable to change. Investment in public health initiatives has in important role to play here in changing the way people behave, in order to improve health at a population level.
Can public health interventions help manage rising demand for health care?
Yes. They do this through the maintenance of good health and the avoidance of illness. This includes helping people to avoid getting ill in the first place (primary prevention) and, for those who do become unwell, helping to ensure they don’t get worse (secondary prevention). Evidence shows well-designed community-based interventions targeting falls prevention among older people, for example, are highly cost effective. They can reduce hospital activity and deliver cost savings within 1 to 2 years.
Paradoxically, spending less on public health now has the potential to add billions of pounds to future NHS service costs.
So why doesn’t the bottom line reflect this?
Public health budgets have historically been viewed as soft targets. Getting policy ‘buy in’ is difficult because public health often – though not exclusively – delivers health pay-offs in the longer-term. Thus the benefits of policy which focuses on prevention will frequently outlive the existence of their political architects.
The challenge to securing political interest is compounded because, in comparison with the attention to problems in acute care and social care, disinvestment in public health is less visible. The impacts of austerity are more easily felt by the public, and more immediately discernible, when impact is measured in terms of accident and emergency targets, or lengthening waits for surgery.
Where to from here?
What is needed now is a clear and credible plan for increasing resilience and the prevention of ill-health, backed by a sustained financial commitment.
Improving population health starts with building communities with resilient children.
More could be done to comprehensively and effectively address childhood obesity. For example, through measures to tackle the aggressive marketing of junk food – on TV, online, and through sponsorship and price promotions – to children.
A policy focus on promoting resilience and mental health among young people is needed. School-based interventions that encourage safe participation in increasingly complex digital environments could play a useful role here.
Policy initiatives should address the importance of choice architecture – that is, the potential to change behaviour by altering the environments within which people make choices. This could usefully draw on empirical work showing that the placement of food, alcohol and tobacco products within the physical environment can influence their selection and consumption. An example would be the Government’s agreement with supermarkets not to display alcohol at the entrances to shops.
Investment in prevention and public health is not only good for the health of individuals.
It is a core pillar of any comprehensive strategy for a financially sustainable future for the NHS.
Cuts to public health are likely to lead to more not less pressure on the NHS in the long-term. We ignore this at our collective peril.
A version of this post originally appeared at the Nuffield Trust here on 12 July 2017.