Stop backing off from prevention

Seven years ago a widely respected public health expert wrote a blog addressing what he described as “the thorny issue of perverse incentives” that were undermining prevention and early intervention strategies within the NHS. Promoting the case for the adoption of a system-wide approach, Brian Ferguson noted, “It would be difficult to argue that [for example] we should not be investing in prevention of diabetes by tackling overweight and obese individuals, since we know that weight is a significant risk factor for Type II diabetes. 

“Yet the healthcare system in effect rewards hospitals for dealing with the very complications of diabetes that we are trying to avoid, by increasing budgets for treatment services at the expense of investing in prevention and early intervention.” 

Three years later Ferguson was still making the case online for more co-ordination across the NHS, and the ditching of separate ‘silo’ budgets for prevention and treatment.

“Local areas are doing a great job with the funding they have available,” he argued, “making increasingly difficult decisions on where to invest or disinvest. But we know there’s frustration that the bar seems to be set higher for justifying public health investments compared to the delivery of healthcare, including calls to demonstrate how investments in prevention will deliver short-term cashable financial savings, which is not something asked for from spending on treatment.” 

The irony here, however, is that Ferguson wasn’t an independent blogger when he wrote the above, but was working for Public Health England (PHE), and his words still appear on the website of one of that organisation’s two successor bodies, the UK Health Security Agency. And in 2019 PHE actually published a joint report with the Chartered Institute of Public Finance and Accountancy, pushing the financial benefits – for the wider economy as well as for the NHS – of integrating prevention and treatment budgets.

Other bodies have been making much the same case – that prioritising expenditure on public health is a wise investment, leading to worthwhile cost-savings in the long term – for the past decade, but to little avail. 

In 2016 the BMJ noted that, despite programmes like ‘falls prevention’ interventions which have historically reported substantial returns in under 12 months, the pay-off from other public health initiatives frequently doesn’t arrive during the five-year parliamentary electoral cycle, thus rendering them a politically soft target for short-sighted budget cuts.

Nevertheless, a review backed by the BMJ that year found that every £1 spent on public health returned an extra £14 on the original investment, representing a commendable average cost-benefit of 8.3. This led the organisation to brand austerity-driven cuts to public health expenditure a false economy, effectively committing the NHS and the Department of Health & Social Care (DHSC) to spending eight times the value of any cuts on additional future treatment costs. 

A follow-up study by the BMJ in 2020 further quantified the relative value of preventive versus reactive health expenditure. It found that each additional QALY (quality-adjusted life year) for a patient costs just £3,800 from the local health budget, but the same benefit cost £13,500 if provided by the NHS. 

The Health Foundation has lobbied long and hard since then to convince successive Conservative administrations to embrace a longer-term ‘whole government’ approach to public health, in order to address stalling life expectancy – according to the King’s Fund, in 2020 life expectancy at birth in England and Wales fell by 1.2 years for males and 0.9 years for females, compared with 2019 – and widening health inequalities between rich and poor across the UK. 

Its wide-ranging 2020 report, Creating Healthy Lives, noted that the strongest determinants of health lie outside of health and care services, and so the government should consider the impact of social security, housing and children’s services policies before imposing further cuts to prevention and early intervention budgets. The report’s analysis showed that expenditure by financially-constrained local councils had shifted dramatically from proactive spending to reactive, crisis management services. It also found that major cuts to the Public Health Grant had similarly skewed spending at a national level away from prevention. 

Fast forward to early 2023, and the picture hasn’t changed – if anything it’s got worse. The Health Foundation’s latest report, published this March, took a look at the current state of the public health grant, which is paid to financially stretched local authorities by the DHSC to provide essential preventive health services – services which include smoking cessation, drug and alcohol treatment, children’s health and sexual health. 

This update found that public health funding was broadly 21 per cent lower on a real-terms-per-person (RTPP) basis than in 2015/16, with spending on smoking cessation services down by as much as 45 per cent. 

And echoing figures released in 2019 by the IPPR – which showed that almost £1 in every £7 cut from public health services came from England’s ten most-deprived communities, compared to just £1 in every £46 in the country’s ten least-deprived places – the Health Foundation’s 2023 report highlighted how cuts to the public health grant still tended to be bigger in socio-economically deprived areas like Blackpool, where RTPP funding was down £33 compared to eight years ago.

The Health Foundation understandably concluded its assessment by flagging up the missed opportunities, saying, “Investment in prevention represents excellent value for money compared with health care spend. Yet recent announcements have continued the trend of disinvesting in the wider funding that helps to maintain and improve people’s health. 

“It is clear that opportunities to prevent the early deterioration of health are being missed, while the need for such interventions is increasing. Failure to invest in vital preventive services will mean health worsening further, widening health inequalities, and the costs of dealing with this poor health will be felt across society and the economy. For instance, preventing people falling into poor health in the first place could help to reduce economic inactivity, increasing the number of people in work.”

So one thing is indeed becoming clear – the provision of public health prevention and early intervention services, which together play a crucial role in the health of every UK citizen – have for more than a decade been prey to short-term and ill-advised political and financial considerations. 

And with chilling memories of Thérèse Coffey’s short-lived tenure at the DHSC and Liz Truss’s at Number Ten – during which it was reported that anti-smoking and anti-obesity measures would both be reversed or not even put in place – still fresh in the mind, it’s surely not difficult on the occasion of the NHS’ 75^th birthday to think of how we can all do more to prevent ill health in the coming years, including campaigning for greater investment in public health services.