Far from an easy target for budget cuts, prevention activities should be seen as essential services that can help meet the immediate pressures facing the NHS.
The government and the NHS talk a good game on prevention. The NHS long-term plan promised action on prevention, with systems moving from a model of reactive care towards one based on ‘active population health management’.
The message has stayed consistent in formal pronouncements. The recent interim report on the new Major conditions strategy underlined the importance of primary prevention (addressing the modifiable risk factors of ill health) and secondary prevention (intervening early to reduce the chance of conditions worsening) as the foundations to improving outcomes in the six prioritised conditions.
There has undeniably been good progress on the back of the NHS long-term plan. Three of the initiatives launched or expanded in that plan – on smoking, alcohol and obesity – have delivered results.
But there are concerns, both with these central schemes and whether prevention is being made enough of a priority. In an HFMA survey towards the end of 2022, looking ahead to the 2023/24 financial year, finance directors said that programmes tackling health inequalities and pursuing prevention and population health were the ones most at risk from financial pressures.
Admittedly this was before chancellor Jeremy Hunt increased NHS funding in his autumn statement. But the point was clear. With immediate pressures of dealing with emergency demand and the government’s clear priority to reduce elective backlogs, finding funds to maintain or expand prevention activities would be difficult.
Despite this there are increasing calls for the service to put its money where its mouth is. And while there is broad acceptance that prevention can reduce demand in the medium term, proponents of greater prevention argue that it can have much quicker impacts and should be seen as part of the NHS recovery programme.
‘We are simply not spending enough money on prevention,’ says Sanjay Agrawal (pictured), clinical prevention lead for the Midlands and national specialty adviser for tobacco dependency at NHS England. He insists that the NHS has to start treating prevention as a mainstream activity and not something additional on top of other treatment services. In fact, he believes there is a danger that prevention is being seen as a ‘new activity’ and required to jump through business case hoops that other mainstream services don’t have to contend with.
Tobacco, alcohol and poor diet remain the big modifiable risk factors that can reduce life and healthy life for people, but also lead to hospital admissions and the use of high-cost NHS treatment. ‘Tobacco is still a big problem,’ he says, highlighting that close to one in seven people still smoke. ‘If I said one in seven people had Covid-19, you’d be shocked. And if I said that one in seven people were dying from something, we’d do something about it. But we are desensitised because smoking has been around forever.
‘The problem with tobacco addiction has not gone away. And it is the same with alcohol – alcohol is shockingly bad as a modifiable risk – not only to individuals, but to their families and wider society, leading to domestic abuse and marital break-up, criminal damage and lost productivity.’
Part of the problem with these issues, as well as unhealthy eating and gambling, is that they continue to be seen as lifestyle choices, when they are really addictions.
Core public health activities are the responsibility of local authorities, funded through the public health grant. Professor Agrawal believes this separation from the NHS is immaterial. ‘The NHS are the foot soldiers of public health,’ he says. He points to the tens of millions of A&E and outpatient attendances and hospital admissions as ‘opportunities to do public health’, on top of the hundreds of millions of GP appointments.
This opportunity can’t be realised just by expecting hard-pressed clinicians to do more during each interaction, he says – especially given the pressure to improve productivity and patient flow.
‘That is the value of having dedicated teams, as supported by the NHS long-term plan, in the same way that we have dedicated teams for tissue viability, diabetic nurses or a pneumonia service,’ he says.
‘I don’t think a patient should have just anyone talking to them about their diabetes, they need a specialist and it is no different for people who are addicted to tobacco or alcohol or who have an unhealthy weight.’
In fact, he sees the label of ‘prevention’ as a bit of an issue. ‘I see it more as treatment,’ he says. ‘So you need specialist tobacco dependency treatment, alcohol treatment and unhealthy weight treatment.’
Professor Agrawal is pleased with the long-term plan’s specific support on prevention. However, he shares a concern about how the services that have been funded move into the mainstream and become regarded as part of core service provision. The key elements of the prevention programme are funded through NHS England’s service development fund, which broadly supports transformation. Headline envelopes for the various schemes were communicated as part of the implementation framework for the duration of the plan. But NHS England says: ‘There is no expectation that funding will cease at the end of 2023/24.’
However, there is enough uncertainty among some trusts to treat the funding as non-recurrent until explicitly told otherwise, meaning that some services have been run on fixed term rather than permanent contracts. This can create recruitment difficulties and there can also be a perception that a service based on fixed-term contracts is easier to cut when systems are looking to balance the books. In summary, he does not want integrated care board or provider boards to see prevention activities as some form of easy cut when faced with difficult decisions to balance the finances.
In any case, he thinks this would be short sighted. Olivia Bush, the NHS strategic lead at ASH (Action on Smoking and Health) says that prevention can help systems meet more immediate operational priorities for the winter ahead – and has produced a briefing to reinforce this message.
‘It is a bit more detailed than just looking at urgent care and electives, although prevention does link with that,’ she says. ‘But it is about saying that if you tackle smoking, it would reduce your readmissions and improve flow throughout your organisation.’
She points to work done in the North East and Yorkshire to highlight the return on investment from treating tobacco dependency – and says that the charity will soon launch a tool that demonstrates the potential savings and capacity improvements that all trusts could realise. Ms Bush says that there is value in going beyond the schemes funded centrally.
She points at the longstanding Fresh and Balance programme in the North East that has brought together all of the region’s tobacco and alcohol services, or trusts that have expanded the tobacco dependency treatment service to A&E departments, moving beyond the purely acute, maternity and mental health settings.
The message is clear. Prevention is part of the solution to delivering a sustainable healthcare service. But it is not just about pay now and see the gains later. The return on prevention can be realised in months not just years. Delaying investment should not be an option.
There is some debate over exactly what is meant by primary and secondary prevention, with slight differences in definition depending on who you ask. Chief medical officer Chris Whitty set out NHS England’s view of what distinguishes the different levels of prevention when he gave evidence to the Health and Social Care Committee’s prevention inquiry earlier in the year.
‘Primary prevention…are things that are done to everybody. It is things like reducing smoking, reducing salt and improving areas for people to exercise – a variety of things that can be done to everybody. Secondary prevention… are things that are done based on someone’s individual risk. Taking heart disease as the example, they are things like identifying that someone has hypertension and putting them on a hypertensive. If they have high cholesterol, they will be on a cholesterol-lowering drug. If an individual is smoking, we can help them individually to come off because we failed to prevent them from smoking in the first place.’
So under this definition, while general warnings and campaigns to discourage smoking would be considered primary prevention, the NHS long-term plan’s tobacco dependence treatment services in acute, maternity and mental health settings are viewed as secondary prevention as they are targeted at individuals.
The growing case for prevention
One in five of the adult population in England will be living with a major disease by 2040, according to analysis by the Health Foundation – a significant increase on current numbers, largely as a result of increasing life expectancy.
Layla McCay, director of policy at the NHS Confederation, says the findings represent a worrying increase in pressure and demand for the NHS. ‘Health leaders are clear that more needs to be done to prevent people from falling ill,’ she says. ‘A greater shift towards preventative health and care services will save money in the long run, improve population health and reduce health inequalities.’
And according to Sarah Clarke, president of the Royal College of Physicians, the projections would be ‘catastrophic’. ‘We know that much of this illness is avoidable – it’s caused by smoking, poor housing, unemployment, poor food and air quality, and obesity,’ she says. ‘It is in the gift of the government to do something about all these things.’
The Health Foundation identifies lots of important reasons to invest in primary prevention, delaying the onset of many conditions or making them easier to treat. It points to lots of evidence that prevention is ‘hugely cost-effective, offering large increases in length and quality of life for relatively little financial or other investment’.
But it warns that while there are ‘many important reasons to invest in primary prevention’, being cost-effective is not the same as cost saving.
‘Any reduction on in-year costs would be weighed against a longer life expectancy, which will tend to increase costs over the longer term,’ it states.
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