By Karen Taylor and Samrina Bhatti, Deloitte Centre for Health Solutions
This week, we launched the fourth report in our future of public health series, Negating the gap: Preventing ill health and promoting healthy behaviours, highlighting the unequal impact of the COVID-19 pandemic and how failing to focus more on preventative services has disproportionately affected people living in more economically disadvantaged areas. It considers how recent policy changes, such as the introduction of Integrated Care Systems (ICSs) and the establishment of the Office of Health Improvement and Disparities (OHID), provides an opportunity to increase the priority given to prevention; and identifies that increasing healthy life years and reducing inequalities requires a population health management (PHM) approach and more effective and targeted funding for prevention. This week’s blog provides an overview of our main findings and why a more concerted effort on ill-health prevention and health promotion is needed.
About health promotion and ill-health prevention
Health promotion enables people to increase control over, and improve, their health by engaging and empowering them to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and other illnesses. Health promotion comprises, medical, behavioural, educational, empowerment, and social change. Health prevention comprises primary prevention to modify or prevent the risk of disease, secondary prevention for early detection of onset of disease and action to stop or slow progression, and tertiary prevention to prevent complications. Each level involves different targeted interventions (see Figure 1).
Figure 1. The three main levels of health prevention
The health prevention challenges pre-pandemic
In the UK, responsibility for health promotion and prevention programmes rests with local authority directors of public health (DPH) and their teams and the NHS. To be effective, however, it requires collaboration and partnership working at all levels. Moreover, NHS front line staff and public health teams need to work in partnership with social care, social enterprises, voluntary organisations, and other stakeholders to provide evidence based public health interventions.
However, following the transfer of responsibility for public health services to local authorities in 2013, approaches to public health prevention have varied across local authorities, linked largely to the availability of funding and the differing needs of local populations. Although the new public health funding formula introduced in 2013-14 sought to account for differences in need, there was limited progress in shifting resources to those areas below target. Consequently, despite the political rhetoric and research evidence about the cost-benefits of improving prevention, the reality is that overall funding for preventative services has reduced (see Figure 2).
To reduce health inequalities, interventions need to be targeted at higher risk groups as part of a PHM approach, underpinned by the collection and collation of not only health and social care data but also data on housing, income levels, and education status, as well as DPH’s knowledge of place. The integration proposals in the Health and Care Bill, that is currently working its way through Parliament, highlights the importance of PHM and should also help improve partnership working. However, it also needs to tackle the low levels and disparities in public health funding.
The Office of Economic Cooperation and Development estimates that most countries spend less than five per cent of their health budget on prevention and mostly on secondary and tertiary interventions rather than on primary prevention. In England, analysis by the Office for National Statistics shows that funding for preventative activities decreased from five per cent of total health spending in 2013 to 4.5 per cent in 2019 with the focus for spending largely on mandated services, with limited funding available for primary prevention.
Figure 2. Funding of preventative care in the UK
Tackling the main risks and drivers of health inequalities and the impact of the COVID-19 pandemic
In our report Identifying the gap: Understanding the drivers of inequality in public health, we identified the impact of the social determinants of health in increasing health inequalities across the social gradient with people in lower socio-economic groups having worse health outcomes than people who are better off. COVID-19 has made these inequalities much worse, particularly for black and ethnic groups, those with learning difficulties or physical disabilities, and other vulnerable groups. The pandemic has also highlighted inequalities in access to health prevention interventions and support; with people living in more deprived areas, experiencing the biggest falls in access to hospital care, and reductions in urgent cancer referrals and first treatments. These disparities in access formed part of the rationale for reforming public health, including expecting the OHID to have an increased focus on health inequalities.
One of the biggest areas of concern during the COVID-19 pandemic has been the increase in mental health problems. Despite multiple policies and programmes to improve mental health services, the focus has been largely on treatment, usually once the condition becomes more severe. Historically there has been limited emphasis on early interventions to improve prevention. Consequently, mental health inequalities persist: 70 per cent of our interviewees said that they had not been well tackled.
Today, there are a range of NHS-approved, digitally enabled models of care especially for mental health, providing insights to help improve healthcare providers understanding of the causes and symptoms of different mental health conditions, how well treatments work, and how each treatment works for individual patients. Care delivered via digital platforms can also help people avoid the social stigma often associated with poor mental health, reduce waiting times, and remove the need to travel and take time off work for treatment. Moreover, content on health promotion is increasingly delivered digitally. Improvements in health literacy and digital literacy are therefore needed to avoid exacerbating health inequalities.
Reimagining public health: Negating the gap in ill-health prevention and health promotion
There is a huge body of research evidence showing clearly that investment in prevention and health promotion is significantly more cost-effective and equitable than dealing with the consequences of health inequalities (the estimated cost of each additional year of good health achieved by public health interventions (£3,800) is 3.5 times lower than the average cost of NHS interventions). Yet, preventable illnesses caused by tobacco, obesity, alcohol, and recreational drugs, cost the taxpayer billions of pounds each year for treatment and long-term care. To address these issues, central and local government, the NHS, the wider public health system, and industry need to collaborate effectively to improve detection and prevention of ill health, and to apply cutting edge science, technology, behavioural health, and other evidence and data to target support where it is most needed.
Moreover, partnership working between primary care, local authorities and the third sector to deliver and adopt well-evidenced interventions implemented at scale, with agreed metrics to measure progress, can help people to avoid poor health, reduce the growth in demand on public services, and support economic growth. However, there is a need for transparency and accountability and for the needs of people from socio-economically deprived backgrounds and more marginalised groups to be reflected in the formula for allocating funding for preventative services.
There is also a huge opportunity to use digital technology to optimise outcomes, including providing upstream primary prevention interventions and supporting people at home through monitoring and earlier interventions and reducing deterioration in a long-term condition.
COVID-19 has shone a spotlight on the unequal impact of the pandemic, disrupted important public health prevention programmes and has shown how failing to prioritise prevention results in disproportionate levels of mortality along the social gradient. To be successful, prevention and promotion need to be based on a PHM approach and be appropriately funded. Moreover, prevention and promotion should be viewed as a partnership between the NHS, public health, and stakeholders across the health ecosystem.
Ultimately success in improving prevention and health promotion will require consistency of purpose, with guaranteed funding and adequate staffing resources over several years. The NHS and local authorities know what needs to be done and what works and what doesn’t with many examples of good practice, but wide variation in adoption; these need to be adopted at scale. Importantly, the OHID and ICSs will have a statutory responsibility to focus on prevention and negate the gaps in services and interventions that we have identified. Local populations should be the ultimate judge and jury and hold ICSs to account for the outcomes they deliver.