Realising the health mission: from emergency care to prevention

I recently had the privilege of joining a shift with the London Ambulance Service. I learnt a lot about how the service is trying to improve its operations and culture, and could write a blog on the impressive work to boost staff morale and drive operational improvements. But the bigger learning – and important reminder – was that much of what our NHS ‘front door’ is facing could be avoided with a more preventive focus.

In seven hours, we attended and admitted three patients. I could broadly categorise them as social care, public health and mental health admissions. In the first case, an older person living with multiple long-term conditions was struggling to live independently and had suffered a nasty fall. The paramedics told me this a classic tipping point, and one they witness frequently, where a care package could help someone stay in their own home for longer, but nothing had been put in place. In the second, a nasty chest infection exacerbated by decades of heavy smoking and vaping resulted in an emergency admission with acute breathlessness. And last, a complex presentation with poor mental health at its core.

The most poignant moment of the morning was a patient asking to be photographed with a paramedic before entering the ambulance to demonstrate to their employer that they were ill and couldn’t work. A reminder of the wider social context in which the NHS operates.

None of this is new or particularly surprising. Lord Darzi’s recent investigation into the NHS concluded that the health service is picking up the pieces of a society in distress. Life expectancy has stagnated, and the gap in healthy life expectancy between the least and most deprived is depressingly wide. Money is not always spent well, with the majority of funding concentrated at the acute end of the system, admitting people to expensive and busy A&E departments, when it could be better deployed upstream, preventing ill health and treating people in their home or community.

The Secretary of State for Health and Social Care has talked about the shift from sickness to prevention and hospital to community as central to his ambitions, and something the 10-year health plan will cover. The Prime Minister recently ‘doubled-down’ on his mission agenda, of which health is one of five – taking a long-term, cross-government approach to improve public services and deliver economic growth. While relatively early in development, the mission aims to tackle the leading modifiable risk factors that cause so much ill health – tobacco, obesity, alcohol, lack of physical activity and air pollution, among other things. The government has made a good start in revamping the Tobacco and Vapes Bill, to restrict the sale of tobacco to children and limit the sale and marketing of vapes, and by pushing forward with restrictions on junk-food advertising that had been delayed by the last government.

But it will need a sustained commitment to reverse our poor national health and to move from sickness to prevention. One in five children leaves primary school obese. ‘Deaths of despair’ from alcohol and drug use are on the rise in some parts of the country. Low levels of physical activity hamper chronic disease prevention. The good news is the public is more supportive of well evidenced public health measures than politicians often believe them to be, particularly when framed around protecting children’s health.

To make the biggest difference, the missions should work together, supporting policies that deliver double or triple wins. There are 2.8 million people out of work due to ill health, with mental health and musculoskeletal conditions the top reasons for people falling out of the workforce. Tackling these issues will contribute to economic growth and improve health. Poor housing affects health for people of all ages. Damp, cold homes can cause respiratory illness, and homes in poor condition increase risk of falls and injury. Similarly, poverty often leads to poor health in childhood, which in turn limits opportunity. A joined-up approach to pursuing health in all policies will positively impact several of the government’s most important goals.

This can’t all be organised and directed from Whitehall. Not much has been said publicly about the role of regions, local authorities, integrated care systems and neighbourhoods to deliver the mission. But this is surely a critical part of the jigsaw and can unlock citizen empowerment and participation in a way that central government policy making rarely does. A lesson from much of our research, reinforced in our analysis of the health care response to Grenfell is the importance of working with, rather than doing to communities, to build trust and drive change.

From the NHS’s vantage point, performance metrics matter. The Secretary of State reinforced this in a recent speech, with the re-emergence of league tables for hospital performance. To deliver better public health, we should measure and report on progress in a similar way as we do elective and A&E waits. There must be a parity with acute metrics, and money should flow to support delivery. We too often rely on heroic leaders to deliver prevention against the grain of what the NHS measures, reports and seems to value most. This must change if we are serious about improving population health and should feature prominently in the 10-year plan.

And on the money, it’s clear the financial climate for the health and care system, as across all public services, is tight and set to stay that way. We don’t have the luxury of waiting for more money to flow in a year or two, which will enable ‘double running’ of acute and community services, while we re-shape the health and care system. The challenge is to make the shift happen within the current envelope, and while incredibly hard to pull off, across the country dedicated leaders and teams are trying to do just this. Our politicians should support and give leaders the space and time to re-imagine our health service.

My thoughts have kept returning to the patients admitted on my shift. Where are they now and do they have the support they need to get home, recover, get well? In future, with a health mission in full flow, our collective hope must be that they wouldn’t need to call the ambulance in the first place.