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Prevention and policy: hoping for a gathering storm and not a storm in a teacup


Anyone who has followed health policy in England over time will recognise the cycle of rhetoric about prevention. We see announcements of revolutionary approaches and then mostly inaction, punctuated by minor announcements, all for the cycle to start again.

18 months out from a Westminster election (at most) we are hearing about prevention again, most recently in a wide-ranging speech from Sir Keir Starmer on the health mission of the Labour party. There are three ways to read this, through the eyes of an optimist, a pessimist or a realist. I’ll leave it to you to judge which I am, but below I set out some of the context and ideas that might mean it’s different this time.

At national level the current government consulted on Advancing our health: prevention in the 2020s and has not followed it up. It has commissioned independent reviews, notably the Khan review on tobacco, which made a radical recommendation on prevention: to turn off the tap of new smokers at source, and you can’t get much more preventive than that. There has been no direct response, although the government has announced new policies on e-cigarettes. Government has however signalled that the upcoming major conditions strategy will have a preventive component, mostly focused on secondary prevention, preventing deterioration once people have conditions and diseases. More broadly the levelling up health mission remains with its laudable aim of improving healthy life expectancy and narrowing health inequalities, albeit without a clear and coherent vehicle to achieve it, given the demise of the Health Disparities White Paper announced by Sajid Javid. The government has made some spending commitments, notably on preventing the harms of illegal drugs and in the early years. In the meantime, critical budgets such as those for public health, remain anaemic at best, losing a cumulative £3 billion of purchasing power against the real terms highpoint in 2015/16.

Beyond current national policy there is hope in integrated care systems (ICSs), now on a legal footing, if they are to meet their potential and not become another way to manage stretched NHS services. ICSs are still developing and growing pains are evident but they have immense potential to help stitch together the leadership, resources and intent needed to take a more preventive approach below the national level. The leaders that I talk to in and around ICSs are committed to shifting towards a more preventive system making the best use of data, expertise and knowledge of all those who have it, including communities themselves. The government-commissioned review carried out by Patricia Hewitt on the future of ICSs had a strong emphasis on this, but currently it sits alongside a list of other reviews awaiting a clear government response. ICSs are also consumed with other issues including reducing management costs and balancing system budgets, and these mustn’t be allowed to derail the bandwidth to fulfil their potential on prevention and population health.

There is hope in the emerging policy debate coming through the think-tank community and others, most importantly from beyond the usual health suspects. There have been a recent slew of reports and thinking and more to come from Demos, Institute for Public Policy Research, the Tony Blair Institute For Global Change, the Centre for Progressive Policy and Reform to name but a few. While the emphasis for each organisation is different, there is high concordance on the health and the broader economic case for change, especially the realisation that a society with avoidable poor health is one with avoidable poor productivity. There is also much agreement on where the focus needs to be, and just as critically how to get there, including investment in communities themselves; stronger incentives for prevention in the health and care system and leveraging the power and innovation of technology business while regulating its excesses; and a cross-government governance structure that finally breaks through short-termism, silo-thinking and results in action. None of these ideas are new but the overall coherence and concordance of the policy proposals from voices beyond the usual suspects, and beyond the confines of the health and care policy world, is new.

There is hope in efforts behind the political scenes, and in the cross-party machinery of scrutiny including the Health and Social Care Committee’s inquiry into prevention, keeping the debate and focus on why we as a nation are so poor at finding the collective will and mechanisms to do what everyone knows is right. And finally, there is hope in politicians and the political process itself. This last point will determine whether this time the rhetoric on prevention really is a coming storm, or a just another storm in a teacup.