A prevention revolution – or another missed opportunity?

The UK’s health is in trouble, and it’s holding us back.

The evidence is stark and consistent: more people are living with long-term illness, working-age health is declining, improvements in life expectancy are stalling, and the health gap between the richest and poorest communities remains stubbornly wide. Just one example, 8.2 million working-age people report a long-term health condition that limits their ability to work, while poor workforce health is estimated to cost UK employers up to £150 billion a year through lost productivity, sickness absence and recruitment costs.

Compared with our international peers, we stand out for all the wrong reasons and are sliding down the international health league tables. Again, just one example – analysis of recent data shows a relative worsening of mortality rates across all four UK nations compared with 21 other high-income countries.

Poor health has consequences. Millions of people face the real-life impact of worsening health on their lives and families. And health and wealth are inextricably linked. A sick nation is an unproductive one. If trends in declining health continue, the government will face a bleak choice: either commit to health care spending rising inexorably, or accept poorer quality care, deeper health inequalities, and a continuing drag on economic growth.

The promise of prevention

The government came to power promising a ‘prevention revolution’, a cross-government mission to create good health in the broadest sense: ‘secure jobs, fair pay, adequate housing, safe streets, clean air, accessible transport, the time and affordable facilities to exercise, nutritious food, and a fair society.’

One year on, the rhetoric has not yet been matched by reality. The first signal of a diluted ambition was signalled in the Plan for Change. The health ambition was scaled back to ‘building an NHS fit for the future’, with a failure to join the dots between plans for ‘kickstarting economic growth’ and the burgeoning working-age health challenge, and ‘creating safer streets’ with the UK’s high rates of drug-related deaths. The subsequent 10 Year Health Plan is a plan for the NHS, not for our health.

Yet good health isn’t built in hospitals. It is built more widely through good living conditions, adequate income, secure housing and thriving communities. It is also built by mitigating exposure to specific harms – tobacco, alcohol, drugs and toxic air, as well as foods that are high in sugar and salt. By signalling in opposition that health would be a cross-government mission, Labour outlined its ambition to reinforce these building blocks of health. Now in office, the health mission is missing in action, while news that the government’s mission delivery unit has been scrapped suggests that its commitment to mission-driven government is in danger of sinking without trace.

Chipping away won’t cut it

Yes, there are some welcome measures. The Tobacco and Vapes Bill is making its way through parliament. The 10 Year Health Plan commits to more lung health checks, increased mental health support for young people, expanded genomics in personalised prevention, and large retailers reporting healthy food sales. The National Audit Office assessed some progress in action on drugs but also noted significant challenges to further improvements.

But other key actions are absent or delayed: the long-promised Clean Air Act, minimum unit pricing for alcohol, the child poverty strategy, regulation and taxation to make the healthy choice the easy choice when it comes to food, stronger action to halt trends in rising drug use and related deaths, and the investment in employment policies that could boost both work and health.

Adding to the urgency, the squeeze on already scarce prevention budgets continues. Public health practitioners report that local NHS systems facing budget crises are cutting tobacco control programmes – a decision that will cost more down the line. NHS leaders also tell us they are seriously concerned about the lack of investment in local-government-funded public health services, such as school nurses, health visitors and sexual health, at the same time as being forced to make tough decisions to cut their own services to support people with smoking or alcohol cessation.

Once services are dismantled, rebuilding them is slow and costly. Prevention is not a tap you can turn off and on without long-term damage. And the stakes are too high to downgrade the ‘prevention first’ revolution to a handful of welcome but disconnected actions.

The power of political bravery

Beyond this fragmented government approach is the blocker of vested interests. There is a long history of lobbying from the food, alcohol and tobacco industries weakening and delaying measures that would improve people’s health. And once again, long-promised restrictions on junk food advertising have been delayed, while Labour’s proposals to extend smoking restrictions to outdoor areas of pubs and restaurants were squashed. Minimum unit pricing for alcohol – successfully implemented in Scotland – and a Clean Air Act, regularly promised by Labour in opposition, have both failed to materialise.

Well-organised, resource-rich industry lobbyists often oppose policies, claiming small gains aren't worth the effort. But prevention works best through the cumulative combination of small actions, such as reducing the availability of junk food, increasing healthier options, and promoting physical activity and weight loss programmes.

Such vested interests aren’t unique to health – they also cast a shadow across government ambitions for net zero, employment rights and tackling online harm. Leadership means confronting vested interests – a commitment Wes Streeting has previously been only too happy to make, warning the food industry before Labour came to power, ‘You either get on board the steamroller or you’re going under it’. Polling shows he is right to have done so – there is strong public support for government intervention to improve the public’s health. And history shows that the public adapts rapidly once these measures are implemented.

However, this steamroller appears to have been parked. While we welcome news of a proposed ban on the sale of high-caffeine energy drinks to children under 16 and that long-promised restrictions on advertising junk food will come into force in the new year, the government needs to go much further and faster on action to tackle the damage caused by unhealthy food.

Time to set radical, decisive plans

The challenges now demand much bolder action. Better and more equal health needs to sit alongside increased economic growth and progress to net zero as a core measure of the nation’s success. Making this a reality under current constraints isn’t easy but it is possible by sharpening policy, boosting accountability, and enhancing delivery. To begin to make tangible progress, the government could do the following:

• Be bold on intervention – the government should grasp the nettle when it comes to raising alcohol taxes, restricting junk food advertising, and tackling inequalities. It can take inspiration from the Labour government’s successful reforms of the early 2000s that reduced health inequalities and cut child poverty. Drug harm and alcohol misuse, which hit the NHS, the police, the courts, the workplace and family life, demand the same decisive approach.

• Focus action on the problem – build on the understanding of why health in the UK has worsened over the past 30 years compared with international peers (long-run consequences of industrial decline, financial, employment and housing insecurity, and under-regulated food and drink systems) by commissioning a rapid audit in the same timescale and approach of the Darzi review but with a wider remit on the health of the nation and what should be done.

• Reboot the health mission – develop a cross-government 10-year plan for rebuilding the health of the nation. This could build on the government’s commitment to publish a work programme for the health mission by the end of the financial year and the audit mentioned above.

• Commit to independent scrutiny on progress – ensure genuine accountability for delivery of improvement in health and inequalities for the long term through independent reporting on progress and future trends.

• Tackle fiscal rules that deter investment in prevention – strengthen the fiscal framework by defining, tracking and, over time, shifting spending towards prevention.

• Invest in local public health services – create ‘parity of accountability and support’ between treatment and prevention with efforts focusing on basics such as increasing NHS screening and vaccination, improved follow-up where needed, and crucially, returning the public health grant to a real-terms equivalent of 2015/16 per person.

Opportunity to lead

The government needs to step up and provide effective leadership to build a healthier UK and tackle health inequalities. History shows that major public health achievements such as the Clean Air Acts of the 1950s and 60s and the smoking ban in public places demand political courage but become celebrated achievements.

The government has a choice. Either accelerate delivery on its prevention promise or stand back and acquiesce to a further decline in our health. Inaction has serious consequences: for people’s lives, for communities, for employers and for the economy.

But this is also existential for the NHS. Health service leaders are telling us that unless we act on prevention, we may not have an NHS to ‘fix’. There is a very real risk that it will collapse under the weight of avoidable illnesses such as heart disease, diabetes and other illnesses that are intimately associated with poor diet, drinking and smoking, and also largely preventable, unless the government acts boldly on these huge threats to the public's health.

The country desperately needs a prevention revolution, and this government should make good on its promise to deliver one.