When it comes to prevention spending in the NHS, ‘some is not a number, soon is not a time’

Here’s a piece of unsolicited advice: if you’re ever feeling depressed about the state of the world, then go and watch one of Don Berwick’s speeches about how to improve health care. He delivered one of my favourites 20 years ago, when he launched a campaign to reduce needless deaths in hospitals by 100,000 by 9am on 14 June 2006. A specific number of deaths avoided. A specific deadline to do it by.¹

The speech was called ‘Some is not a number. Soon is not a time.’

This government wants to turn the health care system in England from a service that treats us when we are sick to a service that helps prevent ill health. That is going to need some fundamental rewiring of how money works in the NHS: how funding is distributed to different organisations, how payments and contracting systems are designed, and how financial performance is measured and managed. Here are just a few illustrative ideas of what that change could look like.

It could look like a big hairy audacious goal. In 2018, the Scottish government’s Health and Social Care: medium term financial framework made a commitment that hospital expenditure would account for less than 50% of frontline NHS expenditure in five years’ time. Data from Lord Darzi’s review of the NHS (see Figure 1) shows that a similar ambition would be a huge stretch, but a big hairy audacious goal would show that the government is serious about its ambition to shift the balance of care.

Or change could look like a prevention investment standard, modelled on the mental health standard that was introduced over five years ago to redress historic underfunding of mental health services. Local councils and integrated care boards (ICBs) could identify how much they spend on prevention (see CIPFA’s excellent work on this topic) and make a commitment to grow this faster than their overall budget (ie, so prevention spending starts to account for a growing share of overall spending).

It could look like the proposals to introduce a new ring-fenced budget for public spending at a national level: ‘PDEL’ (preventative departmental expenditure limit). This would identify departmental spending on preventive activities and draw a protective border around these budgets so they couldn’t be raided for other purposes. And although NHS England leaders are cutting the number of ringfenced funds, they are not opposed to targeted ringfenced funding in principle.

It could look like a local ‘top-slice’, with integrated care boards taking 1% of the funding (or future growth in funding) earmarked for acute hospitals and redirecting this to support preventive services.

It could look like the once fashionable blended payments and capitated outcomes-based incentivised contracts, which were intended to bring together different health care providers to deliver services that maintain the health of their populations.

Or it could look like something more prosaic but still important – growing the public health grant after the previous years of per capita real terms cuts it has experienced.

So, if this government is serious about transforming our health care system and in investing more in preventive services, it should pick one of these funding options. Pick more than one. Or pick something else. But pick something to demonstrate that financial incentives in the NHS are going to support the preventive agenda.

Of course, none of this is as easy or binary as I make out. There will be debates over what the money should be repurposed for. Should money be taken from the acute sector to support primary prevention, secondary prevention, tertiary prevention or more care in the community (All these areas are valuable but they are not synonymous.)? And technocratic changes to funding can support a more preventive approach, but they can’t guarantee it without changes to clinical practice and how services are delivered on the ground.

There will be debates over who should receive the redirected funding. Some NHS trusts now bring specialised, acute, community, mental health and primary care services under one board. So in some cases money will be reshuffled within an organisation rather than taken from an organisation. And no doubt there will be debates over how to identify and ‘count’ preventive spending and all the potential gaming that might incentivise.

Finally, we are kidding ourselves if we think that the quality and access to hospital services won’t suffer in the near term if we reallocate funding in this way. The exact impact will depend on whether acute funding growth is slowed, stopped or reversed. But either way, funding that would have gone on more hospital staff, beds and equipment will be diverted – and no hospital efficiency or productivity drive will compensate for this. Longer waits, poorer access, and poorer quality hospital services will be part of the short-term deal.

Of course, the reality check on this logic is that key hospital performance standards are still being missed despite acute services taking up a larger share of health care spending over the past decade. The current approach is a busted flush.

Ultimately, though, what happens if the government ducks the challenge? It has happened before. In 2023, Patricia Hewitt’s independent review of integrated care systems (ICSs) recommended that the share of NHS ICS budgets spent on prevention should increase by at least 1% over the next five years. But the previous government demurred in its response to Patricia Hewitt, saying: ‘We do not agree with imposing a national expectation of an essentially arbitrary shift in spending.’

So, what happened next? The government said ‘no’, which is normally the end of the matter. But not this time. From London to Yorkshire, individual ICSs decided that Patricia Hewitt was right. They started identifying spending on prevention. They committed to growing it by at least 1% each year. They didn’t shout about it, they just did it. And yes, it does feel odd that this commitment to prevention still feels like a guerilla movement despite it being the stated aim of the current government.

The PR expert James W Frick once said, ‘Don’t tell me where your priorities are. Show me where you spend your money and I’ll tell you what they are.’ These ICBs are doing just that. It isn’t the only way to invest more in preventive services, and it may not work for every part of the country, but these are the type of one-percenters I can get on board with. Some is not a number, soon is not a time. 1% is a number. And as for the time? They’re doing it right now.