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The prevention Green Paper: the right time to put it in its place?


Prevention is one of the three pillars (alongside workforce and technology) of the Secretary of State’s stated priorities, and his Department has been working towards a Green Paper, due relatively soon as far as we can tell. What’s likely to be in it, and what should be in it?

There has been welcome engagement with the Department of Health and Social Care on the sorts of things we may expect to see, some of this emerging thinking being set at our recent conference Towards population health systems: what next? Unsurprisingly, there is a clear lineage from Prevention is better than cure (the Secretary of State’s early thoughts in November last year) but it has been developed.

Where we are now

  • Set out the scope of the Green Paper and the challenges it will address – there will be different levels of 'green-ness'.

  • We've identified the range of outcomes it could achieve and potential areas for action.

  • We are now developing the content with ministers:

    • valuing health as an asset

    • smarter services – prevention to become 'predictive, proactive and personalised'

    • making healthy choices easier (levelling the playing field; acknowledging the 'headwinds' that people face in trying to be healthy

    • laying the foundations for better health – e.g. a good start in life; environmental risks; valuing health in all policy-making

This signals that the Green Paper will be a healthy mix of relatively hard proposals and more innovative ideas. On the former, it would be a surprise if this didn’t include childhood obesity given the consultations that are currently under way following chapter 2 of the childhood obesity strategy The framing of health as an asset is very welcome, as is the recognition that prevention is the foundation for better health. If it really does follow through on the beguilingly simple, 'valuing health in all policy-making' then it truly will be a ground-breaking document. And as part of that, it could take lessons from Wales, including a focus on the impact of policies on future generations and mandatory health impact assessment.

But for me there are two things that need more unpacking. The first is the impact of timing. If current government policy stays reasonably stable into the autumn, then this Green Paper will be out before some big decisions that will affect its chances of success have been taken: the Spending Review; next steps on the NHS long-term plan; and critical decisions on local government funding mechanisms which long-term will have implications for the public’s health (including business rate retention and the fairer funding review, which will affect the balance of where funding comes from (Whitehall or local taxes and charges) and the way areas that can raise less funding than is needed are ‘topped up’, respectively) ). This could be seen as a challenge, but the Green Paper needs to see it as an opportunity, setting out clear positions on the need to increase investment in prevention, how the implementation of the NHS long-term plan will move beyond its current narrow focus on secondary prevention, and what the Department’s position is on decisions that will affect local government funding for years to come.

If [the Green Paper] really does follow through on the beguilingly simple, ‘valuing health in all policy-making’ then it truly will be a ground-breaking document

The other thing that needs more detail is what the Green Paper will offer for local systems and place-based health and care. As we’ve pointed out in respect to behaviour change, government policy provides much exhortation to local systems on prevention, but little beyond that. The Green Paper is therefore the opportunity for central government to set out its thinking on how it can better support local government, the NHS and others to be more preventive.

I would suggest five areas that leap out. First, local systems need stronger direction and guidance from the centre on the implications of the rarely used existing provisions in legislation to support prevention including the Social Value Act, the inequalities duties in the Health and Social Care Act, and the Care Act; in addition, local authorities have very permissive powers around improving citizens’ wellbeing. There is a need for more clarity on how all these can be creatively and appropriately used to shift towards more preventive systems.

Second, the Green Paper needs to promote both stronger leadership and accountability for prevention in local systems as our Vision for population health argued. Health and wellbeing boards could step up and provide a stronger leadership role – their time may finally have come. Accountability and governance around population health, of which prevention is a key part, is too complex and weak, so the Green Paper needs to signal this is something that the government will address.

The Green Paper needs to promote both stronger leadership and accountability for prevention in local systems

Third, we need to be clearer about what proportion of spending on public services (including the NHS) should be on prevention. The Green Paper should therefore commit to taking forward the recent PHE/CIPFA report on identifying investment in prevention through setting, monitoring and reporting against expected expenditure levels and/or percentages of wider spend.

Fourth, there needs to be a focus on communities and their contribution to health, which we and many others, including Public Health England and the New Local Government Network, have been drawing more attention to. In the next few weeks, we will publish an in-depth report on the transformative experience of Wigan Council’s work with its residents over the past decade, becoming a stronger partner for health with its community. The Green Paper needs to show a commitment to supporting such change across the country.

Finally, and most specifically, the Green Paper should accelerate the development of integrated health and wellbeing services that support people’s behaviour change but critically recognise that for many people, this requires support with wider problems and issues in their lives. These emerging services frequently deliver through digital channels as well as face to face, something that the Secretary of State would surely welcome, given that technology is one of the other pillars of his policy priorities.