Although successive governments have understood the importance of preventing illness, none has been able to transform the NHS from a service that diagnoses and treats sickness, to one that predicts and prevents it.
Health inequalities – the gap in health outcomes between different groups in society – also remain stubbornly persistent. And as the population ages, more people will be living longer with conditions such as diabetes, heart disease and dementia; this requires a fundamental shift in how the NHS and social services deliver care.
Promoting healthier lifestyles and tackling health inequalities
Making the shift from treating illness to preventing it requires a long-term political commitment and a significant shift in the way the NHS works to embed health promotion at all levels of the system. Public health has been a soft target for spending cuts in the past. In a challenging economic climate, incoming ministers will need to hold their nerve and resist the temptation to sacrifice long-term gains in favour of policies that deliver short-term political dividends.
Given the scale of the challenge, a combination of strong state action (in a similar vein to the ban on smoking in public places), awareness raising and encouraging people to change their behaviour is likely to be needed. However, changing behaviour in relation to smoking, alcohol misuse, poor diet and lack of exercise is complex, and the evidence on the most effective ways of intervening to deliver sustained change is patchy. The NHS needs to do more to promote existing good practice and learn from emerging thinking from other disciplines such as behavioural economics and psychology.Although life expectancy has risen consistently across the population, there are still significant variations between and within different geographical areas. Tackling health inequalities is not a task for the Department of Heath or NHS alone. Several reports have highlighted the need to address the social and environmental causes of ill health – such as poverty, poor housing and low educational achievement – as part of a co-ordinated approach. This needs a long-term commitment across government and, at a local level, more effective co-operation between local authorities and health services so that other services such as education, leisure and housing can play their part in improving the health of local communities.
More personalised care and support for those with long-term conditions
More than 15 million people – almost one in three of the population – suffer from a long-term condition. With the majority of people over 60 suffering from one or more chronic condition and rising numbers of frail older people living for longer in ill health, the demand for services will increase as the population ages.
As financial pressures focus minds on finding the best and most cost-effective ways of delivering care to this large group in the population, the government should see the provision of more care in the community, and at home, as an opportunity to improve quality of care and to save money by reducing inappropriate hospital stays. New technology – for example, the use of sensors to detect movement or remote monitoring of blood pressure – also provides opportunities to support people with chronic conditions to live independently in their own homes.
More should also be done to enable people with long-term conditions, physical and learning disabilities and mental health problems to live independently and exercise control over their care. Personal health budgets – which allow patients to decide how funding should be spent to meet their needs – could give them much more choice over the services they receive. They must be accompanied by advice and support so that patients are able to make informed choices.
People's needs, understanding and expectations of health and social care services do not correspond with organisational structures. For example, people with long-term conditions, physical and learning disabilities and mental health problems often require co-ordinated services that straddle health and social care.The incoming government should create a policy framework that encourages local authorities and primary care trusts to work together in looking at needs across their local population and to jointly commission services that meet those needs. This will enable a broader focus on the health and well-being of local communities.
Comprehensive reform of social care
The current system for providing care and support to older people is widely regarded as unfair, often falls short of meeting the needs of those who rely on it and will not be able to cope with the increasing demands placed on it as the population ages. The King's Fund has proposed a partnership-based approach to reforming social care funding, with responsibility for the costs of care shared fairly between the individual and the state. This would guarantee everyone some help in meeting their care costs, benefit those with moderate incomes who are penalised by the current system, and give people an incentive to save for their old age.The incoming government must make social care reform an early priority for action and build a cross-party consensus on the key elements of a new settlement that will stand the test of time. The prize for doing so – a fair and affordable care system that provides older people with independence, dignity and security – is a significant one.
Priority for end-of-life care
A patient who is dying should be free of pain, treated with dignity and respect and, wherever possible, should die at home if they wish to do so. Yet, the quality of end-of-life care remains variable – hospitals receive more complaints about this than any other aspect of their care – and, although two-thirds of people say they would prefer to die at home, on current trends, only 1 in 10 will do so by 2030. The number of deaths is set to rise by nearly a fifth between 2012 and 2030, with more people dying at an older age and with a complex range of illnesses and disabilities.With budgets likely to be squeezed for the foreseeable future and pressure on services set to grow, the incoming government must ensure that end-of-life care an early priority. Patients at the end of life should have access to support 24 hours a day and, wherever possible, die at home if they wish to, rather than being admitted to hospital.
The King's Fund's work on promoting wellbeing and independence
The King's Fund has an extensive programme of research, policy and health care improvement work covering public health, the social care system and end of life care.
- In 2006, we published the most authoritative analysis of social care undertaken in recent years, following a review led by Sir Derek Wanless. We recently launched a new report updating this analysis and setting out a blueprint for reforming social care.
- Our award-winning Enhancing the Healing Environment programme works with staff and patients to improve the environment in which health care is delivered. It has recently launched a number of new projects in dementia services and prisons.
- We are currently working with Marie Curie to evaluate services to deliver choice at the end of life and recently hosted a summit with leading policy-makers and stakeholders to identify the critical actions needed to improve end of life care.
- To support the NHS in helping people to become healthier, our Kicking Bad Habits programme developed recommendations and good practice in changing people's behaviour and encouraging them to adopt healthier lifestyles.