The case for change
Over the past 100 years, in common with other developed countries, England has made a great escape from poor health and short life expectancy. This has been due to improvements in sanitation, medicines and health care, underpinned by economic growth, improved living standards and the establishment of the welfare state. Life expectancy has improved and, although inequalities in health have been ever-present, as a population we are healthier than ever before.
However, progress against many key measures has stalled and risks going into reverse. Data shows that there has been little or no improvement since 1990 in how long people live with illness and disease. England lags behind comparable nations on many key measures of health outcomes, and our obesity rates are among the worst in western Europe. Improvements in life expectancy have ground to a halt. Inequalities in health are widening, condemning some people to live much shorter lives, in poorer health.
An important shift is taking place in the burden of disease, from mortality to morbidity, with people living for many years with chronic conditions, in pain and with mental ill health. Much of this is preventable, yet the NHS remains, at heart, a treatment service for people when they become ill, and we lack a comprehensive approach to keeping us well.
NHS organisations have a critical role, not just as providers of health services but as employers, key players in their local economies and anchor institutions in their communities. However, these challenges cannot be addressed by the health and care system alone; a much broader approach is required that pays more attention to the wider determinants of health and the role of people and communities.
The Secretary of State for Health and Social Care has published a vision for prevention, identifying this as a key priority and signalling that a Green Paper will be published in 2019. This is encouraging, but previous ministers have arrived in office with good intentions and talked up the importance of prevention and public health only to end up not delivering as other challenges consume their time and political capital. It must be different this time.
What affects our health?
Our health is shaped by a range of factors, as set out in Figure 1. It is hard to be precise about how much each of these factors contributes to our health, but the evidence is convincing that the wider determinants of health in the outer ring have the most impact, followed by our lifestyles and health behaviours, and the health and care system. There is also now greater recognition of the importance of the communities we live and work in, and the social networks we belong to.
What is population health?
Population health is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population. There is no single accepted definition of population health. We see it as a broad overarching concept, encompassing but going beyond the NHS, public health and population health management.1 Crucially, it focuses on the wider determinants of health and the role of people and communities.
Our vision for population health
Our vision for population health is that:
Health outcomes and inequalities in health in England will be on a par with the best in the world. This will be achieved by a consistent and coherent focus on population health locally, regionally and nationally.
In recent years, health policy has focused on the funding, organisation and delivery of services, with insufficient attention paid to population health outcomes and the factors shaping them. Progress has been measured by how the system is performing rather than by the health of the whole population. The first step to achieving our vision therefore is to set a small number of ambitious and binding national goals to drive improvements in population health, including reductions in health inequalities.
A framework for action: the four pillars of population health
Our vision for population health is based on the four interconnecting pillars in Figure 2.
- There is now a wealth of evidence that the wider determinants of health are the most important driver of health. In addition to income and wealth, these determinants include education, housing, transport and leisure.
- Our health behaviours and lifestyles are the second most important driver of health. They include smoking, alcohol consumption, diet and exercise. For example, while reductions in smoking have been a key factor in rising life expectancy since the 1950s, obesity rates have increased and now pose a significant threat to health outcomes.
- There is now increasing recognition of the key role that places and communities play in our health. For example, our local environment is an important influence on our health behaviours, while there is strong evidence of the impact of social relationships and community networks, including on mental health.
- Recent years have seen a strong focus on developing an integrated health and care system. This reflects the growing number of patients with multiple long-term conditions and the need to integrate health and care services around their needs rather than within organisational silos.
Together, the four pillars form the basis for a population health system. As a concept, this is not new. However, current efforts in relation to the pillars are not in balance and there is not enough focus on the pillars as interconnecting parts of the same system. A more balanced approach is required that distributes effort across all four pillars and, crucially, makes the connections between them.
- 1. Population health management uses data to plan and deliver care to achieve maximum impact on the health of a population.
What needs to change?
Achieving our vision and delivering improvements in population health will require concerted action at national, regional and local levels, drawing on the assets of people and communities. Improving population health is a shared responsibility and progress also depends on supporting people to live healthier lives. We recommend change in three main areas.
Strong political leadership is essential to ensure that improving population health is a key priority for the health and care system and across government. In reducing health inequalities, lessons can be learnt from the progress made under the last Labour government. England can also learn from other countries, including Scotland and Wales, which have taken a bolder approach to improving population health. Effective local system leadership is also vital. The complexity of local structures means that approaches will vary from place to place with health and wellbeing boards, integrated care systems (ICSs), sustainability and transformation partnerships (STPs) and political leaders such as elected mayors all having key roles to play.
Our recommendations to strengthen leadership for population health include the following.
- Population health and health inequalities must be at the heart of the role of the Secretary of State for Health and Social Care.
- The government should announce a new cross-government strategy to reduce health inequalities.
- The government should ensure that arrangements are in place to co-ordinate action on population health across Whitehall departments and that all relevant government policies are subject to a health impact assessment.
- Lessons should be learnt from previous successes in tackling health inequalities and from the experience of other countries, including Scotland and Wales.
- Local system leaders and politicians should champion population health. Local authorities have a key role to play working with the NHS and other partners including through health and wellbeing boards, STPs and ICSs.
Roles and accountability
At national level, greater clarity is needed about the roles and responsibilities of NHS England and Public Health England in particular. Accountability for improving population health at local and regional levels is currently weak and confusing. Strategic bodies, such as HWBs, STPs, ICSs and political leaders such as elected mayors have important roles to play in ensuring that local actions are aligned with national goals. The NHS long-term plan, new five-year STPs to be developed in 2019 and the forthcoming Green Paper on prevention provide opportunities to clarify this.
Our recommendations to clarify roles and strengthen accountability include the following.
- The government should set ambitious and binding national goals for population health and health inequalities.
- The government should provide greater clarity about the roles of NHS England and Public Health England in achieving these goals. As part of this, the role of Public Health England should be reviewed to ensure it has the authority to provide effective leadership and challenge to government.
- Strategic bodies, such as HWBs, ICSs, STPs and local political leaders such as elected mayors should ensure clarity about roles and accountability for population health and alignment of local actions with national goals.
Funding and funding mechanisms
Political attention tends to focus on the NHS, with funding following accordingly. In contrast, short-sighted cuts to the public health grant mean that local authority spending per head on key prevention services is on track to fall by almost a quarter in real terms between 2014/15 and 2019/20. We need to rebalance resources between the four pillars in our framework, starting with the restoration and protection of public health funding. The government can also play a strong role in supporting people to live healthier lives through tax and regulation, as shown by the impact of the Soft Drinks Industry Levy.
Our recommendations to rebalance spending to support population health include the following.
- The forthcoming Spending Review should restore public health grants to local authorities to at least 2015/16 levels (an increase of at least £690 million) and move to multi‑year funding settlements.
- The Spending Review should announce moves to trial new funding mechanisms for prevention, such as a prevention transformation fund.
- Building on the lessons from the Soft Drinks Industry Levy, the government should be bold in using taxation and regulation to support health improvement.
Making our vision for population health a reality will require concerted, systematic and coherent efforts over many years. We hope that the framework we have set out will provide a starting point for this and a useful tool for developing population health systems at national, regional and local levels.
This also signals a new phase of work for The King’s Fund. Building on our work to promote integrated care and support place-based systems of care, population health will be a key focus for us in future. We hope that you will join us as we embark on the next stage in our journey.
I work with children aged 5-19 as a School Nurse Practice Educator, and preventative and public health is at the heart of everything that we do, but sadly our budgets have been cut locally by 5% this last year. Our role is to provide preventative health messages to our future generation, but with the numbers of qualified School Nurses at an all time low, our work is totally unsustainable. More funding is required locally as prevention is always an oversight and especially with our children.
I do not comprehend how a report on Health by your organisation can fail to mention the affects on health provision of the drive towards the privatisation of health services.
Year on year cuts in services- described dishonestly as increases- have dramatically reduced the possibility of meeting the needs of our growing population. But even more importantly cuts in wages, difficulties affording housing, and the overall growth of poverty are all ensuring that health inequality grows. The enabled poisoning of the population by the so called food industry which adds sugar and chemicals to almost everything we eat in order to extend shelf life and make us addicted to certain foods is actively causing the rise in obesity and diabetes yet the private sector under this government is sacrosanct.
And "place based provision" simply means the rolling out of Accountable care type organisations which break up the cohesion of services even further, lose the economy of scale and enable the easy take over of our health services by mainly US private health providers, which will result in a massive reduction in services as they skim off 20-30% of the funding we provide to pay their individual costs and profits.
I have witnessed the decline of services in Health and Social Care to those suffering from a LTC (Mental Health) over years. It's EASY to DISMISS this Group, because they have no idea on their RIGHTS. 'Integration' is 'dead' in the water, first you need to identify ALL the AGENCIES involved. LEADERS are NOT LEADERS if they have NOT worked at the 'coal face'.
Mental Health and Homelessness is on the increase. The questions is: how is 'integration' collecting DATA on anything?
Carers, and others! are supposed to be recognised for what they do, how is this DATA collected?
Health & Wellbeing Boards, are a group of individuals who meet 'each other' on a regular basis, but for what purpose? if they do not engage with the Public.
The CQC latest REPORT provides an accurate account on the state of Mental Health Services, why are they not invited on a Regional basis to put forward their 'findings' to the CCGs and Health and Wellbeing Boards, including the PUBLIC.
I speak and meet with the CQC on a regular basis, my next meeting is in January.
My latest 'find' was of an elderly lady who fell down the stairs, admitted to Hospital: the following day they were busy trying to 'ship' her out to any Community Hospital, unfortunately there was insufficient staff, (beds remained empty) the following day, she was in ICU with a fractured Pelvic, fractured ribs, and Jaw, and on dialysis.
I rest my case, nothing is improving for the Mentally Ill or the elderly.
Is any of this news? I can't help remembering that
- Buddhism and Yoga developed practical integrated health theory about 2,000 years ago.
- My village was founded as a community 100 years ago.
- The Black report, in 1980, concluded that health inequalities were "not mainly attributable to failings in the NHS, but rather to many other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work.
And now, in 2018, the King's Fund has a vision.
It could, of course, be helpful to ask: if all this has been known for a long time, what has prevented it being acted on before? And do those hindrances persist? (Well, yes, I'm afraid they do. Greed and self-interest remain as popular as ever.)
So where do the reforms really need to start?