With the publication of Prevention Is Better Than Cure in November (Department of Health and Social Care (DHSC), 2018a), the government has placed the prevention of ill health at the core of its NHS long-term plan. The new policy intends to shift the focus of health management to primary and community care services, with a focus on the benefits of offering early support.
Background
In the introduction to the initiative, Health and Social Care Secretary Matt Hancock acknowledges the progress made in improving people's health and extending longevity. However, he highlights that too many people are living too long in ill health, which is preventable. The Health Secretary is adamant that prevention is better than cure.
Marcum (2004) pointed out that in modern western medicine the machine is the predominant model of the human body. In this mechanistic, or biomechanical model of medicine, the patient is reduced to individual body parts, much as a car engine is reduced to components by a mechanic. Today, many health professionals think it is more effective to prevent the engine (the human body) from breaking down in the first place and that prevention is crucial to improving the health of whole populations. However, such is the legacy of mechanistic medicine that in the UK £97 billion of public money is spent annually on treating disease versus just £8 billion on prevention (DHSC, 2018b).
Within public health, the concepts of ‘downstream’ and ‘upstream’ interventions have been used as analogies for interventions supported by mechanistic medicine and preventive medicine respectively.
These metaphors can be explained by imagining someone on a river bank witnessing an apparently dead body floating past, as the fast current carries it downstream. The person has a smartphone and calls for help; within minutes an ambulance arrives, the paramedics rescue the victim and commence life support procedures. They continue until the ambulance reaches the emergency department (ED) of the local NHS trust. The victim makes a good recovery and the morning headlines extol the professionalism of the emergency care staff in treating the drowned patient without any reference to why the person fell in the river in the first place.
However now, rather than treat people once they have become ill, the Government intends to promote health and focus on what is causing people to become ill—that is, on preventing illness—which is the concept of ‘upstream’ intervention. It is the attention on upstream determinants of health that may mitigate or prevent the emergence of costly illness (University of Ottawa, 2018).
Despite the lack of financial balance between prevention and treatment, there have been spectacular strides in prevention, not least the success of immunisation, starting with English physician Edward Jenner's pioneering work in vaccination in the 17th century and, recently, the ban on smoking in public places.
Making prevention pivotal
Prevention will not only improve the nation's wellbeing, it will also help the citizens of this country to live well for longer, leading healthier and more independent lives. In essence, prevention stops health problems from arising in the first place. If the NHS concentrates on helping people to stay healthy, rather than treating them once they succumb to illness, this will support them to take charge and be more effective in managing their health earlier in their lives.
Good physical and mental health is desirable not only for individual wellbeing, but also for a country's economic health. The latest policy document shows that ill health among the working-age population alone costs the economy around £100 billion a year, which is unsustainable (DHSC, 2018a).
Failing to prevent illness puts unnecessary strain on health and social care sectors. In 2017, attendance at NHS EDs soared to a record 24 million (up 22% in less than a decade). Spending on health care has risen to almost 10% of national income and this new policy initiative aspires to make the NHS sustainable for future generations (DHSC, 2018a).
With these escalating costs of health care, it is not surprising that the Government needs to use stringent preventive measures to tackle the incidence of diseases. It is important to stress that the new policy is about more than just saving money—it aspires to help people to enjoy at least five extra healthy, independent years of life by 2035, while simultaneously addressing the health discrepancies between the rich and poor.
Despite major advances in health promotion, the policy document points out that about 20% of people's lives are spent in poor health and that the post-war improvements in life expectancy may not be sustainable, partly because people are living longer with long-term conditions.
The number of patients living with four or more illnesses is projected to double by 2035, with an estimated 33% of these having mental health problems. Furthermore, health inequalities persist; the policy document shows that a boy born in 2018 in the most deprived area of England can expect to live about 19 fewer years in good health and die 9 years earlier than his counterpart born in the least deprived area. It also reveals that people with severe mental health illness have a life span that is 15-20 years shorter than those without.
The document links traumatic experiences in childhood with later mental health problems, but it also cites evidence that links improvements in an individual's feelings of wellbeing with a reduction in some mental health problems. It recommends five actions to promote wellbeing and improved mental health, called the five ways to wellbeing (Government Office for Science, 2008):
Preventing health problems
A significant part of the new policy focuses on how individuals can be helped to make better choices in life. These can be small decisions, such as selecting a low-sugar drink, or bigger choices, such as not smoking or reducing their alcohol consumption. The decisions individuals make can affect others, especially their family members. For example, preparing healthy meals, ensuring children have their vaccinations or encouraging them to exercise fall under the jurisdiction of parents or carers.
Many causes of ill health are preventable, and this document shows that more than 50% of the attributed burden of poor health and early death can be linked to behavioural, social and environmental factors—and these can be tackled before they lead to disease that requires treatment. The link between social inequality and disease has been known for more than 100 years, with English industrialist and social reformer Seebohm Rowntree showing that poverty was highly influential in patterns of ill health (Rowntree Society, 2014).
Peate (2018) laments the failure of the now famous Black report (1980) into the causes of inequalities in health, which was ignored by the Conservative Government of the day. However, nearly 40 years later, the new document by the current Conservative Government fully recognises these links and accepts that health is commensurate with the social and economic environments in which citizens are born, grow up, live and work.
The Government is keen to stress the importance of healthy lifestyles and, because the nation is facing an obesity crisis, it is seeking to support initiatives such as the NHS Diabetes Prevention Programme, which helps identify adults at high risk of obesity. A recent audit conducted by the Organisation for Economic Co-operation and Development (2018) highlights that life expectancy in the UK is being threatened by risk factors such as obesity. It is not surprising that the new policy emphasises the Government's ambition to halve the incidence of childhood obesity by 2030 and, significantly, to eradicate the difference in obesity between children from the most and least deprived sections of society.
Similarly, the policy is targeting hypertension for preventive action because it is currently the cause of 15% of all deaths. Of concern is that more than five million people have undiagnosed hypertension and are therefore putting themselves at risk of developing the complications of this disease, including stroke. The new health promotion policy has also identified and is targeting excessive alcohol consumption because this remains a major cause of morbidity and mortality and aims to work with the Home Office to develop an effective alcohol strategy
Encouraging healthier choices
It is important to stress that local government and the NHS have a responsibility to produce a joint assessment of local need. This is delivered through health and wellbeing boards, which were established under the auspices of the Health and Social Care Act 2012 and through which leaders in the local health and care system work in partnership to improve the health and wellbeing of their local populations (The King's Fund, 2018).
In particular, the policy looks to the future by highlighting the health needs of families and children by:
Conclusion
The old adage that prevention is better than cure is brought to life in the Government's latest policy initiative, which aspires to stop health problems from arising in the first place. Crucially, it seeks to change the direction of the NHS by making prevention pivotal to safeguarding the nation's health. Achieving this will require the talents of the whole of the NHS workforce.