The idea that the NHS should be involved in prevention is not a new one. However, in an environment of strained resources and widening health inequalities, with low investment in public services which support people's health such as social care, transport, and housing, the argument for prevention to be embedded as 'everyday business' for partners across systems – including trusts – has never been stronger. The COVID-19 pandemic has thrown into sharp relief the consequences of the pervasive inequalities present in society that have the potential to damage people's health.
Since statutory responsibility for prevention and public health was transferred to local authorities in 2014, the duty to contribute to reducing health inequalities has been viewed increasingly as a narrow set of services commissioned by directors of public health at local councils. The NHS was seen as having become divorced from the wider context influencing people's health - described by some as a 'national treatment service', rather than a 'national health service'.
But the NHS Long Term Plan, and progress in system working, has reinvigorated a focus on the role of prevention in securing the long term sustainability and high quality of NHS services, as well as it being the right thing to do for patients using NHS services. As the NHS navigates the recovery from COVID-19, and prepares for the winter period in a 'with-COVID' world, the spotlight on health inequalities will continue as the health and care system returns to providing services for the full range of people's needs.
As system working progresses, with STPs expected to become ICSs across the country by April 2021, the NHS is increasingly turning its attention to its role in prevention and public health. STP and ICS plans are expected to show how system partners will collaborate to improve the health of their populations. Trusts across the country are tackling this in innovative ways, and supporting patients and communities to improve their health.
The national context for prevention and public health
Overall, life expectancy has stopped improving at the rate that was expected before 2011. The publication earlier this year of Health Equity in England: the Marmot review 10 years on documents an overall stagnation in life expectancy and points out that in some more deprived areas, it has actually started to fall.
Health inequalities are greatest among those living in deprived communities and excluded groups. The gap in life expectancy at birth between people in the most deprived and the least deprived areas is 9.4 years for men and 7.4 years for women. The gap in healthy life expectancy – the number of years lived in good health – is 19.1 years for men and 18.8 years for women.
This stall in life expectancy, and the widening of health inequalities, comes in the context of a long period of austerity in which resources that contribute to population health have become increasingly strained. Most notably, cuts to central funding for local authorities, including the public health grant, have reduced local councils’ ability to provide services which support the health of people living in deprived communities. On top of this, with rising social care needs among the older and disabled population and the increased proportion of council funding this requires, local authorities have had to scale back investment in other services which contribute to health, including housing, transport, infrastructure and voluntary sector funding.
The central government public health grant was reduced by £531m between 2015/16 and 2019/20. This has a direct impact on how much local authorities spend on public health - 85% of councils reported reducing their spending on core public health services in 2017/18 and like-for-like spending on public health services was 8% lower in 2017/18 than in 2013/14. Councils have warned that the 2020/21 uplift is likely to be ‘wiped out’ by staff pay pressures related to a dispute over Agenda for Change funding.
Public health emergencies, such as the COVID-19 pandemic, reinforce the importance of joint working. Where local government plays a role in coordinating public health efforts in line with the national response, and the voluntary sector and social care support vulnerable groups during times of disruption, trusts play an integral role in managing those who become unwell, and contributing to research. As services return to their new normal, there will be a renewed focus on ensuring equity of access to services.
Trusts are concerned, however, about the impact of growing social and economic hardship in their local communities, particularly after the effects of the lockdown, with consequences for rates of homelessness as well as substance misuse among those facing financial hardship. Our survey of mental health leaders found that the majority felt that socioeconomic factors were contributing to increased demand on mental health services:
- Changes to benefits / universal credit – 92% said they had seen an increase in demand for mental health services as a result
- Financial hardship – 98%
- Housing – 97%
- Loneliness and isolation – 97%
- Cuts to local services – 91%
- Homelessness – 95%
It's no surprise, then, that demand for NHS services has risen substantially during this time. As services which support people to stay in good health become more scarce, A&E demand is rising in particular among those with unmet social care needs, pressure on outpatient services has led to growing waiting lists, and trusts are facing a rising gap between demand and capacity to provide services.
Delivering on the wider determinants of health
As the recent ten-year Marmot review update points out, 'The health of the population is not just a matter of how well the health service is funded and functions, important as that is.' It points out that health is linked to the conditions in which people are born, live, work and age, with inequities in power, money and resources contributing to people’s health as wider determinants – those which go beyond the influence of health services people receive.
While these are all seen as being primarily the realm of councils, the voluntary sector and local employers, trusts as anchor institutions are increasingly getting involved beyond their core remit of health services by offering high quality employment opportunities, better housing, improved air quality and environmental sustainability for their communities.
Barriers to making prevention 'core business'
These innovations come in the context of a number of challenges, in particular around funding, commissioning, and accountabilities. The secretary of state for health and social care set out the ambition that prevention should become 'everyone’s business', and it is certainly the case that all system partners must take ownership of the opportunities to contribute to prevention if system-wide efforts are to have their maximum impact.
However, if prevention is everyone’s business, a question arises of how we avoid it becoming nobody’s business, through unclear accountabilities, funding barriers and commissioning challenges. While local authorities commission core public health services, it is often trusts that deliver them. But across wider services run by the provider sector, prevention activity is not reimbursed, meaning that in a financial and operationally pressured environment this is the first service to be pared back. Then there is the challenge of evaluating and scaling up the diverse programmes trusts are running – by definition, these interventions are locally designed, and tailored to the needs of local communities. Where trends in population health are concerned, it can be difficult for either improvements or deterioration to be attributed to any one factor.
One way of tackling these challenges is to look at prevention as a puzzle, of which trusts make up one piece – offering a different type of preventative approach to local authorities, primary care, and the voluntary sector. In a system, all the different players contribute valuable interventions which make up a holistic approach to preventing and managing ill health. Trusts are in a unique position along the prevention journey to reach those who have needs which can’t be met in primary care settings or by local authority services, but can still benefit from an approach which takes a long term view of not just treating their illness, but preventing others.
Collaborating to improve health
The national story about prevention often focuses on primary prevention – that is, stopping ill health from arising in the first place, particularly through improved diet, physical activity, and reductions in smoking and alcohol intake. Within this narrative, trusts' role is to treat illness when it arises, as a passive receiver of patients who have slipped through the net elsewhere.
In contrast, within a narrative which takes account of the diversity of populations and their needs, and the mutual responsibility of all system partners to provide input at all points of a person’s health journey, trusts are in a unique position to support patients with existing health needs, to improve their overall wellbeing, manage existing conditions, and avoid further deterioration. By the nature of the services trusts provide, patients often don’t arrive at their doors until they already have a condition that needs emergency or secondary care, but trusts are ideally placed to help prevent deterioration, complications and new conditions arising. As the trusts showcased in this report demonstrate, prevention-focused care is an ideal complement to more traditional forms of healthcare.
Trusts also have unique reach into communities, making them ideally placed to make a difference to people's health. For example, ambulance trusts come into contact with people at their most vulnerable, and can identify unmet needs which may be contributing to preventable ill health, as well as intervening where they can to prevent admissions. Acute trusts providing inpatient and outpatient services often build relationships with their patients over long periods of time. The long term plan states an ambition for patients to have access to smoking cessation services during their stay in hospital. Clinicians can also offer advice about diet, physical activity and alcohol consumption as part of their regular conversations with patients, thus embedding prevention into all elements of the care people receive and joining up the dots of people’s lives to understand the circumstances in which they live.
This is where providers can make the most impact: through secondary prevention – intervening to prevent the worsening of an existing condition, or tertiary prevention – lessening the impact of a serious illness, as well as collaborating with system partners to connect people with preventative services addressing the wider determinants of health. These approaches support the work of system partners to bolster the health of their communities and reduce health inequalities.
What our case studies show is that while prevention initiatives in trust settings are dispersed, diverse in scope, and often limited in evaluation, trusts see themselves not only as institutions that treat illness, but are also committed to improving the health of their communities. These case studies are a snapshot of the sector before COVID-19, and as the NHS moves towards recovery, there is an opportunity for the trust sector to contribute to sophisticated, collaborative efforts to improve and maintain population health.