Realising Prevention: Practical policies for a healthier society

Dr Jack Newman sets out how the new government should harness tools and evidence to prioritise health for a successful preventative approach in urban places.

The scale of the crisis

There is a health crisis in the UK. In the wake of the Covid pandemic, there are health crises in many countries, but this does not make the UK’s situation inevitable. The problems in the UK are the product of poor public policy choices over decades. In 2022 alone, there were 125,612 avoidable deaths in England and Wales, a fifth of all deaths. Unlike most developed countries, life expectancy has stopped increasing in the UK, and it is now declining in half of all local authorities. In comparison to London and the South East, a baby born in the North East will live three years fewer, while the north of England as a whole has 144 extra infant deaths a year. Black women have a four times higher risk of dying in pregnancy and childbirth. The waiting list for NHS treatment stands at 7.6 million. The number of workers economically inactive due to ill health is at a 30-year high, and ill-health among working age people is estimated to cost the economy £150bn a year. These are just some of the indicators of the scale of the crisis.

The newly installed Labour government has a plan to tackle the health crisis. One of its overarching missions is “to deliver an NHS fit for the future”. At the heart of the approach is a familiar refrain, one common to every major party manifesto of the last 20 years: to transition from reactive to preventative health. However, the plans laid out by Labour so far seem to have the opposite emphasis, prioritising acute services over proactive prevention.

The government’s response

Labour’s proposed tools of change fall into four buckets. The most prominent is on acute services. The flagship 40,000 new appoints per week sit alongside a series of technological investments and reforms.

Next comes the focus on primary care, with plans on GPs, pharmacists, dentistry, mental health, and (less-concretely) on social care. This is supported by initiatives to improve workforce planning and patient experience across multiple services. With ideas like the ‘neighbourhood health service’, the welcome focus on primary care will certainly prevent ill-health from getting worse, but this is only a partial transition to preventative health policy.

In the third bucket are behavioural interventions. These are more preventative, though as a result they will take longer to have an effect. They are the interventions that seek to nudge people – and sometimes push them – away from poor health choices. Here there is less clarity on government plans, but they will take aim at smoking, vaping, energy drinks, junk food advertising, gambling, and harmful social media content. These interventions are likely to have a positive social benefit, though the scale of the benefit will depend significantly on the as yet unspecified policy details.

It is the fourth bucket that contains the truly preventative policies, the ones that will start the fundamental shift towards a healthy population, and in the longer term lift the intense pressure from the NHS. These are policies to tackle the ‘wider determinants of health’: education, the built environment, workplace conditions, social networks. Brought to prominence by the Marmot Review, and consistently backed by the evidence, the most effective and efficient route to a healthy society is to change the conditions in which people live.

This is also the only way to make a serious impact on health inequalities. In their manifesto, Labour promise to “tackle the social determinants of health, halving the gap in healthy life expectancy between the richest and poorest regions in England”. However, this bucket of interventions appears to be almost entirely empty. The are currently no identifiable policies here, just a good intention and an ambitious target.

First steps to truly preventative health policy

It is of course important to prioritise shoring up acute services, and in the medium term to rebuild primary care, but there must be a long-term strategy for the wider determinants of health. The real challenge is ensuring that such a strategy has concrete first steps and is not just a vague set of future ambitions. Over years, repeated governments have offered rhetoric on the wider determinants but struggled to find tangible starting points.

In a new suite of policy briefs from the TRUUD project, we mobilise the evidence from our five-year interdisciplinary research project to identify some concrete steps for the first government strategy on the wider determinants of health.

In our first policy brief, we call for government to prioritise healthy urban development. Decisions about urban development have a significant impact on public health but this is rarely recognised in the decision-making process. When new infrastructure is built, when transport systems are improved, when housing developments and commercial developments are planned, big decisions about public health are being made unconsciously. We offer five steps to embed health in urban development decision making:

1. Include health outcomes in decision-making
2. Invest in local government capacity
3. Give combined authorities more spending flexibility
4. Support the agency of real estate developers
5. Help investors deliver on existing ESG obligations

Find out more… tackling health inequalities with healthy urban development

In the second policy brief, we argue that the ongoing reforms to the planning system need to develop a healthy planning system. Planning is rightly facing a major upheaval under the current government, but very little connection has been made to the health mission. When planning applications are approved or rejected, public health needs to be much more prominent. Our proposals for a healthier approach to planning include:

1. Understand the health outcomes of different development proposals
2. Embed health data in appraisal processes
3. Give planning and development teams the capacity they need
4. Ensure public health is strong enough in Local Plans
5. Promote the use of Health Impact Assessments, but understand their limits

Find out more… Planning reform and public health

The third policy brief calls for central government to empower metro mayors to deliver on public health. Tackling the wider determinants of health will require place-specific policy interventions, rather than top-down, one-size-fits-all approaches that have failed for decades. If, as we propose, urban development and planning reform are the focus for improving public health, metro mayors will play a leading role. To empower metro mayors to deliver on health, we make the following recommendations:

1. Increase and simplify funding for health prevention
2. Build a national health-metrics framework for local spending
3. Finish and align the devo map
4. Embed health in MCA urban development strategies
5. Embed urban development in ICS health strategies

Find out more… Empowering mayors for preventative health

The fourth and final policy brief focuses on how to join up government for public health. Labour have committed to a new era of mission-driven government, with health being one of the five cross-government missions. But delivering cross-government initiatives is notoriously difficult, and there is a history of repeated failed attempts. Our recommendations offer three ways forward on strengthening joined-up government for public health:

1. Upscale existing collaborations
2. Establish comprehensive strategy for cross-government working
3. Create the conditions for more collaboration

Find out more… Joining up government for public health

Conclusion

The short-term focus of the Government’s health mission is understandable – there is an immediate health service crisis. However, there is also a deeply entrenched public health crisis that fuels declining healthy life expectancy and increasing health inequalities. Unless this is solved, the health service will continue to struggle against a rising tide of ill health. Addressing the longer-term public health challenge is much more difficult, and solutions are often vague or over-ambitious. There is of course a temptation to commission another review of the evidence and kick the problem into a future parliament. But there is no time to wait; the long-term change must start immediately. As a result, there will need to be some first steps. From the wide range of evidence gathered over our five-year, multidisciplinary research project, TRUUD offers a range of ideas on what these first steps could be. If no first steps are taken, public health will continue to decline, with increasingly expensive and catastrophic consequences.