Better Health For All

This is the first in a two-part blog that lays out our thoughts on the recently-published #NHSLongTermPlan, and where the NHS could focus its prevention efforts. The second part can be read here.

I thought it might be interesting to assess the recently-published NHS Long Term Plan against the shortlist of prevention priorities FPH set out in our December Prevention in the NHS discussion paper.

First some quick background. In October last year, FPH invited more than 40 senior NHS and public health leaders to a policy workshop to discuss where they thought the NHS should focus its prevention efforts.

One of the most challenging things we did was to co-create a ‘long list’ of prevention priorities. We then encouraged workshop attendees to vote for eight of these priorities – eight and eight only.

From a longlist of around 30 ideas, the group collectively identified 11 key priorities.

While the process had its flaws, the shortlist of priorities produced from this ‘hive mind’ of senior experts was fascinating:

1. A systems approach to prevention
2. Better governance for prevention
3. Realising the potential of the community
4. Tackling inequalities
5. Tackling multi-morbidities
6. NHS staff health and wellbeing
7. Mental health and wellbeing
8. Smoking
9. Alcohol
10. Early years
11. Health promotion

We set out this shortlist in a discussion paper published before Christmas. It is the first of three we’ll be writing as part of our ‘The Role of the NHS in Prevention’ project, which is being supported by the Health Foundation.

So to the assessment of how well the NHS Long Term Plan measures up against the first five of 11 priorities. (The remaining six priorities will be discussed in tomorrow’s blog.) Like many assessments in blogs it is subjective (sorry) so please do let me know your own thoughts via policy@fph.org.uk.

1. A systems approach to prevention

The NHS Long Term Plan says that its renewed NHS prevention programme has been shaped by the Global Burden of Disease study of the various risk factors that cause premature deaths in England. These risks are smoking, poor diet, high blood pressure, obesity, and alcohol and drug use, with air pollution and lack of exercise also seen as important.

The specificity of the focus for the NHS prevention push is in many ways very welcome. A lack of prioritisation can sometimes prevent non-public health decision-makers from ‘buying-in’ to a prevention agenda. But the biggest message we heard from our workshop experts was that a collection of individual interventions alone will not achieve the change we need to deliver at a population level. This, they argued, requires a systems approach.

FPH’s view is that it isn’t an ‘either or’. We do need to prioritise – and then implement well – prevention interventions that we already know are impactful, cost-effective, and deliverable. If that is the work of, say, the first five years of the ten year plan, it is up to public health leaders to start to explain simply and compellingly what a ‘systems approach’ is now and how it can be adopted by an organisation as complex as the NHS. This could then be the work of years’ six to 10 of the Plan. In return, the NHS needs to be willing to think even more innovatively about how to create a truly prevention-focused NHS.

Verdict: the initial prevention focus on specific individual interventions is understandable and welcome. But there’s significantly more for the public health community and NHS to do in partnership during the second half of the Plan if the aim is to transform the NHS’ approach to prevention.

2. Better governance for prevention

The NHS is full of people passionate about keeping local and national populations healthy and happy. It’s just that this passion for prevention doesn’t necessarily translate sufficiently into how NHS ‘success’ is really measured and how NHS leaders are really rewarded. The Plan talks about an increasing focus by local NHS organisations on population health and on contributing to the government’s ambition of ‘five years of extra healthy life expectancy by 2035’ but there’s not much additional detail.

Importantly, it is not clear how the NHS Long Term Plan and the DHSC’s ‘Prevention is Better than cure’ Vision complement and support each other. As Rachel Chapman and FPH President, John Middleton, argue in their assessment of the Plan, the NHS needs expanded capacity in population health management and public health skills, specialist public health expertise in all NHS institutions, and a ‘dashboard’ for assessing progress against clearly defined prevention milestones and goals.

Verdict: more to do. A good indicator of the NHS’s commitment to population health will be its willingness to take shared responsibility for the outcomes set out in the forthcoming Prevention Green Paper.

3. Realising the potential of the community

The Plan commits to doubling the number of NHS volunteers over the next three years and to scaling-up successful volunteering programmes across the country. The NHS will also continue to work with local charities, social enterprises and community interest companies providing services and support to vulnerable and at-risk groups. There is also a commitment to significantly increase the number of people benefiting from ‘social prescribing’. While all this is welcome, it is difficult not to feel that there remains an untapped opportunity to harness community resources more effectively to improve the population’s health and wellbeing.

Verdict: more to do but the emerging thinking around the NHS as an ‘anchor institution’ shows promise.

4. Tackling inequalities

The Plan makes clear the NHS’s commitment to reducing health inequalities. This is hugely significant, especially as FPH’s recent evidence review found that some NHS prevention programmes can reinforce health inequalities. This new commitment is backed by action. The NHS commits to set out specific, measurable goals for narrowing inequalities and to developing a ‘menu’ of evidence-based interventions to help deliver these goals. The Plan also promises better assessments of local health inequalities, a commitment to reducing inequalities as a pre-condition of new funding, to invest more in areas with high health inequalities, and new action targeted at those who are traditionally left-behind such as homeless people, people with severe mental illness, people with a learning disability and young carers. Expanding key programmes like the Diabetes Prevention Programme are also recognised as an important vehicle for tackling health inequalities given the high prevalence of type 2 diabetes in certain Black, Asian and Minority Ethnic groups.

Verdict: well done NHS! But implementation and monitoring of progress will be key.

5. Tackling multi-morbidities

The plan says it ‘goes further’ on multi-morbidities than the agenda set out in the Five Year Forward View. But it is difficult not to feel that this was an opportunity missed to signal more clearly that this is a key NHS priority for the next 10 years. The Health Foundation argues that the lack of an explicit national strategy to address one of the biggest challenges facing the health services is one of the most significant gaps in the Plan. Of course a month is a long time in healthcare and since the Plan was published NHS England has now published Universal Personalised Care Early feedback from stakeholders suggests it goes some of the way to answering the multi-morbidity criticism.

Verdict: perhaps not as bad as initially appeared.

Click here to read the second part of my blog and in the meantime, share your thoughts via email: policy@fph.org.uk.

Written by Gus Baldwin, Director of Policy and Communications, FPH. You can follow Gus on Twitter @Gus_Baldwin.