The future of public health
In 1918, the Prime Minister, David Lloyd George, delivered a speech pledging “to make Britain a fit country for heroes to live in.” However, over 100 years later the UK is in the midst of a major health crisis, fuelled by policies that have, over time, consistently focussed on treatment and failed to invest in prevention. As a result, existing health inequalities have worsened, and health outcomes are still strongly linked to socioeconomic status. People living in the least deprived areas of the UK have a healthy life expectancy of 19.3 more years than those living in the most deprived areas,[i] while a woman born in Wokingham can expect to live 15 more healthy years than a woman born in Blackpool.[ii]
The UK’s high burden of preventable ill health and premature mortality is caused by risk factors such as smoking, poor diet, low levels of physical activity, and high alcohol use. In fact, the UK has a higher prevalence of largely preventable illness, relative to comparative European countries. For example, our obesity rates are the highest in Europe.[iii]
As the health of our nation deteriorates, the gap in health inequalities is growing, caused by a variety of factors including repeated cuts to public health spending and the Covid-19 pandemic. People are living more of their lives in worse health, putting our healthcare system under increasing pressure. An additional 2.5 million people are projected to be living with a major illness by 2040[iv] which will not only affect the quality of life of individuals and their families but will result in increased workplace absence and demand on the NHS, having significant knock on consequences for the economy as a whole. It is therefore imperative that our health and social care systems adapt to this growing requirement.
In the past, successive Governments have promoted policies which encourage individual behaviour change but do not account for the influence our environment has on the leading risk factors to our health. This emphasis on personal responsibility has been compounded by manufacturers of harmful products, such as tobacco, alcohol, junk food and gambling, who spend billions on marketing and advertising to drive sales.
It is widely recognised that prevention is better than cure and health promotion initiatives, such as preventing obesity through increasing access to healthy, nutritional foods and encouraging people to increase their physical activity, improve the health of the local population on a long-term basis.
We know that these population-level interventions, which tackle the commercial and social determinants of health target non-conscious changes to our behaviour and are therefore most likely to be effective. However, industry giants continue to push the narrative that preventable ill-health resulting from harmful products is a result of ‘personal choice’.
Now, and in the future, encouraging behavioural changes and healthier life choices alongside policies which tackle the social and commercial determinants of health, is the only way to provide a sustainable solution to tackle the root causes of the issue whilst ensuring it’s longevity. Of course, investing in prevention of illness and early death should not be a replacement for urgent care and treatment but run in tandem to slow the trends we are seeing.
As well as resounding health benefits, the economic argument for taking this approach is clear – a 2020 study concluded that public health expenditure is more productive than NHS expenditure, with an additional year spent in perfect health costing just £3800 in public health funding compared to £13500 from the NHS budget.[v]
The future of public health needs to be based in a system-wide approach, which facilitates primary and secondary care working alongside public health teams and their partners. In fact, local partnerships between public health, national and local governments, businesses, schools, civic organisations and individual communities already exist and work to implement policy and action which shapes the health of the population. Taking advantage of these pre-existing collaborative partnerships across sectors, which Directors of Public Health have a wealth of experience in building, enables a preventative, joined-up approach. This local working was highlighted during the pandemic, when national Governments poorly understood the local drivers needed to achieve sustained, preventative change.
Scaling up this existing, successful model of partnership working to a national, system-wide, preventative approach is achievable. In the Association of Directors of Public Health’s (ADPH) Manifesto for a Healthier Nation, key recommendations are laid out which would achieve these long-term goals that would improve public health, reduce health inequalities and boost the UK economy.
The development of a new Public Health Act, which consolidates existing legislation and places health and wellbeing at the heart of all policy, is one of the recommendations made. Amalgamating the many Acts of Parliament concerning public health would not only demonstrate the Government’s commitment to protect public health but would also reduce the fragmentation which exists in this policy space and ensure public health policy is fit for the 21st century.
Public health cannot escape the ever-widening gap in health inequalities. A new, funded strategy, with clearly defined targets and the actions needed to achieve them is needed. It would require a cross-Government approach, implementing Health in All Policies across the four nations and the sharing of good practice. For example, it is widely hoped that after the successes of Minimum Unit Pricing seen in Scotland, similar regulation will be introduced in England.
Local public health authorities should be utilised, and community engagement maximised to ensure policy is informed by population need and communities feel empowered to influence their environment.
Sharing good practice is already usual within the public health community. ADPH, alongside the former Public Health England, co-produced a series of ‘What Good Looks Like’ (WGLL) publications that set out the guiding principles of ‘what good quality looks like’ for population health. These publications are based on the evidence of ‘what works and how it works’ including effectiveness, efficiency, equity, examples of best practices, opinions and viewpoints and, where available, a return on investment.
They serve as a tool to assist in practice improvement and to support local resource decisions. Local lessons can also be applied nationally to great effect. Where successful public health programmes are in place, networks should continue to promote them to ensure progress is made across the UK and the principle of proportionate universalism is applied. The deliverance of services at a scale and intensity proportional to need means that they are universal, not targeted, and are able to respond to the level of presenting need. It requires an understanding of the issues socially excluded people are more likely to encounter, which ensures interventions are designed and implemented with these communities as a focus. This will in turn reduce health inequalities and improve community cohesion.
There is no doubt that public health has developed at pace over the last 175 years since the first Public Health Act was passed in 1848. The measures which have been introduced have fundamentally improved and protected the health of people. As a result, we live longer, healthier lives than our 19th century counterparts.
However, these strides forward are being compromised by new threats and a sustained lack of investment in prevention and promotion of good health. As a result, health inequalities continue to emerge and the gap between our most and least vulnerable in society continues to widen.
We must implement new, innovative methods, equivalent in stature to those brought in by the Victorians, to ensure the lessons of the last 175 years are not forgotten and that public health continues to improve so that everyone can live a healthier, longer life.
[i] https://www.theguardian.com/society/2022/apr/25/growing-gap-in-healthy-life-expectancy-between-poorest-and-richest-in-england
[ii] https://www.health.org.uk/evidence-hub/health-inequalities
[iii] https://www.health.org.uk/publications/reports/addressing-the-leading-risk-factors-for-ill-health
[iv] https://www.health.org.uk/publications/health-in-2040
[v] https://pure.york.ac.uk/portal/en/publications/is-an-ounce-of-prevention-worth-a-pound-of-cure-a-cross-sectional-2