Chapter 6: Public health, prevention and patient responsibility
280.Effective public health strategies can deliver an extensive range of benefits, not just to individuals but to communities, the health service and the economy as a whole. We heard, however, that action on public health and prevention in the past has been insufficient and frustratingly slow, and that it is now chronically underfunded. This chapter highlights the multiple concerns raised about the apparent low level of priority assigned to public health and prevention.
Preventable ill health: causes and costs
281.Non-communicable diseases (those not caused by infectious agents, also known as chronic diseases) account for around two-thirds of deaths worldwide.241 The four main types of non-communicable disease are cardiovascular disease, cancers, chronic respiratory disease and diabetes. In the UK non-communicable diseases cause an estimated 89% of deaths,242 the most significant cause being the major diseases of the health and circulatory system (coronary heart disease and stroke).243 These conditions are also, to a significant extent, preventable and the costs, in human, social and economic terms, are largely avoidable. The World Health Organisation identifies the four most important modifiable risk factors for these diseases as tobacco use, physical inactivity, the harmful use of alcohol and unhealthy eating.
282.Social determinants of health (for example economic and social conditions) also contribute significantly to levels of preventable ill health. When it published its report in 2010, the Marmot Review, Fair Society Healthy Lives identified striking levels of health inequalities across the country, including that people in the poorest neighbourhoods in England would on average die seven years earlier and spend more of their life living with a disability.244
283.From the evidence we received, it appears that preventative ill health continues to place a significant burden on patients and on the health service, and is undoubtedly a major threat to the long-term sustainability of the NHS. The UK Health Forum warned that: “The current and escalating future burden of non-communicable disease on the NHS is unsustainable.”245 We received a wealth of evidence on the scale of this burden, including that:
- About a third of all deaths are classed as premature. That equates to 44 years of lost life per 1,000 people or 2.6 million years each year across England and Wales.”246
- Around 40% of premature mortality in the UK is caused by preventable cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary disease.247
- It is estimated that 40% of the burden on health services in England may be preventable through action on the determinants of avoidable chronic conditions.248
Inaction on public health and prevention
284.The Five Year Forward View included a clear commitment on prevention, calling for a “radical upgrade” in prevention and public health.249 It acknowledged that robust action on prevention is long-overdue: “Twelve years ago, Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded and the NHS is on the hook for the consequences.”250
285.Despite this renewed emphasis, we heard repeated concerns that the NHS was still failing on public health and prevention. The Academy of Medical Royal Colleges expressed disappointment at the progress made on the Forward View’s ambition on prevention: “Almost two years after the publication of the Five Year Forward View, there appears to have been little meaningful development; the ‘radical upgrade in prevention’ has failed to materialise.”251
286.The lack of progress on prevention was evident in the scale of the burden of some of the key public health issues that witnesses reported. Ian Forde, from the OECD, confirmed that in comparison to other countries, the UK was “poor on public health prevention” stating that harmful drinking and smoking, although improving, were still above the OECD average.252
287.Mark Davies, Director of Health and Wellbeing at the Department of Health, told us: “We have made lots of improvements in the way we address alcohol, through the Chief Medical Officer and the messages that the industry puts out, and people’s alcohol use, through things like the health checks.”253 However, witnesses were clear that harmful drinking continues to place a significant burden on the health and care services. Public Health England estimates that around 10.8 million adults in England are drinking at levels that pose some risk to their health254 and that the NHS incurs around £3.5 billion a year in costs related to alcohol.255 While there has been some progress, much more should be done to reduce consumption.
288.There has been some progress with smoking, with smoking prevalence falling to 16.9% in England, a significant fall from previous years.256 However, Action on Smoking Health told us that smoking still costs the NHS an estimated £2 billion a year and remains the major cause of preventable premature death in England, causing around 80,000 premature deaths a year.257
289.It was also suggested that not enough was being done to address health inequalities. We expected that we would receive evidence to suggest that health inequalities still existed but were disappointed to learn that progress at tackling inequalities and the social determinants of poor health was stalling. Professor Sir Michael Marmot told us:
“If we look at early child development, the decline in child poverty stopped, became flat and is now increasing, and the projections are that child poverty will increase over the next four years …
On employment and working conditions, the quality of work matters. There has been a rise in the proportion of work-related illness related to stress, depression and anxiety, which is complicated.
There will be increased poverty and increased inequality over the next five years, which will potentially damage health, particularly for families with children; they will be selectively hurt the worst. If you look at the gap between the minimum income standard for healthy living and the national living wage, projected over the next five years, it will be particularly large for families with children and single parents with children; they will be in real poverty, which will, of course, have an adverse effect on early child development.”258
290.We acknowledge that there are multiple serious public health issues, which require more robust action to tackle their impact on both patients and the health service. We felt, however, that two public health issues—mental health and obesity—warranted particular focus. Both conditions affect millions of people in England and both cost the NHS and the wider economy billions of pounds a year, but the progress made in tackling both conditions has been wholly inadequate, with potentially devastating implications for the long-term sustainability of the health and care systems.
Mental health
291.We recognise that mental health has emerged as a more prominent policy priority in recent years and, as a consequence, there have been a number of high profile initiatives aimed at addressing long-standing issues in the provision of mental health services. Since parity of esteem between physical and mental health services was enshrined in the Health and Social Care Act 2012 there has been a renewed emphasis on the need to develop integrated care spanning physical, mental and social needs to improve mental health care and outcomes. Most recently, the Government has responded to the Five Year Forward View for Mental Health (published in February 2016), committing to meeting its recommendations in full, including additional investment of £1 billion a year to improve mental health services.259 At the beginning of this year, the Prime Minister also announced a package of measures aimed at improving mental health support in schools, workplaces and communities.260
292.Despite a renewed focus on mental health, witnesses were clear that there is still a persistent and considerable divide between physical and mental health. People with mental health problems continue to receive lower levels of appropriate treatment and achieve poorer outcomes. The charity Mind outlined some of the key issues in the provision and delivery of mental care services, including that:
- Mental health problems cause 23% of all illness in the UK but mental health care receives only 11% of health spending.
- Two-thirds of people with common mental health problems such as anxiety and depression receive no appropriate treatment (compared to a quarter of people with physical health problems).
- There is a lack of access to physical healthcare for people with mental health problems—less than a third of people with schizophrenia in hospital received the recommended assessment of cardiovascular risk in the previous 12 months.261
293.Sophie Corlett, Director of External Relations at Mind, told us:
We know that we may have some great healthcare here compared to the rest of the world, but compared to our own healthcare in physical health we do extremely poorly. We have got to the heady heights of a third of people with mental health problems getting mental health care at the moment, which means two-thirds of people do not.”262
294.We also heard that, as well as the disparity in care and outcomes for people with mental health issues, preventative action on mental health has also been limited. Claire Murdoch Director of NHS National Mental Health at NHS England, told us:
“ … the incidence of undetected, untreated diabetes in this country is something like 8%, so we have more work still to do to reach people around detecting and treating their diabetes, and of course now prevention. The incidence of undetected, untreated mental illness or mental ill-health is thought to be closer to 70% in this country.”263
295.We welcome the greater prominence that mental health has received in recent years and we are encouraged by the Government’s commitment to a five-year strategy for mental health. Notwithstanding the progress made, there is still a need for sustained and determined action to close the gap between the care received and outcomes achieved by people with mental and physical health issues. Achieving parity of esteem between the two must remain a top priority for service commissioners and regulators.
Obesity
296.The evidence suggested that in comparison to other areas of public health policy, there had been a particular failure, by successive governments, to tackle obesity effectively and a reluctance to take robust action on the issue. As opposed to other public health issues such as smoking, the Government was accused of taking a watered-down approach to obesity and failing to provide consistent nutritional advice to the public. Some argued that governments often cite an unwillingness to behave as a ‘nanny state’ as an excuse for inaction.264
297.Obesity costs the NHS around £5.1 billion a year,265 with an estimated cost to the economy of £27 billion due to its effect on productivity, earnings and welfare payments.266 It is also thought that more than 1 in 20 cancers are linked to being overweight or obese.267 There is widespread recognition that obesity, and the increasing prevalence of obesity, is a significant threat to the sustainability of the health service. In July 2016 Simon Stevens, the Chief Executive of NHS England, warned that:
“… obesity is the new smoking: poor diet is now our biggest avoidable cause of ill health. Piling on the pounds around our children’s waistlines is piling on billions in future NHS costs. We now spend more on obesity than on the police and fire service combined.”268
298.The failure to instigate firm action on obesity and prioritise this as a public health issue was particularly evident in the Government’s recent action on the childhood obesity strategy, which was ongoing at the beginning of our inquiry. In July 2016, Mark Davies, Director of Health and Wellbeing at the Department of Health, assured us that:
“We have been working for many months on a childhood obesity strategy. There is a lot of anticipation about that piece of work. We have one prepared. It has been announced that it will be launched in the summer, but we are still waiting to press the button on it. If and when it is published, we hope that it will be a really cross-sectoral look at all aspects of childhood obesity and all the things that drive it, including behaviour, family attitude, promotion, reformulation of food and what happens in school. We are working on a comprehensive strategy. It is a long-term strategy. If we get it right, it will have intergenerational impact and will stretch way beyond the next five or 10 years.”269
299.However, when the strategy was published in August 2016, it received widespread criticism suggesting that its proposals were “weak and watered down”.270 It was also criticised for falling far short of what was required to properly address the issue and failing to reflect the seriousness of the impact that obesity was having on the health service. In its evidence, the Royal College of Physicians expressed its disappointment at the childhood obesity strategy, and warned that a failure to address obesity would have serious implications for the sustainability of the health service:
“Despite a commitment to introduce a levy on sugar sweetened beverages, the RCP is extremely disappointed that after such a long wait for the childhood obesity strategy, the government has published a downgraded plan that fails to address key issues such as marketing and promotion of sugar-filled and unhealthy foods to children.271 The estimated cost of obesity to the UK economy is approximately £27bn.272 The consequence of failing to act now is to commit the NHS to greater expense in the future as it struggles to fund care and treatment for obesity-related medical conditions. A strong package of measures and concerted action across all government departments is required to turn the tide on obesity.”273
300.Similarly, the Academy of Royal Colleges warned that:
“If we do not tackle childhood obesity with the seriousness it deserves, the NHS will face an existential crisis. The decision to water down the childhood obesity strategy suggests that the Government does not take prevention and the sustainability of the NHS seriously.”274
301.A number of witnesses suggested that a renewed, cross-government emphasis was needed to tackle the devastating effects of obesity—the “public health time bomb that needs to be tackled urgently.”275 When asked about the possibility of a nationwide campaign to educate people on the effects of obesity and poor diet the Secretary of State for Health, signalled his support for such a move:
“I think it would be an excellent idea. We have looked very hard at the scientific evidence, and there has been research done by people such as McKinsey as to what policy interventions make the biggest difference. I agree with you that obesity is rapidly overtaking smoking as the biggest public health threat.”276
302.We consider that there is insufficient political recognition, across the parties, of the major threat to the long-term sustainability of the NHS posed by the absence of any credible, well-led and sustained action on obesity, as is already the case for smoking and harmful drinking which makes use of regulatory, tax and nudge techniques.
303.There is still widespread dissatisfaction with the prevention agenda. We share the views expressed by many of our witnesses of the need to realise the long-awaited ambition to move from an ‘illness’ to a ‘wellness’ service. The NHS must shift the rhetoric to reality and make genuine progress on refocusing the system towards preventative care.
304.We recommend that the Government urgently embarks on a nationwide campaign to highlight the many complications arising from the obesity epidemic, including its links with many chronic diseases. Such a campaign must be a cross-departmental effort, target the entire population and involve those who sell food and drink to the public, especially those whose products are consumed by children.
Cuts to public health
305.Some public health measures can have an immediate impact. Such is the case with immunisation programmes in the prevention of a range of childhood and adult diseases. Water fluoridation, folic acid supplementation and of increasing dietary vitamin D consumption all have considerable benefits.
306.Adding to our concern that the prevention agenda continues to receive inadequate focus was the fact that many witnesses drew our attention to the cuts that had been made to public health budgets, and the resulting cuts to public health programmes, both locally and nationally.
307.In 2013, much of the responsibility for public health was transferred from the NHS to local authorities through the Health and Social Care Act 2012, supported by ring-fenced public health funding. The House of Commons Health Committee’s report on public health highlighted that the public health landscape had also become more complex.277 This is partly because of the addition of a national and regional public health agency—Public Health England—but also because some public health responsibilities still sit with the NHS through NHS England. The Secretary of State retains ultimate responsibility for both public health and health protection.
308.In June 2015, the Chancellor of the Exchequer announced a range of measures to bring down public debt, which included Department of Health non-NHS savings of £200 million.278 This amounted to a 7% cut to the public health budget. This was followed in the 2015 Spending Review with the announcement of a 3.9% cut per year over the next five years to local authority public health budgets.279 The Health Foundation and Nuffield Trust estimated that only 5.29% of the NHS budget in England was spent on prevention in 2014–15.280
309.This means that vital public health services that provide front-line preventative care now risk being scaled back or even decommissioned, as local authorities respond to the cuts. Dr Sarah Wollaston said:
“… a lot of what they [local authorities] do is also what we would traditionally think of as front-line health services, such as sexual health and various other prevention services—for example, smoking cessation services. All these kinds of things and health visiting are now sitting within local authorities. If their budgets are being restricted and squeezed, the things that they have to provide as statutory services can continue, but it is the rest of it that is being very severely cut back in prevention services, such as weight management services and stop-smoking services. This, I think, is a real threat to making the changes we want to see going forward of having people leading healthier lives, and it is things around physical activity which, we know and I agree, independently of diet, are very important. All those kinds of services are being cut back, which is a great shame; it is very short-sighted.”281
310.The Local Government Association put the cuts into context highlighting that: “public health funding will be cut by 9.7% by 2020/21 in cash terms of £331 million, on top of the £200 million cut in-year for 2015/16 announced in November 2015.”282 UNISON were one of the many voices who pointed to how undermining and potentially damaging reductions in public health spending could be, saying:
“This is likely to prove highly counter-productive, as a failure to tackle issues such as obesity and sexual ill health stores up future costs for the wider NHS.”283
311.There was some disagreement, however, on the connection between cuts to public health funding and the success of public health initiatives. The Secretary of State for Health, in response to a question on funding for public health said: “I’m afraid I don’t accept that a public health budget being cut automatically means that we are unable to make progress on the big public health issues of the day.” 284
312.We were totally unconvinced by this assertion, given the weight of evidence to the contrary. Significant cuts to public health budgets struck us as a false economy and clearly at odds with the core aims on prevention contained in the Five Year Forward View.
313.Given the multiple pressures facing the health and care system we can no longer defer action on prevention. We heard multiple calls for a different approach to prevention, one that takes a longer-term, more strategic view to planning. The UK Health Forum suggested that: “Like the OBR, a joint analytical relationship with the Treasury and PHE” could help with investment in public health measures and “better inform fiscal and economic planning.”285
314.The Government’s failure to invest in public health and the lack of progress on prevention, as evidenced by the significant burden preventative ill health continues to place on patients and the health service, was further evidence of the type of short-sighted, compartmentalised thinking that seems to prevail across health policy. Prevention, as with other areas of NHS policy, seems to be driven by short-term payback rather than longer term sustainability, and subject to shifting prioritisations with each political cycle.
315.We are of the opinion that a continued failure to both protect and enhance the public health budget is not only short-sighted but counter-productive. Cuts already made could lead to a greater burden of disease and are bound to result in a greater strain on all services. The Government should restore the funds which have been cut in recent years and maintain ring-fenced national and local public health budgets, for at least the next ten years, to allow local authorities to implement sustainable and effective public health measures.
Patient responsibility
316.The NHS Constitution not only sets out what patients should expect from their health services, but also the responsibilities of patients and the public. It asks the public to: “Please recognise that you can make a significant contribution to your own, and your family’s good health and wellbeing, and take personal responsibility for it.”286
317.Some witnesses were keen to stress that promoting personal responsibility for health was an important, but largely unfulfilled, aspect to current public health and prevention policy. There were numerous calls for greater investment to be made to empower individuals to take responsibility for their own health. The British Medical Association stressed that:
“Increasing health literacy, particularly from an early age, is key to achieving public health prevention measures and promoting better awareness of self-care. This will also help to reduce pressure on overstretched health services and support the sustainability of the NHS by preventing ill-health in the long-term.”287
318.There was general agreement that a better balance needed to be achieved between the Government’s responsibility for implementing effective prevention strategies and public health programmes, and patients taking responsibility for maintaining their own health. The British Dietetic Association alluded to the need for this balance to be readdressed, stating that:
“Our healthcare system needs to realign itself fundamentally to prevention, even if that involves shifting funding from acute care and regulating to improve the public’s diet. At the same time the UK population needs to take greater responsibility for its own health and wellbeing, or face losing the NHS it values so much.”288
319.We also heard of the role that employers have in supporting people to stay healthy and in helping to reduce demand on the system. Norman Lamb MP raised the role of employers and how they are engaged more in the well-being of their workforces, acknowledging that “we could be achieving much more in terms of good, preventative care in that way.”289 Sophie Corlett from Mind explained the significant role employers have in relation to work-related mental health issues:
“We do quite a lot of work at Mind with employers. Those whom we work with are able to make quite a difference to their workforce well-being generally to make it a healthier workplace but also to support people who do develop mental health problems to stay in work. That does not necessarily always work because sometimes their employee cannot get access to the health services that they need in time, but it may be to hold a job open if somebody does have to fall out of work, to support somebody to work more flexibly while they are unwell or come back at a slower pace—all of those are things that an employer can do.”290
320.The Government should be clear with the public that access to the NHS involves patient responsibilities as well as patient rights. The NHS Constitution should be redrafted with a greater emphasis on these often overlooked individual responsibilities. The Government should relaunch the Constitution as part of a renewed and sustained drive to improve health literacy and educate the public about their common duty to support the sustainability of the health service, with children, young people, schools, colleges, further education institutions and employers forming a major part of this initiative.
241 World Health Organization, Global status report on noncommunicable diseases (2010): http://www.who.int/nmh/publications/ncd_report_full_en.pdf [accessed 28 March 2017]
242 World Health Organization, Non-communicable Diseases (NCD) Country Profiles (2014): http://www.who.int/nmh/countries/gbr_en.pdf [accessed 28 March 2017]
243 The King’s Fund, ‘Non-communicable diseases’: https://www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/non-communicable-diseases [accessed 28 March 2017]
244 Q 322 (Professor Sir Michael Marmot) and The Marmot Review, Fair Society Healthy Lives (2010): http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf [accessed 28 March 2017]
249 NHS England, Five Year Forward View (October 2014): https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf [accessed 28 March 2017]
250 Ibid.
254 Public Health England, ‘Health matters: harmful drinking and alcohol dependence’: https://www.gov.uk/government/publications/health-matters-harmful-drinking-and-alcohol-dependence/health-matters-harmful-drinking-and-alcohol-dependence [accessed 28 March 2017]
255 Public Health England, Alcohol treatment in England 2013–14 (October 2014), p 3: http://www.nta.nhs.uk/uploads/adult-alcohol-statistics-2013–14-commentary.pdf [accessed 28 March 2017]
259 HM Government, The Government’s response to the Five Year Forward View for Mental Health (January 2017), p 1: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582120/FYFV_mental_health__government_response.pdf [accessed 28 March 2017]
260 Prime Minister’s Office, Press Release: ‘Prime Minister unveils plans to transform mental health support’, 9 January 2017: https://www.gov.uk/government/news/prime-minister-unveils-plans-to-transform-mental-health-support [accessed 28 March 2017]
265 Peter Scarborough et al, ‘The economic burden off ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006–07 NHS costs’, Journal of Public Health (May 2011),
pp 1–9: http://iasnew.onepiecejigsaw.com/uploads/pdf/Economic%20impacts%20docs/pubmed.fdr033full.pdf [accessed 28 March 2017]
266 Public Health England, ‘Economic impact’: https://www.noo.org.uk/LA/impact/economic [accessed 28 March 2017] cited in written evidence from The King’s Fund (NHS0717)
267 Cancer Research UK, ‘How being overweight causes cancer’: http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/bodyweight-and-cancer/how-being-overweight-causes-cancer [accessed 28 March 2017]
268 Simon Stevens, ‘The radical blueprint the NHS needs to survive life after Brexit’ The Telegraph (18 July 2016): http://www.telegraph.co.uk/news/2016/07/18/the-radical-blueprint-the-nhs-needs-to-survive-life-after-brexit [accessed 28 March 2017]
270 BBC, ‘Childhood obesity: Plan attacked as ‘weak’ and ‘watered down’: http://www.bbc.co.uk/news/health-37108767 [accessed 28 March 2017]
271 Royal College of Physicians, ‘RCP president Jane Dacre ‘disappointed’ with government childhood obesity plan’: https://www.rcplondon.ac.uk/news/rcp-president-jane-dacre-disappointed-government-childhood-obesity-plan [accessed 28 March 2017]
272 National Obesity Observatory, The Economic burden of Obesity (October 2010): http://www.noo.org.uk/uploads/doc/vid_8575_Burdenofobesity151110MG.pdf [accessed 28 March 2017]
277 Health Select Committee, Public health post-2013 (Second Report, Session 2016–17, HC 140)
278 HM Treasury, ‘Chancellor announces £4.5 billion of measures to bring down debt’: https://www.gov.uk/government/news/chancellor-announces-4-billion-of-measures-to-bring-down-debt [accessed 28 March 2017]
279 QualityWatch, Focus on: Public health and prevention Has the quality of services changed over recent years? (April 2016): http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/FULL%20REPORT_QualityWatch_Public%20health_and_prevention_WEB.pdf [accessed 28 March 2017]
280 Ibid.
286 Department of Health, ‘The NHS Constitution for England’: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#patients-and-the-public-your-responsibilities [accessed 28 March 2017]