If prevention is better than cure, why is funding overlooked in the very public services that can improve health? A project is attempting to understand local preventive spending to help build an investment case and, in turn, help us all. Journalist Vivienne Russell reports.
By 2040, the number of people living with a major illness will have increased by 37% (The Health Foundation, 2023). In the same timeframe, the size of the working age population paying the taxes to fund care for this group will have grown by just 4%, according to projections (Health Foundation, 2023).
Indeed, the costs of healthcare have rapidly outstripped population growth. Over the last century the population of the UK has grown by around 50%, but since the NHS was set up in 1948 health, spending has increased by 1200% (The Health Foundation, 2023).
These figures present a stark picture that is prompting health and finance experts to ask how we can keep people in good health for longer while putting health finances on a more sustainable, long-term footing.
SPEND IT EARLY
A range of health and other public policy voices are now coming together on the importance of prevention and calling for a better understanding of what the government spends on preventive services. They also want to see stronger protective measures for this type of funding, which is vulnerable to being squeezed as demands for acute care rise.
In her review of integrated care systems (ICS) published in April, former Labour health secretary Patricia Hewitt called for the share of total NHS budgets at ICS level spent on prevention to increase by at least 1% over the next five years (Department of Health and Social Care, 2023a).
But significant action on prevention is not just an NHS responsibility. It’s long been recognised that good health is about more than having access to healthcare (WHO, 2023; Institute of Health Equity, 2010). The social determinants of health – such as housing, education, income, social inclusion and communities – all play an important part in ensuring people enjoy healthy lives.
In his recent annual report, England’s chief medical officer Chris Whitty highlighted the important role that preventive approaches play across the public sector in keeping people healthier for longer (Department of Health and Social Care, 2023b).
|THE ROLE OF
|More than 300 local authorities in
England provide a wide range of services
in their communities – from social care
and leisure to licensing, housing and
regeneration. Councils also shouldered
more responsibility for public health in
2013 and all upper tier and unitary local
authorities have a duty to improve the
health of their local populations.
Many council services help to support
health and wellbeing. People who have
good housing, have access to green
spaces and leisure facilities, and who live
and work in thriving economies are more
likely to enjoy good health.
‘Housing services, education services,
how the local economy is performing –
all those could fall within the prevention
box. They have an impact on how
you are born, live and age within a
community,’ says Eleanor Roy, health
and integration policy manager at the
Chartered Institute of Public Finance and
Accountancy (CIPFA), the professional
body for public sector accountants.
Eleanor argues that even lower-tier
district and borough councils have
important community-focused roles that
can have an impact on health.
Over at independent charity The Health Foundation, senior economist Anna Gazzillo says it’s important to move conversations about health away from reactive services towards the wider determinants – or ‘building blocks’ – of health, such as housing or education. One problem she highlights, however, is the lack of a clear picture of what is currently being spent on ‘preventive activity’ in public services.
At the same time, the current political and public finance system does little to incentivise preventive investment. Politicians tend to focus more on the next election, rather than what might be best in the long term.
EXPLORING WHAT’S POSSIBLE
The Health Foundation and CIPFA are linking up in a bid to discover how much local government spends on preventive measures (CIPFA and The Health Foundation, 2023). In a two-year project, which kicked off last November, the two organisations are partnering with a number of local authorities in England. Together they will try to determine what kinds of preventative spending in the public services that shape health is actually taking place. Councils offer a useful case study because they provide a broad range of services that strengthen the building blocks of health. They are also locality-based organisations with a strong understanding of their communities.
It’s no easy task, however, as the data is not always available. Local authority spending is reported and classified by service area, not whether spending is for a preventive activity or not. Even when there is some data – social care, for example, has some preventive spending categories within it – what is meant by that is not always clear.
‘It’s been extremely challenging to try and define and identify what we mean by prevention and then find that within the financial data,’ explains Eleanor.
The researchers want to work with a small number of partner councils, of all types, to, in Eleanor’s words, ‘lift the lid’ on the financial data and see what information may be lurking inside. She stresses that it won’t be a one-size-fits-all approach and the team expects to work with different councils in various ways. ‘It’s very much an exploratory project,’ says Eleanor. ‘We’re exploring the art of the possible.’
Anna from The Health Foundation adds that the study will also examine how repeated cuts to local government budgets during the ‘austerity years’ affected their financial clout. ‘Spending shifted away from areas that we can consider preventive in the long term, like housing, towards meeting acute needs.’ This shift from ‘upstream’ preventive spending towards more ‘downstream’ acute spending is one issue the team is keen to highlight.
This concern is echoed by Clare Keogh, Unite’s national officer for local authorities, who says: ‘Many of the services cut or lost – such a neighbourhood safety, parks and open spaces, leisure and libraries, children and youth services and even social care – are essential for keeping communities happy, safe and healthy.
‘This has meant that, not only are councils focusing on reactive, emergency or crisis services, but actually demand for these are now higher, with fewer resources overall.’
COMMUNITY IS KEY
Eleanor stresses that putting the focus on prevention makes sense financially and health-wise. ‘At the moment every headline is about urgent and emergency care and the acute end of the spectrum, and, clearly, we can’t stop doing any of that,’ says Eleanor. ‘But if we keep following that trajectory, then logic dictates that more and more activity and resource go to that acute end of the spectrum and less go further upstream into those more community-based preventive services.
‘If we can have a more cost-effective intervention upstream that stops people from getting to the point where they need that acute intervention that is the best use of public money.’
|30% to 50%
of health outcomes are accounted for
by the social determinants of health
The Health Foundation and CIPFA are not the only organisations thinking about prevention, public money and the so-called ‘upstream and downstream pressures’.
‘Everybody bangs on about prevention, but it never seems to happen – and I guess the question is why,’ says Andrew O’Brien, director of policy and impact at the cross-party think-tank Demos.
He agrees that public services should attempt to tackle problems upstream to stop them leading to worse outcomes, which are both costly to manage and can have devastating impacts on people’s lives.
In a paper published in October, Demos and The Health Foundation called for the introduction of a new third category of public spending called Preventative Departmental Expenditure Limit (Demos, 2023). The first two categories are revenue spending (which funds salaries and other day-to-day spending) and capital (which pays for buildings and infrastructure). Whitehall departments would then ask the Treasury for a preventive spending allocation, alongside their revenue and capital requests, which would then be ring-fenced with preventive activity tracked and its impact evaluated.
Andrew welcomes The Health Foundation-CIPFA research. He cites a move in politics to push activity away from the centre of government down to local authorities and integrated health boards, which are embedded in communities. Preventive investment needs to flow through the system, he says.
HOW IT HELPS
At the Local Government Association, community wellbeing board chair councillor David Forthergill backs a shift towards more spending on preventive measures.
the number of people living
with a major illness will have
increased by 37%
the size of the working age
population paying the taxes
to fund care for this group will
have grown by 4%
‘The current social care and health system is unsustainable and will buckle under the weight of demand unless we re-engineer our planning and service provision to promote healthy choices, prevent sickness and intervene early to minimise the need for costly treatment and care,’ he says.
While acknowledging that data and definitions are useful, he adds that prioritising preventive spending to improve people’s health also demands political will and the right culture and leadership to make it happen.
The team behind The Health Foundation-CIPFA project hopes it will help to make the case for investing more resources in preventive approaches more broadly.
‘Ideally, we successfully manage to map preventive activity to spend across a number of authorities in a variety of different local authority service areas or by different outcomes,’ Eleanor explains. This would help to build a local picture of total preventive investment, helping councils make the case for further preventive spend as well as informing regional and national understanding of preventive spending in the public services that shape health and other outcomes.
But even if the project falls short of achieving this goal, Eleanor adds that forging a better understanding of data gaps will be valuable.
Andrew from Demos is hopeful that with a clearer picture of prevention spending and some protection for this kind of investment in place, new patterns of healthcare delivery will be likely to emerge. Delivery that is more community-based and builds on the preventative work that health visitors, school nurses and other community practitioners are already doing.
Changes to the underpinning funding system so that prevention becomes a priority could help to advance the impact of these professions and the vital work CPs do. And, most importantly, ensure young people get the help when they need it, long before they hit a crisis point.
‘Any measure of prevention in health would mean we’re investing more into relational public services,’ says Andrew, ‘… going out into communities building an understanding of citizens and local populations and taking action that can have long-term benefits to the individuals and communities and their overall levels of health and wellbeing.’
He adds: ‘That would be the hope.’
WHAT DO YOU THINK?
What preventive initiatives across the public sector have helped your clients’ health, or have you noticed a decline in these kind of activities over the years? What do you think is the answer?
Email editor Aviva Attias:
CIPFA and The Health Foundation. (2023) Exploring preventative investment in local government. See: bit.ly/49VriQa (accessed 28 November 2023).
Department of Health and Social Care. (2023a) The Hewitt Review: an independent review of integrated care systems. See: bit.ly/46Aw4zC (accessed 28 November 2023).
Department of Health and Social Care. (2023b) Chief Medical Officer’s annual report 2023: health in an ageing society. See: bit.ly/410ndpT (accessed 28 November 2023).
Demos. (2023) Revenue, capital, prevention: A new public spending framework for the future. See: bit.ly/3RfAEPv (accessed 28 November 2023).
Institute of Health Equity. (2010) Fair Society, Healthy Lives (The Marmot Review). See: bit.ly/4a01a71 (accessed 28 November 2023).
The Health Foundation. (2023) Health in 2040, Projected Patterns of Illness in England. See: bit.ly/46C8AKL (accessed 28 November 2023).
WHO. (2023) Social determinants of health. See: bit.ly/3RkBN8E (accessed 28 November 2023).
Image | AdobeStock