Prevention in healthcare: turning words into action

Although the words “prevention is better than the cure” are often said, this still largely remains a mantra. The UK government has committed to a shift from “sickness to prevention” in the NHS.1 However, there is vagueness about how programmes that will improve health outcomes will be implemented.

Twenty years ago, Derek Wanless, a former banker, was appointed by Gordon Brown, then Chancellor of the Exchequer, to conduct a review of the NHS’s future needs and the likely costs. The Wanless review proposed a “fully engaged scenario,” which placed health improvement and prevention as a crucial element of a strategy to relieve demand on the NHS.

If anything, the opposite has happened since the report was published in 2002. On many measures, including life expectancy, the health of the British population has stagnated or has got worse. But part of the problem was that it was never clear how the iconic “fully engaged” population was to become reality.2

So how can we shift the mantra of prevention into reality? It is ever more important that we do so. The UK is experiencing an escalating pandemic of chronic ill health across the population which is resulting in a loss of productivity. In the first quarter of 2024, there were 2.8m economically inactive people in the UK due to long term sickness. This ill health is also resulting in avoidable deaths (125 612 – 22% of the total in 2022), as well as causing people misery from living in poor health or with chronic pain. Obesity alone is costing the UK £100bn per year. As most of this is unequally distributed in our population, with poorer communities more likely to be affected, this is also a serious failure of social justice.3

There are proven preventive interventions that could help individuals and the nation, which include the spectrum of nutrition, mental health, employment, and health equity456 but they are episodic or not widely implemented. Children in the UK have been hit hard over the past decade.7 Many are unable to get the best start in life. Those with social and clinical disadvantage struggle to access early interventions integrated with education, or to access school nurses, who are very important, but have declined in numbers by one third since 2009. Mental health needs of children in poverty are particularly unmet.89 This delays their development of speech and language and other milestones and limits their ability to achieve their potential. These services are more important than ever. Shamefully almost half of children in large families are now living in poverty.10 This has attracted growing media and professional attention11 but did not feature in the 2024 election campaign and has not been tackled by the government since.

We need to be clear about what people can do on their own to safeguard their health. Too often health messages ignore the constraints that people, and especially those at highest risk, face. Telling people to “eat healthily” is pointless if they cannot afford a square meal daily with healthier food increasing in price at twice the rate of unhealthy items in the past two years.12 In the UK, severe funding reductions in local preventive services, including those for sexual health, smoking cessation, and substance misuse, have removed much needed support for those who want to choose a healthy lifestyle. A recent national injection for local government health services is welcome, but constitutes small redress to what has been already cut. The abolition of the national public health service has removed access to advice and social marketing programmes enabling people to make good choices.

What does this mean for policy, NHS commissioning, and clinical practice? We need political willingness at the highest level to tackle the lack of support for substantial proportions of the population who want to sustain and regain good health. This needs a strong health workforce. Yet, if anything, until recently we have moved in the opposite direction, with funding cuts and poorly thought through reorganisations piling once successful national and local initiatives on the scrap heap.13 Support is needed for what is already well evidenced and in place but struggling, rather than wasting time and money on “playbooks” and the allure of wonder interventions.14 We need to re-invigorate policies that focus on the earliest years of life and support for families who are struggling. We urgently need to fund access to child mental health services. Given the cost and impact of obesity, national government interventions on affordable, better-quality food are needed to counteract food giants picking off local government efforts for the nation’s health.15

The Hewitt Review on integrated care systems16 recommended an increase to the budgets spent on prevention. For example, the stalled £70m investment on local smoking cessation has recommenced, but fails to connect local authority and NHS programmes—the latter often dependent on heroic efforts by clinician champions. For the population, preventive programme pathways between hospital, community, health protection, and local government are in critical need of being re-established. Given the lack of national focus, some Integrated Care Boards are pressing ahead but in isolation of a wider strategy.17

For clinical services, there are substantial opportunities to implement prevention strategies. Although some primary care practices are already embracing evidence-based lifestyle medicine approaches, this is neither the norm nor incentivised.18 Hospitals and healthcare institutions need to focus on creating healthy environments and tackling the unhealthy provision of hospital food.

Many hospital clinicians are innovating on a range of lifestyle interventions, such as the Vital 5 in South East London, which focuses on identifying and managing the five key health factors that will make a big difference to the population’s health—smoking, alcohol, obesity, blood pressure, and mental health.19 Sustainability needs to be central to all health policies. Reducing our reliance on pharmaceutical and surgical interventions remains central to achieving planet-friendly healthcare services.

Clinicians and non-clinicians already work together to support each other in an otherwise unrewarded component of clinical practice by creating networks focused on prevention. Their preventive work is growing and is leading to better and more cost effective outcomes for patients.2021 In 2013, public health was mainly removed from within health services. Clinicians consequently became isolated from national and local public health support. Re-establishing a professional public health input which integrates prevention in a coherent approach within the NHS will also better address our serious health challenges. Without these changes “prevention” will continue to be consigned to nothing more than a mantra.