Channelling money into frontline care, while cutting away at public health, is a false economy

Two years ago the Five Year Forward View articulated the need for a “radical upgrade in public health and prevention” for the “health of millions of children” and the “sustainability of the NHS.” Yet public health budgets have been cut by £200 million in recent years and there is more to come.

In a like for like comparison to 2016/17, planned public health budgets for 2017/18 show a decline of £85 million in cash terms, which is equivalent to a 5% cut in real terms, according to analyses by the King’s Fund. Worst hit are funding for sexual health services and tobacco control, where the percentage change in local authorities’ planned budgets includes funding cuts of more than 30%. This is likely to store up a multitude of problems for the NHS in the future.

Our successes and our failures in supporting public health manifest themselves in the health of our population. And, at the moment, the outlook is bleak.

More than one in four adults in the UK is obese. One in five children in reception in England is now obese or overweight, with children in the most deprived areas twice as likely to be obese as children in the least deprived areas. This is bad news for individuals. But it is also bad news for the long term financial sustainability of the NHS. Obesity—which increases your risk of diabetes and cancer—costs the NHS £5.1bn a year.

Almost one quarter of children and teenagers experience difficulties in accessing mental health services—in particular early intervention and mental health prevention. The number of A&E attendances due to psychiatric conditions or self-harm among young people more than doubled between 2010-11 and 2014-15 (from 9328 to 18 673). Prevention and early intervention are key here, especially given that over half of all mental ill health starts before the age of 14 and 75% has developed by the age of 18.

So, would public health make a good return on investment? The short answer (spoiler alert) seems to be yes.

Evidence shows that public health interventions offer good payback both in terms of better population health and wellbeing and NHS finances. For every £1 spent on public health interventions, the monetary value of the benefit has been estimated to be around £14.

Investing to improve the population’s health makes economic sense. It is estimated that in the UK smoking costs the NHS £3.3 billion a year, alcohol £3.3 billion, and physical inactivity £0.9 billion. Yet these drivers of demand for healthcare are amenable to change if we can help people change their lifestyles.

This is where public health interventions come in, which by maintaining people’s good health and helping them avoid illness—through both primary and secondary prevention—can help manage rising demand for healthcare. For example, evidence shows that well designed, community based interventions targeting falls prevention among older people are highly cost effective. They can reduce hospital activity and deliver cost savings within one to two years.

Paradoxically, spending less on public health now has the potential to add billions of pounds to future NHS service costs.

So why doesn’t the bottom line reflect this? Well, public health budgets have historically been viewed as soft targets. Getting policy “buy-in” is difficult because public health often—though not exclusively—delivers health payoffs in the longer term. Consequently, the benefits of policies that focus on prevention will frequently outlive the existence of their political architects.

The challenge of securing political interest is compounded because, in comparison with the attention given to problems in acute and social care, disinvestment in public health is less visible. The impact of austerity is more easily and immediately felt by the public when that impact is measured in terms of accident and emergency targets, or lengthening waits for surgery.

But the government needs to realise that channelling money into frontline care, while cutting away at public health, is a false economy. What we need now is a clear and credible plan for increasing resilience and the prevention of ill health, which is backed by financial commitment.

Improving population health starts with building communities with resilient children. More could be done to comprehensively and effectively address childhood obesity. One example would be through tackling the aggressive marketing of junk food—on TV, online, and through sponsorship and promotions—to children.

A policy focus on promoting resilience and mental health among children and adolescents is also needed. School based interventions that encourage safe participation in increasingly complex digital environments could have a useful role here.

Policy initiatives should address the importance of choice architecture and the interactions between individual behaviour and environmental contexts. This could draw on empirical work showing that the placement of food, alcohol, and tobacco products within the physical environment can influence their selection and consumption.

Investing in prevention and public health is not only good for the health of individuals: it is a core pillar of any comprehensive strategy for a financially sustainable NHS into the future.

Cuts to public health are likely to lead to more not less pressure on the NHS in the long term. We ignore this at our collective peril.

Charlotte Paddison joined the Nuffield Trust as deputy director of policy in 2017, where her work focuses on improving health and social care. Prior to this Charlotte worked in behavioural science, primary care, and public health at the University of Cambridge, after completing her PhD in New Zealand. Twitter @CAM_Paddison

Declaration of interests: Charlotte Paddison is an employee of the Nuffield Trust and a public governor for the Cambridge and Peterborough NHS Foundation Trust.

A version of this post originally appeared on the Nuffield Trust’s website on 12 July 2017.