We all believe in prevention. But do we agree what it means?
Both negative factors, such as the seemingly intractable problem of matching NHS capacity to demand, and positive ones including the creation of Integrated Care Systems, have increased the focus of policy makers and public service leaders on prevention.
At meetings hosted by the NHS Confederation, system health leaders, including local authority figures chairing Integrated Care Partnerships or place bodies, express the ambition to focus on health outcomes and shift resources upstream along with frustration at how hard this is in the face of resource constraints and Whitehall silos and short termism.
But to understand the barriers to prevention, let alone set about removing them, we need to break up the concept. Different types of intervention require different strategies.
‘Medical’ prevention is essentially about the core business of the NHS; how can we encourage and support commissioners and clinicians to intervene earlier and more effectively either in care pathways or in relation to people with multiple conditions? Medical prevention also involves investment in vaccination and diagnostic services, but these services take us to a second prevention challenge.
‘Public’ prevention is focused on empowering the population to make wise health choices. In part this is about encouraging people to keep fit and eat well, but work in this domain is also about helping people take advantage of new ways of managing their health. Arguably this is the area where the landscape is changing most quickly.
Technological and biomedical innovation makes it ever more possible for people to be informed about their health status and to identify sickness early. Indeed, over the next decade we may see an epochal shift in the way we think about medicine. Better diagnostics – faster, more accurate and cheaper – will mean we will no longer wait to have symptoms to seek medical advice but instead identify and respond to risks revealed in genetic profiles and blood tests. The big danger here is that the privileged and confident take advantage of these new possibilities – more of which are being aggressively marketed by the private sector – leading to an exacerbation of our already massive health inequalities.
The third domain is largely managed by local government. ‘Environmental’ prevention is about addressing health-impacting factors largely beyond the control of individual citizens. This area of policy and practice stretches from the monitoring of infectious diseases to the regulation of health risks from water and air quality to vaping to food hygiene. The key challenges here include the need for effective regulation (which can mean pushing back against charges of nanny statism) and adequate investment.
Finally, ‘social’ prevention is focused on influencing the policies of organisations for whom health is not their primary concern. These will range from housing associations and schools to local community groups and employers. The challenges here are to promote collaboration and to provide the evidence to these bodies that their policies can both make a difference to health outcomes and generate benefits in relation to their own objectives.
This framework is far from perfect. The domains overlap and it is unhelpful that my ‘environmental’ category largely overlaps with what local government calls ‘public health’. But the purpose of the classification is to show not only that prevention involves many different forms of activity but, more importantly, it faces different kinds of hurdles, not all of which are simply a matter of greater investment.
As with all complex human-centred policy challenges, the best way to make a difference may be to ‘think like a system and act like an entrepreneur’. This means working with partners to develop a compelling and mobilising vision of what a holistically preventative system might look like. But then adopting an agile, opportunistic approach to making progress in different areas.
Also, as partners work together it is important to develop shared tools and resources. Key to this is the economics of prevention. The principle that effective investment in prevention (in all four domains) saves money is widely accepted, but not only does the evidence too often fail to match the rhetoric but we are a long way from generating the benign feedback loops through which investment leads to identifiable savings and this leads to further scope for investment.
The genuine enthusiasm for prevention is an opportunity. But to make a difference our commitment needs to be matched by clarity of purpose and action.
Matthew Taylor is a public policy expert, former adviser to Tony Blair while Prime Minister and currently chief executive of the NHS Confederation
@ConfedMatthew
