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NHS prevention drive unlikely to address root causes of inequality

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An LGC briefing on the government’s forthcoming prevention green paper.

The 2004 report by Derek Wanless, Securing Good Health for the Whole Population, includes a striking quote from Elizabeth Blackwell, the first woman to be entered onto the General Medical Council’s register in 1859.

Dr Blackwell said: “We are not tinkers who merely patch and mend what is broken… we must be watchmen, guardians of the life and the health of our generation, so that stronger and more able generations may come after.”

More than a 150 years later, it feels as if Dr Blackwell’s compelling logic that health services should not be focused solely on treating conditions but fully engaged in preventing them in the first place has still not been fully accepted by the nation’s political leadership.

A failure to address the regional imbalances in the economy and put tackling poverty at the heart of policymaking is having dire consequences.

According to the Social Metrics Commission, more than 14 million people are living in poverty, including 4.5 million children.

Evidence published in The Lancet shows multi-morbidity, when an individual has two or more chronic conditions, occurs 10 to 15 years earlier in deprived communities. This, as David Buck, senior fellow, public health and inequalities at The King’s Fund, points out, “should shock and shame us”.

In a powerful and particularly worrying presentation at the King’s Fund conference last month, Blackburn with Darwen BC’s director of public health Dominic Harrison said children from the poorest communities are two-and-a-half times less likely to reach adulthood than children from rich communities, while life expectancy has gone backwards over the last two years in about 20% of local authority areas.

The Conservatives are not the only party with a questionable record in this area. Analysis by the Institute of Fiscal Studies in 2013 found there was little change in income inequality under a Labour government between 1997 and 2010. Child and pensioner poverty did fall significantly, the IFS said, but warned the falls “might prove fragile given that they were mostly based on very large increases in spending on benefits and tax credits”.

Those who have been making the case for action to address social and economic determinants of health, including those in local government who deal the devastating impact of poverty every day, will have felt intense frustration that previous claims of a new dawn for prevention have proved to be false.

Therefore, the health and social care secretary Matt Hancock’s “vision” for prevention, the promise of using NHS funding to invest in community services and a green paper next year, will only be welcomed with caution.

There is an impression that the government’s prevention agenda is merely an afterthought to the NHS long-term plan and will be driven by the NHS which, as Hertfordshire CC’s director of public health Jim McManus points out, has a questionable record when compared to the best local government approaches.

The fact that Public Health England’s regional directors will be aligned with the new NHS England structures is a positive move to ensure public health has a seat at the table and prevention is embedded in the direction of policy travel, PHE chief executive Duncan Selbie assured LGC.

But Mr Hancock’s confirmation that the seismic cuts to the public health grant to local authorities will continue suggests a potential shift in approach away from locally-devised and driven policies to address the distinct needs of communities.

More centrally-imposed, prescriptive interventions, which fail to address the complexities of the challenges and bypass wider determinants of health by failing to address the central issues of poverty and inequality, could simply end up doing more harm than good.

A more sophisticated strategy is needed which requires the government and all public bodies, especially local ones, to make long-term decisions to tackle the issues and act in the best interest of their communities, rather than continuing to spin in the short political cycles.

Jon Bunn, senior reporter

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