The Future of Public Health: Preventing Ill-Health and Promoting Healthy Behaviors | Deloitte US has been saved
By Karen Taylor and Samrina Bhatti, Deloitte UK Centre for Health Solutions
We recently launched the fourth report in our Future of Public Health series, Negating the gap: Preventing ill health and promoting healthy behaviors. The report highlights the unequal impact of the COVID-19 pandemic and how failing to focus more on preventative services has disproportionately affected people who live in economically disadvantaged areas. It also notes that increasing healthy life years and reducing inequalities requires a population health management (PHM) approach and more effective and targeted funding for prevention. This blog offers an overview of our main findings and explains why a more concerted effort on ill-health prevention and health promotion is needed.
About health promotion and ill-health prevention
Health promotion enables people to increase control over their health, and improve it, by engaging them and empowering them to choose healthy behaviors and to make changes that reduce the risk of developing chronic diseases and other illnesses. Health promotion includes medical, behavioral, educational, empowerment, and social change. Health prevention comprises primary prevention to modify or avert the risk of disease, secondary prevention for early detection of disease and action to stop or slow progression, and tertiary prevention to prevent complications. Each level involves different targeted interventions.
Health prevention challenges pre-pandemic
In the United Kingdom, responsibility for health promotion and prevention programs rests with local directors of public health (DPH), their teams, and the National Health Service (NHS). To be effective, however, it requires collaboration and partnership at all levels. Moreover, NHS frontline staff and public health teams should work in partnership with social care, social enterprises, voluntary organizations, and other stakeholders to provide evidence-based public health interventions.
However, following the transfer of responsibility for public health services to local authorities in 2013, approaches to public health prevention have varied across local authorities, linked largely to the availability of funding and the differing needs of local populations. Although the new public health funding formula (introduced in 2013-14) sought to account for differences in need, there was limited progress in shifting resources to those areas below target. Consequently, despite the political rhetoric and research evidence about the cost-benefits of better prevention, overall funding for preventative services has declined.
To reduce health inequalities, interventions should be aimed at higher-risk groups, underpinned by the collection and collation of not only health and social care data but also data on housing, income levels, and education status, as well as DPH’s knowledge of place.
The Office of Economic Cooperation and Development estimates that most countries spend less than 5% of their health budget on prevention. Most funds go toward secondary and tertiary interventions rather than on primary prevention. In England, funding for preventative activities decreased from 5% of total health spending in 2013 to 4.5% in 2019, according to an analysis by the Office for National Statistics. Most spending went toward mandated services, with limited funding available for primary prevention.
Tackling the drivers of health
In our report Identifying the gap: Understanding the drivers of inequality in public health, we identified the impact the drivers of health (also known as social determinants of health) have on increasing health inequalities across the social gradient. People in lower socio-economic groups tend to have worse health outcomes than people who are better off. COVID-19 has helped to make existing inequalities much worse—particularly for Black and ethnic groups, people who have learning difficulties or physical disabilities, and other vulnerable groups. The pandemic has also highlighted inequalities in access to health prevention interventions and support. People who live in more deprived areas tend to have more limited access to hospital care, urgent cancer referrals, and first treatments. These disparities in access formed part of the rationale for reforming public health and increasing the focus on health inequalities.
One of the biggest areas of concern during the pandemic has been the increase in mental health issues. Despite multiple policies and programs to improve mental health services, the focus has been largely on treatment, and usually only after the condition becomes more severe. Historically, there has been limited emphasis on early interventions. Consequently, mental health inequalities persist: 70% of our interviewees said that their issues had not been well addressed.
Today, there are a range of NHS-approved, digitally enabled models of care especially for mental health. These models can offer insights to health care providers that can improve their understanding of the causes and symptoms of mental health conditions, how well treatments work, and how each treatment works for individual patients. Care delivered via digital platforms can also help people avoid the social stigma often associated with poor mental health, reduce waiting times, and remove the need to travel and take time off work for treatment. Moreover, content related to health promotion is increasingly delivered digitally. However, improvements in health literacy and digital literacy are needed to avoid exacerbating health inequalities.
Negating the gap in prevention and health promotion
Investment in prevention and health promotion is significantly more cost-effective and equitable than dealing with the consequences of health inequalities. The estimated cost of each additional year of good health achieved by public health interventions is 3.5 times lower than the average cost of NHS interventions. Yet, preventable illnesses caused by tobacco, obesity, alcohol, and recreational drugs, cost the taxpayer billions each year for treatment and long-term care. To address these issues, central and local governments, the NHS, the wider public health system, and industry should look for ways to collaborate to improve detection and prevention of ill health, and to apply cutting-edge science, technology, behavioral health, and other evidence and data to target support where it is most needed.
Moreover, partnerships between primary care, local authorities, and the third sector to deliver and adopt well-evidenced interventions implemented at scale—with agreed-to metrics to measure progress—can help people to avoid poor health, reduce growing demand on public services, and support economic growth. However, there is a need for transparency and accountability. In addition, the needs of people from socio-economically deprived backgrounds and more marginalized groups should be reflected in any formula used for allocating funding for preventative services.
There is likely also a huge opportunity to use digital technology to optimize outcomes. This includes providing upstream primary preventive care and supporting people at home through monitoring and earlier interventions and reducing deterioration in a long-term condition.
Conclusion
COVID-19 has shown how failing to prioritize health prevention can result in disproportionate levels of mortality along the social gradient. To be successful, health prevention and promotion need to be based on an appropriately funded PHM approach. Moreover, prevention and promotion should be viewed as a partnership between the NHS, public health, and stakeholders across the health ecosystem. Ultimately, success in improving prevention and health promotion will require consistency of purpose, with guaranteed funding and adequate staffing resources over several years. Local populations should be the ultimate judge and jury and hold stakeholders to account for the outcomes they deliver.
(A version of this blog was previously published by Deloitte’s UK Centre for Health Solutions/Thoughts from the Center)
