Shifting from sickness to prevention: we must go further

After years of campaigning on public health and prevention, the Royal College of Physicians (RCP) welcomed government making the shift from ‘sickness to prevention’ one of its three major priorities in its 10 Year Plan for Health.

We know too many people are avoidably unwell, and unless we reduce those levels of avoidable ill health, the NHS will continue to face unmanageable demand and pressure. Over two decades on from the Wanless report, the same themes returned in the 2024 Darzi review. We need to invest in prevention, empower individuals to manage their own health, and tackle the root causes of illness which often sit beyond the remit of the health service.

There were some positive commitments in the plan – and other areas where it was more disappointing, for example the lack of focus on tackling alcohol harms.

Common to all the shifts in the 10 Year Health Plan is that three months on from its publication, we still lack detail on implementation. We need to understand how government’s vision for the sickness to prevention shift will be realised with milestones and metrics for success. There are some positive commitments in the 10 Year Health Plan, and other areas where more action is urgently needed.

Action on smoking and obesity

The plan promised new healthy food standards and mandatory reporting on them, and an update to nutrient profile models which categorise which foods are more or less healthy. Manifesto commitments to pass the Tobacco and Vapes Bill and to deliver opt out tobacco dependence treatment across all routine hospital care were also reaffirmed.

These are welcome given the significant impact of these two major public health issues on our nations’ health. In an RCP member snapshot survey earlier this year, 53% of respondents said that at least half of their average caseload was made up of patients whose conditions were caused or worsened by smoking, rising to 59% for reporting obesity-related ill health accounting for at least half of their caseload.

We welcome the commitment to expand access to weight loss medication – weight-loss jabs are an important part of the picture – but medication alone won’t go far enough to make meaningful progress on reducing rates of obesity. We need to tackle our broken food system, make it easier for everyone to choose to eat healthily, better community infrastructure to facilitate and promote good health and activity, better education on food and budgeting.

What matters is delivery. We now need to see implementation plans for government’s commitments on tobacco and obesity with clear timelines. The long-promised restrictions to junk food advertising and marketing must be delivered in January without more delay and government must get the Tobacco and Vapes Bill in statute.

A new way of working

The plan talks about a fundamental reorientation of the health system, moving away from a model that waits for people to become sick towards one that helps people stay well. Shifting care from hospital to community could support earlier intervention and reduce pressure on the NHS. Our clinical vice president has set out the key areas government must consider to make earlier access via neighbourhood health models a success.

The model integrated care board (ICB) blueprint encourages closer collaboration between NHS trusts, local authorities, and public health teams, and envisages a future in which trusts hold the entire health budget for a local population. It sets out that ICBs have a key role to play as strategic commissioners to improve population health and reduce inequalities. But, as the blueprint highlights, for this to succeed, ICBs will need to facilitate stronger public health specialist support, hospitals will need a better understanding of the health needs of their populations, and how inequality affects service use in order to develop long term population health strategies. ICBs must follow national policy direction and use the funding it is given to deliver critical prevention services.

Air quality

The role of air pollution is acknowledged in the plan – this is welcome, given air quality has often been historically seen as an environmental issue, but it is notable that the actions covered in the plan sit outside the Department of Health and Social Care. We need more acknowledgement within DHSC to tackle its very real health effects.

Evidence gained over the last decade shows there are links between air pollution and almost every organ in the body. The RCP’s report published earlier this year found that around 30,000 deaths per year in the UK are estimated to be attributed to air pollution, with an economic cost of £27 billion in the UK due to healthcare costs, productivity losses and reduced quality of life. When wider impacts such as dementia are accounted for, the economic cost may be as high as £50bn.

The government’s commitment to review its long term PM2.5 targets provides a critical opportunity to do more to tackle air pollution at source and set out robust pathways towards the delivery of the World Health Organization’s 2021 guidelines. Beyond that, we need an indoor air quality strategy and to ensure that air quality is part of net zero planning and delivery. In its health mission published before the election, the Labour party promised a new Clean Air Act – we hope to see that committed to in the next King’s Speech.

We also need a government funded and delivered UK-wide public health clean air campaign to provide accurate and trusted information about the health impacts of short- and long-term air pollution exposure. The public need to understand the harms of air pollution, the key sources, and how to reduce their personal exposure.

Health inequalities

Nearly 90% of respondents to an RCP snapshot survey earlier this year reported they were concerned about the impact of health inequalities on their patients. Despite the plan acknowledging the importance of wider determinants, it offers next to nothing on how to tackle them. There is an almost 20-year gap in healthy life expectancy between the most and least deprived areas of England. The government’s manifesto was clear that it would tackle the social determinants of health to halve that gap. The health mission is now rarely mentioned, the mission delivery unit closed, and despite repeated calls from the RCP and hundreds of other organisations, there remains no cross-government strategy to reduce health inequalities.

Before the plan’s publication, the RCP set out three areas that must be addressed to enable lasting change: prevention, early intervention, and tackling the social determinants of health. The 10 Year Health Plan just doesn’t go far enough on the most important one: tackling the root causes of illness. Housing, employment, poverty, racism and discrimination, community – these are the things that shape and determine our health. We will keep calling for a coordinated cross-government strategy to reduce health inequalities to tackle what makes us ill in the first place. Without it, the positive commitments in the plan don’t add up to the bold vision needed for this shift.

If we are serious about moving towards a prevention-first healthcare system, reducing pressure on the NHS, meeting manifesto commitments like the healthiest generation of children ever, and closing the gap in healthy life expectancy, the promises made in the 10 Year Health Plan need to be delivered without delay, and then we need to go much further still.