Public health – increasing need, falling investment

By Lewis Peake, Clinical Fellow Royal College of Physicians

In its 500th year, the RCP is aiming to promote debate among healthcare workers and the public, about what the UK’s healthcare service should look like. One of the questions raised in the remit of Our Future Health is how investment could be targeted to improve the wellbeing of the population. There is perhaps no more apt a time than now, following an influenza plagued winter, to consider the implications of falling public health funding on our secondary care services.

Financial backing given to public health interventions has been falling for some time. From £2.66 billion in 2013/14 to £2.52 billion in real terms for 2017/181, the effects of this 5.2% drop in local authority allocations may not be apparent for many years. To put this overall spending into context, £124 billion was spent on the entirety of NHS in 2013/14. It is clear that this falling public health expenditure is a false economy. Taking smoking prevention schemes as an example, for every £1 spent on education in UK schools, £15 is saved in long-term health costs to the NHS.2 With regards to the controversial policy implementing a tax on sugary drinks, a US model suggests savings of $55 for every $1 spent.3

Of course, not all arguments that make economic sense translate to government policy – there are other considerations. But in the case of public health interventions, which also translate to measurable health benefits, the case seems watertight; especially considering the NHS’ long term survival. The NHS is seemingly reliant on cutting costs and reducing demand, both factors that are directly addressed by public health interventions. So, what other considerations are at play?

It is easy to be cynical about governments and their lack of interest in interventions that deliver long-term benefits, with potentially no or few short-term gains. Investing money in areas that may only provide positive outcomes for future governments seems counterintuitive, and is just one justification for positioning the NHS outside of parliamentary control.

Beyond that, there is an argument that the general public simply do not want increased pressure to follow lifestyle recommendations or accept public health impositions. If that is the case, should an individual’s autonomy take precedence over what is ‘best’ for society? This winter, we have seen the impact influenza can have on already struggling hospitals. Putting aside the relative effectiveness of the vaccine, a heavy case load of flu was expected given the high incidence in Australia this season, yet uptake was no greater than previous years. Up to late December 2017 vaccination rates were less than 50% in some recommended groups (44.6% for pregnant women, 45.6% for those <65 years with at-risk comorbidities). Even among frontline healthcare workers the most recent estimates put uptake at less than 60%.4 In addition, it seems that many GP surgeries have been favouring the cheaper, but less effective, trivalent vaccine over the quadrivalent alternative. Could flu cases have been reduced by greater spending on awareness of the vaccine programme, on dispelling myths attributed to it, and on availability of the quadrivalent iteration? Or does the poor uptake of the vaccine reflect a society unwilling to engage in preventative medicine, where ‘expert culture’ is shunned and paternalistic government resisted?

Putting aside influenza, there is plenty of data to suggest shortcomings in national public health measures, whether due to funding of services (a recent survey found only 61% of local authorities can provide their patients with help to stop smoking in keeping with NICE guidance5) or the funding and impact of health awareness campaigns. Earlier this year we heard from the Alcohol Health Alliance that only 16% of the public are aware of the most up-to-date guidelines from the chief medical officer on the maximum recommended alcohol units (14 units a week for those wishing to remain at a low-risk).6 Similarly, a study last year showed that just 25% of British people knew of the link between obesity and cancer.7 Many businesses go to great lengths to understand their audience, and target messages with consideration of human psychology and sociology – is enough attention given to this approach in healthcare?

Furthermore, is there support that the media could provide in delivering these health messages? So much of what society believes, thinks and does is influenced by what we hear, read and watch. Medical success stories are commonplace in newspapers: cases of life saving treatment for horrific diseases are, quite rightly, celebrated and revered as the epitome of human invention. Printed public health success stories seem few and far between – reports of weight loss and diabetes prevention programmes rarely make headlines, and don’t elicit the same public emotion as triumphs in acute care.

This blog raises many questions and offers few answers. Our Future Health will explore some of these questions in more detail, while allowing doctors, patients and policy makers a platform for debate. In his Harveian Oration this year,8 Professor Chris Witty noted that the areas where health trends are declining (for example obesity) will rely not on physiology research for their remedy, but on the social sciences. It remains to be seen how much investment in this area will be made, and what effect it will have on the public health issues afflicting our NHS.

  1. The King’s Fund. Spending on public health. https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/spending-public-health [Accessed 18 January 2018]
  2. The King’s Fund. Making the case for public health interventions. https://www.kingsfund.org.uk/sites/default/files/media/making-case-public-health-interventions-sep-2014.pdf [Accessed 18 January 2018]
  3. Gortmaker SL, et al. Cost effectiveness of childhood obesity interventions: evidence and methods for CHOICES. Am J Prevent Med 2015;49:102–11.
  4. Public Health England. Weekly national influenza reports. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/673200/Weekly_national_influenza_report_week_02_2018.pdf [Accessed 18 January 2018]
  5. Feeling the heat: The decline of Stop Smoking Services in England. http://ash.org.uk/download/feeling-heat-decline-stop-smoking-services-england/ [Accessed 18 January 2018]
  6. Alcohol Health Alliance. Awareness of drinking guidelines remains low, 2 years after their release. News release. http://ahauk.org/awareness-drinking-guidelines-remains-low-2-years-release/ [Accessed 11 January 2018]
  7. Hooper et al. Public awareness and healthcare professional advice for obesity as a risk factor for cancer in the UK: a cross-sectional survey, Journal of Public Health, Nov 2017.
  8. Harveian oration, Royal College of Physicians, November 2017.

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