Prospects for public health in a sustainable NHS
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2017)

“A culture of short-termism seems to prevail in the NHS and adult social care.” With this opening statement, identifying a critical failing in current planning for England's National Health Service (NHS), the House of Lords Select Committee on the Long-Term Sustainability of the NHS last month launched its conclusions after almost a year of taking evidence from every part of the health service. Their main recommendation is to create a new Office for Health and Care Sustainability. But the most striking findings—and recommendations—concern public health: the opportunities to be seized, and the woeful failure to seize them. The priority given to public health in England is not new. Simon Stevens, Chief Executive of the NHS, made prevention a cornerstone of his Five-Year Forward View published in 2014. He put “a radical upgrade in prevention and public health” top of his list. He reiterated the importance of government commitment to public health. The House of Lords report sets out in excruciating detail how this promise has turned out. The Select Committee, chaired by Lord Narendra Patel, expected evidence to show progress on addressing health inequalities. They learned, from Michael Marmot for example, that, “There will be increased poverty and increased inequality over the next five years [in England], which will potentially damage health, particularly for families with children; they will be selectively hurt the worst.” The Committee chose to focus on two major public health issues that have been especially neglected—mental health and obesity. On mental health, the Committee welcomed the commitment to “parity of esteem” between mental and physical health. But while mental ill-health causes 23% of all illness in the UK, mental health services receive only 11% of health spending. “There is still a need for sustained and determined action to close the gap between the care received and outcomes achieved by people with mental and physical care issues.” On obesity, they concurred with evidence from Simon Stevens that, “obesity is the new smoking.” But they concluded that, “there is insufficient political recognition, across the parties, of the major threat to the long-term sustainability of the NHS posed by the absence of any credible, well-led and sustained action on obesity.” They recommended that the government “urgently embarks on a nationwide campaign to highlight the many complications arising from the obesity epidemic, “and redoubles efforts “to educate the public about the true costs to the NHS of poor lifestyle choices”. Obesity should be the focus of enhanced prevention to avoid morbidity-associated burden but also cost-associated burden. Indeed, as Seamus Kent and colleagues show in their Article published in this issue of The Lancet Public Health, obesity does have a cost to the NHS. Kent and colleagues examined data for 1·1 million women in England aged 50–64 years recruited into the Million Women Study between 1996 and 2001 through 60 NHS breast cancer screening centres and who provided information on height and weight. 1·84 million hospital admissions were recorded. Nearly 15% of hospital care costs were attributed to overweight and obesity, with almost all of the excess costs involving hospital procedures. Every 2 kg/m2 increase in BMI above 20 kg/m2 was associated with a 7·4% (7·1–7·6) increase in annual hospital costs. Maybe the most worrying aspect of the Select Committee's analysis concerns the financing of public health. In 2015–16, public health was cut by £200 million; 7% of its total budget. On current projections, that budget will be cut by a further £331 million (or 9·7%) by 2020–21. They recommend that the government restores all the funding that has been cut and implements ring-fenced public health budgets, for at least the next 10 years. What is saddest about this latest report is that so little of it is new. Public Health England prefigured many of these latest recommendations in its own analysis of the burden of disease in England, led by John Newton, and published in The Lancet in 2015. The UK's public health community has done much to measure and monitor trends in mortality, morbidity, and health risks. They have provided the best available evidence to policy makers. The failures have been in translation. The government needs to do more to prove its concern both for evidence and for the health of those it has a duty to protect. Hospital costs in relation to body-mass index in 1·1 million women in England: a prospective cohort studyExcess body weight is associated with increased hospital costs for middle-aged and older women in England across a broad range of conditions, especially knee replacement surgery and diabetes. These results provide reliable up-to-date estimates of the health-care costs of excess weight and emphasise the need for investment to tackle this public health issue. Full-Text PDF Open Access