Health isn’t just about the NHS – from funding to investment in healthcare
Good health is not just a matter of more funding for healthcare.
Investment in areas such as early years childcare provision and decent housing can make significant improvements to health outcomes.
Funding in front-line services should not come at the expense of public health and other interventions, which should be considered as a long-term investment.
The UK government’s 2018 budget announced on Monday confirmed the government’s earlier pledge to provide extra funds to NHS England. This ‘birthday gift’, announced in the summer, on the eve of the NHS’s 70th anniversary, will increase NHS England’s budget by some £20bn in real terms by 2023/24.
Given the financial pressures placed on public services since the crisis, an increase in NHS funding is certainly welcome. However, as the Nuffield Trust’s budget response asserted, most of that money is needed just to get things back on track.
There is also much that lies outside of NHS England’s ringfenced budget, not least the upkeep of the estate itself, which is accumulating an unhealthy maintenance backlog.
In this light, the budget didn’t clearly confront the long-term realities of growing demand and an ageing population.
This is also true of the extra £650m for social care next year. That money will help narrow but far from close the gap. As far as the long term is concerned, the much-anticipated green paper on social care remains still-anticipated.
Health isn’t just about the NHS, or even healthcare
Research, such as the King’s Fund’s ‘Broader determinants of health: Future trends’, shows that healthcare services account for just 15-25% of health outcomes.
Collectively, a range of wider determinants matters more, such as individual characteristics and behaviours, socioeconomic circumstances and environmental factors. There’s a complex web of causes of ill-health and a narrow focus on the NHS risks driving a reactive, treatment-led mindset. We can fix a broken leg but it’d be far smarter to avoid the soon-to-be patient falling in the first place.
Prevention is largely beyond the scope of the NHS and here, if it’s an older person, may be a question for the local council about appropriate housing adaptations. Action outside of the NHS is vital to addressing the long-term challenges.
The evidence supports broad-based, preventative action
Compared to health and social care provision (in many respects, the frontline), preventative programmes often involve long-term investments.
Here, the evidence is positive, suggesting the potential for substantial returns on that investment at a population level. This is a return in the broadest sense, encompassing benefits like longer, healthy lives.
For this reason, just putting more money into the frontline at the expense of public health grants (which have been falling) is a cause for concern. It’s also emblematic of a longstanding stated recognition of wider upstream causes (prevention) while continuing to focus efforts and resources downstream (treatment).
The experience of the 1997-2010 English health inequalities strategy is instructive. The strategy sought to tackle a range of issues, including various wider determinants of health. While it’s not clear that the strategy met all its objectives, it seems to have had at least some success in reducing geographical inequalities in life expectancy. A concerted broad-based strategy can shift outcomes: we’ve made progress before.
Interactions with other policies matters
The English health inequalities strategy was broad-based and, looking to wider determinants, there’s an association between health and socioeconomic inequality: a social gradient. Public Health England highlights stark differences in life expectancy associated with deprivation around the country.
The life expectancy of a man living in one of the most deprived areas of England is nine years less than a man living in one of the least deprived areas. For women, the gap is seven years. More worrying still is the gap in healthy life expectancy: the number of years spent in a state of ‘good general health’. This gap is over 19 years for both men and women.
Both health and socioeconomic inequalities have proved stubborn to address, not least because these kinds of disadvantage accumulate over the life course, right back to early years. Interactions with other economic and social policies (including education and housing) matter and it’s possible that policies since the English health inequalities strategy may be undoing some of the gains.
There is a risk of false economies across the piece
From a European study, the rise of atypical and insecure work, and the absence or deregulation of labour market protections, could compound existing socioeconomic and health inequalities.
In that light, it is worth considering the implications of the latest European Skills Index, which shows that while the UK has low rates of long-term unemployment, those jobs are often of fewer hours than people would like and mismatched with their skills.
There are questions about the quality of jobs that the UK economy can generate and how this might impair health and wellbeing. Turning the problem around, poor health can lead to people dropping out of the workforce, especially older workers. This is to the detriment of our economy.
While there are costs to providing good health, there are also costs to failing to provide it. In that sense, good health is an investment and may also have budgetary benefits if it helps grow the economy, generating more tax revenues.
As welcome as a birthday gift should be for our septuagenarian health service, good health isn’t solely achieved by putting more resources into healthcare. The most effective (and long-term) solutions should take prevention seriously, investing in public health but also in a range of other actions that influence socioeconomic determinants for the better. This covers a range of other measures outside of the NHS, like public health, economic and social policies. Crucially, we need to know how these all fit together. That’s an even more complex task than getting your budget sums to add up.
No holiday would be complete without a spreadsheet but, if you’re going to take one, make sure it’s big enough.