Solving the policy paradox: what will it take to build good health?

The UK’s health is far worse, and far more unequal, than it should be. Without addressing the underlying causes of ill health and inequality, things won’t improve at the scale and pace needed – no matter how much money we commit to the NHS.

Avoidable poor health is obviously bad for individuals, but also undermines the economy, which in turn means there is less money from tax for public services. It’s a vicious cycle. Health is shaped by the circumstances in which we’re born, grow, live, work and age – so action to improve population health must extend far beyond our health care system.

Improving health and reducing inequalities requires coordinated effort across government, with a strong focus on prevention. In this context, we use the word ‘prevention’ to mean a series of policy interventions aiming to improve health and reducing health inequalities by addressing the wider determinants of health.

It is a persuasive elevator pitch that has been accepted by generations of policymakers and politicians across all parties. So why aren’t we seeing results?

Sam Freedman calls this the policy paradox: the more obvious a policy solution is, the less likely it is to get done – because if it were easy then it would already have been done. 

Derek Wanless’s 2004 report, Securing good health for the whole population, focused on prevention and the wider determinants of health in England. A few years previously I’d led the secretariat of the first Wanless review and it was clear to us that prevention – in policy areas far beyond the NHS – would play a critical role in improving long-term health and addressing health inequalities. Many of the recommendations from that work seem depressingly familiar to anyone engaged in the current debate.

So is a preventative approach to health and reducing inequalities a pipe dream? Thankfully, no. Despite initial scepticism, and it taking more than a decade to see the results, evidence shows that government attempts to reduce health inequalities in the 1990s and 2000s did work. Learning from these past successes, we can build a more cohesive approach to addressing the wider determinants of health, and – crucially – ensure that progress is sustained. 

The task is not to make the case for prevention: that has been done. It is to show, with workings, what specifically is needed to overcome the barriers blocking long-term, cross-government action on health. For instance, Freedman highlights the role of treasury rules – as a former director of public spending at the Treasury, I’m all too familiar with the unintended consequences of well-meant approaches to public spending. That’s why, with Demos colleagues, I’m pushing for a new ring-fenced category of government expenditure that incentivises investment in long-term prevention. 

But though the Treasury’s role is important, it is far from the whole story. It is widely accepted that a greater focus on prevention requires a cross-government approach, but while delivering such a strategy is rather difficult, committing to one is remarkably easy. Too often governments have settled for sporadic ‘cross-cutting’ meetings of junior ministers to show that something is being done, instead of prioritising systematic and sustained work to develop mechanisms that would enable long-term cross-government policy change.

At the Health Foundation, we have started with the assumption that – in principle – political parties want to make good on the promise of prevention, but that in practice it is challenging to deliver. With an election only months away, we want to help the next government by showing a way forward on this generational challenge.

To that end, I’m pleased to be chairing an expert panel to make recommendations for a ‘Bill of Health’. Together, we’re exploring specific, realistic proposals to deliver, coordinate and sustain cross-government action on prevention. We will consider the role of targets – and whether any of these should be statutory – as well as other levers that local and national government can use.

We are lucky to have convened a group of experts with huge depths of experience in national government, local public health and civil society. Panel members have led important work on prevention (IfG, IPPR, A Covenant for Health, Tony Blair Institute) and studied similar challenges in fields such as climate change. Over the coming months we will draw on their expertise to develop recommendations to turn prevention from an obvious but much ignored principle into a galvanising approach across government and beyond.