Good health is our most precious asset, enabling people to achieve their potential, fuelling the economy and helping to build a stronger society. But the UK’s health is fraying. Improvements in life expectancy have stalled; more people are living with preventable health conditions for longer periods of their lives, and record numbers are unable to access the care they need. Deep inequalities in health exist and are widening, with people living in more deprived areas living for longer in poor health and dying earlier than those in less deprived areas. 

The UK has a higher prevalence of largely preventable, non-communicable conditions than many comparable European countries, with the Office for National Statistics estimating that around 1 in 7 deaths in the UK in 2019 could have been preventable through effective public health and prevention interventions. 

This is placing a growing burden on individuals and on the UK economy. More people than ever before are out of the workforce due to ill health and the numbers in work who report work-limiting health conditions have increased. The Office for Budget Responsibility has estimated that these combined impacts of rising ill health in working age adults have added £15.7bn to annual borrowing since the pandemic. 

The avoidable costs of failing to put prevention first can be seen across broad areas of public spending. Estimates of these costs vary depending on what is included and assumptions being made but, for example, recent UK estimates put the cost of obesity to the NHS at £11bn in 2021. Adding the costs arising from overweight increases this estimate to £19bn. Wider costs of overweight and obesity to the UK, including inactivity in work and formal social care, are estimated at £16bn. Similarly, estimates for reduced productivity from alcohol and tobacco misuse are £11bn and £18bn respectively.

Failing to prevent problems does not only cost the economy. There are costs to people affected including through lost health, lost opportunities and lost years of life. For example, it has been estimated that child poverty cost the UK more than £39bn in 2023, of which an estimated £12bn represents a reduction in future prosperity of those experiencing child poverty – the remainder being costs to the state including future lost income tax, future benefits and costs to universal public services. 

The focus on relieving short-term pressures on health services from rising ill health has left many people unable to get the care they need. And spending on the preventive care necessary to address this has been squeezed, with the proportion of the NHS budget spent on prevention, primary care and community health services having declined before the pandemic.

Without comprehensive action to prevent ill health, the pressures on services and public spending will increase. And if working-age ill health continues to grow at current rates, this will act as a brake on growth and our future prosperity. Health Foundation research has projected that on current trends, the number of people in England living with major illness could rise by over a third by 2040 meaning stark inequalities in health would persist. People living in the most deprived tenth of areas can expect to be diagnosed with major illness a decade earlier than those in the least deprived tenth of areas by 2040, and 80% of the projected increase in working-age people living with major illness would be concentrated in the most deprived half of areas.

This is not inevitable, but a different future will require concerted action by the next government. Here, we set out how the new government can take a prevention-led approach: one that enables people to stay healthy for longer, prioritises the reduction of health inequalities, and that detects and treats health problems early to reduce harm. 

Over the past century, life expectancy in the UK has increased by more than 20 years. But since 2010 improvements have slowed – a slowdown that has been more marked than in many other comparable countries, and people are living with illness for more of their lives. But this is not inevitable, particularly as the UK has a higher prevalence of many largely preventable non-communicable conditions relative to comparable European countries including obesity, some types of cancer, type 2 diabetes, COPD and asthma. 

Inequalities in health are stark in all parts of the UK. On average, people in the most deprived areas are expected to live around a decade less than those in the least deprived areas. They are also more likely to spend more of their lives in poor health, with a gap in healthy life expectancy of almost 20 years between women in the richest and poorest areas in England and Wales; and more than 20 years in Scotland. 

By 2040, people in the UK are projected to be living with major illness for longer periods. This trend, together with an increase in the population aged 70 years and older, could increase the number of people living with major illness in England by more than a third to almost 1 in 5 of the population (9.3 million people). Of these, 3.7 million would be working age (20–69 years), with significant implications for the UK workforce. 

Our health is shaped by a broad and complex range of influences in our environments – the building blocks of good health. These include adequate income, good-quality and affordable housing and access to safe green spaces and clean air. When some of these building blocks are missing our health suffers. For too many people in the UK, these building blocks are neither strong nor secure – cutting lives short and driving the stark health inequalities that persist in the UK.

Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the high burden of preventable ill health and premature mortality. People’s ability to adopt healthy behaviours is strongly shaped by their life circumstances, commercial drivers of unhealthy commodities and access to the building blocks of good health, meaning that harm from these risk factors is generally far greater among communities in more deprived areas.

Improving health and reducing inequalities requires a comprehensive approach that goes far beyond the reach of the Department of Health and Social Care. Most – if not all – government departments have a role to play in building a healthy nation. 

We identify five barriers to a prevention-led policy agenda: short-termism; siloed government working; the current financial climate; depleted local government resourcing and the failure of government to galvanise all parts of society. 

1. Short-termism: Improving health and reducing inequalities requires a long-term strategy. Current political cycles, and an absence of cross-party consensus, leads to prioritisation of acute pressures on public services rather than investing in the future health of the population. This is exacerbated by the time lag between the investments made to maintain good health and the benefits accruing – as was seen in short-sighted decisions to cut funding to the Sure Start programme.
2. Siloed government: To be effective and equitable, a prevention-led approach must harness all parts of government that influence health – from transport policy to welfare systems, housing to food regulation. Government departments currently operate mainly in siloes with little incentive to act toward a shared goal of preventing ill health and creating healthier lives. A focus on sickness and health services dominates, and health remains narrowly the focus of the Department of Health and Social Care rather than the whole of government. 
3. Financial climate: Prioritising prevention is challenging in the current financial climate, with resources constrained in all parts of the system and acute need rising. Public services including schools, police and neighbourhood services are under considerable strain with performance declining after years of tight funding, staffing problems and underinvestment in capital, eroding key building blocks of good health. Statutory funding for some public services has increasingly focused on acute services since 2010, at the expense of preventative ones. For example, local authority spending on children’s centres and youth services has been cut by more than half since 2010, while that on safeguarding and care for children in care has risen dramatically. 
4. Depleted local government resourcing: With overall spending power reduced by 10% between 2009/10 and 2021/22, driven in large part by a 31% reduction in funding from central government, councils are struggling to provide and maintain services that create the building blocks of good health, including decent housing and access to transport and safe green spaces. These cuts have fallen more heavily on local authorities in more deprived areas, which have seen the greatest fall in spending power over this period due to the way government allocated funding cuts. More than 8 in 10 local authorities report facing funding gaps in 2024/25, leaving them with difficult decisions to rectify shortfalls – many of which will negatively impact residents’ health, especially the most vulnerable in society. The ringfenced public health grant to local authorities has been cut by 28% on a real-terms per person basis since 2015/16. This has reduced the capacity of local public health teams to take action to prevent ill health, particularly in more deprived areas. 
5. Failure to galvanise all parts of society: Improving health requires a whole-society response, but an absence of government leadership in this area has limited progress across society. Local and combined authorities, public services, businesses, employers and communities all have an important role in preventing ill health but are not enabled or incentivised by government to use the levers they hold to do this.    

Put health at the heart of the new government

The new government must set out an ambitious goal to improve the nation’s health and reduce inequalities, aligning action across government departments and providing leadership to all of society to deliver this goal. This needs to be a key driver of government policy over the next decade and beyond.

The Health Foundation has convened an expert panel to develop detailed recommendations for how to create a long-term shift towards a prevention-led approach across government. The panel – which will publish its final report later in 2024 – will make recommendations on areas including:

• how targets for health improvement and health inequalities can be used as part of a wider strategy and whether these targets should be statutory
• the structures and roles needed in the centre of government to drive an ambitious approach to strengthening the building blocks of health 
• support and powers that will be needed by local, regional and national delivery agencies to play their role fully
• how to ensure accountably for delivery, including considering the value of an independent body to review progress and hold government to account   
• the funding mechanisms that will best incentivise long-term policymaking to improve health and tackle inequalities. 

Not all the actions we have highlighted require additional funding. Many are about how funding can be protected for long-term preventive action, rather than diverted to acute need; how existing money across government can be focused on preventing ill health, and how funding can be fairly allocated to local areas to better meet need. 

To address the imbalance between spending on acute and preventive action, government needs to create a system of public spending decision making that incentivises and supports long-term preventive investment. A new category within government expenditure – Preventative Departmental Expenditure Limits (PDEL) – to classify and ringfence investment for prevention, would signal the importance of investment in prevention, enabling departments to be held to account for preventive spending, and providing a baseline to track whether the balance of spending is shifting toward prevention. Separating prevention spend in this way would help to ensure that budget holders are not forced to choose between helping people in need now and preventing such needs arising in future. To inform the practices required to track and measure prevention spend, we are working with CIPFA to understand the extent to which local authorities’ spending on preventative action can be quantified.

Address gaps in the building blocks of good health

A cross-government strategy is needed to drive action on the building blocks of health, tackling critical gaps in these that cut lives short, including in income, employment and housing, particularly in more deprived parts of the UK. This should include:

• reforming the welfare system in ways that will keep families out of poverty 
• supporting people with ill health or disabilities who are out of the labour market but want to work to do so, and working with employers to keep people in-work and in good health in the first place, including through reform to Statutory Sick Pay and improving job quality.
• increasing access to secure, decent housing including by bringing back a strengthened Renters Reform Bill in the next parliament that abolishes no-fault evictions and improves the Decent Homes Standard, applying it to the private rented sector.   

Government should also work with business to ensure that good business practice is a solid building block of health. This includes supporting employee health, promoting healthier workplaces, and helping those with health challenges to remain in work. Government can support employers, including by raising awareness and uptake of the Access to Work scheme; extending subsidies for Occupational Health provision to smaller businesses; advocating for inclusive recruitment practices; reforming the Apprenticeship Levy; developing a support service with disability experts; and encouraging employers to introduce improvements that benefit health, such as around working conditions and remuneration, supported by financial incentives. 

Take population-level action on the leading risk factors for ill health

Tobacco, unhealthy food and alcohol remain the leading causes of preventable ill health in the UK and are key drivers of inequalities. Population-level policy approaches that support everyone to be healthy are likely to be the most effective and equitable, and the public is supportive of greater national action. Yet despite this, recent governments have favoured policies aimed at supporting individual behaviour change and largely neglected population-level approaches. 

A new government needs to prioritise population-level action, including bolder use of tax and regulation. This should include:  

• minimum unit alcohol pricing in England (which has been implemented in Scotland and Wales)
• delivering the smoke-free generation policy alongside banning tobacco sales in supermarkets and online
• introducing the planned ban on unhealthy food advertising on TV before 21.00 and online, and expanding the Soft Drinks Industry Levy to include unhealthy food, as recommended in the National Food Strategy.    

The public also supports local government having more responsibility for tackling harms from tobacco, alcohol and unhealthy food and there are a range of policies that could help, including:

• adding health as a licensing objective for alcohol licensing decisions
• allowing local authorities to limit advertising of unhealthy food and alcohol on non-council owned advertising spaces
• introducing tobacco licensing for retailers
• more closely integrating planning and public health at both local and national levels.

These policies and their implementation are described in more detail in our recent briefing.

Enable and support (including through sufficient funding) approaches led by local and combined authorities

Local and regional authorities hold responsibility for many of the key building blocks of health and play an important role in supporting local communities and the voluntary sector. They will need sufficient and sustainable funding for local areas, with multi-year settlements and appropriate workforce planning and flexibility on how money can be spent most effectively to meet local needs. 

Adequate funding is needed for public health infrastructure at national and regional levels, and to reverse cuts to local public health budgets to boost investment in local public health interventions. These provide excellent value for money, with each additional year of good health achieved in the population costing £3,800 – three times lower than the cost of each additional year of good health resulting from treatment in the NHS (£13,500). 

A fair system is needed for the allocation of central government funding for services that support health. On average, more deprived areas receive more funding than less deprived areas, but they tend to receive a lower share of overall government funding relative to their estimated local needs than less deprived areas. This is particularly the case for local government funding, with the most deprived fifth of areas receiving, on average, 9% less than their estimated share of needs (£92 per person). The least deprived receive on average 15% more local government funding than their share of needs (£108 per person). Problems are exacerbated by longstanding workforce shortages in areas such as trading standards, licensing and planning. For example, trading standards officer numbers fell by up to 50% between 2008/09 and 2018/19, over half of local authorities report environmental health vacancies of more than 6 months, and 82% of councils had difficulties hiring planners in the past year.

Reorient health services to prevention

Preventing ill health is a core purpose of health services, and the NHS delivers services for the prevention as well as the early detection and treatment of disease. These include screening programmes, vaccinations and prevention of non-communicable diseases, including cardiovascular disease and diabetes.

Policymakers already expect NHS services to contribute to prevention in a variety of ways, but the promise of these plans are far from being fully realised. The 2019 NHS Long Term Plan promised more support for people at risk of poor health outcomes due to smoking, alcohol and obesity, but progress was disrupted by the pandemic, which has also led to higher than expected demand for some of these services. More widely, social prescribing – which aims to create health and prevent illness by connecting people with local community assets like charities, social groups and advisory services – has been rolled out across England, but more disadvantaged patients may face greater barriers to accessing support.

The creation of integrated care systems (ICSs) also provides opportunities to improve health outcomes and address inequalities in local populations, by developing population health management approaches and working with local authorities. However, these priorities risk being crowded out by a short-term focus on more immediate pressures on the NHS and severe financial challenges facing local authorities.

Primary care and community health services are central to delivering these preventative services, but the NHS Long Term Plan commitment to invest a growing proportion of the NHS budget in these services has not been met. General practice is in crisis, with public satisfaction at record lows and the most acute pressures in more deprived areas, which receive less funding and workforce relative to their population health needs. There are also recent reports of funding for preventative services such as vaccinations and screeningdelivered by the NHS being cut by 3.5% (around £50m) to meet funding shortfalls elsewhere. Much has also been made of the potential for technology, genomics and artificial intelligence to deliver personalised prevention services and advice at scale. While there is promise in some areas, this potential remains a long way from being realised. 

Beyond the provision of health care services, NHS organisations can contribute to the health of the population through their roles as ‘anchor’ organisations rooted in local communities. This includes as large employers providing good work and healthy workplaces, through using their purchasing power for local and social benefit, reducing their environmental impact, and supporting local communities.  

The NHS's role in prevention needs to be given greater priority under a new government. This will require:

• growing the share of funding going to primary, community and preventative services, in line with the public’s priorities. Adequate funding must be protected in the face of acute pressures arising from near-record waiting lists and must be allocated fairly by need
• a new deal for primary care, including a focus on tackling the ‘inverse care law’ that leaves practices in poorer areas underfunded and under-doctored compared with richer areas 
• ICS spending and action to improve population health and tackle inequalities in health – including due to ethnic background or socioeconomic deprivation – should form a proportionate focus for oversight of ICSs by national bodies. 

As we head into the general election, all parties need to address the faltering and unequal health of the nation. A prevention-led approach to improving health and reducing inequalities is urgently needed. Such promises have been made in the past, but have repeatedly failed to materialise. Acute pressures are rising across many public services as a result, pulling constrained resources into a vicious cycle of treating problems at the expense of preventing them. The social and economic impact of this is stark, especially for people in the most deprived areas. 

Good health is key for a thriving and prosperous UK, so this time it needs to be different. There is an urgent need for a new government to act on the UK’s worsening and increasingly unequal health. This will require a comprehensive prevention-led approach to action across the broad range of factors that influence health and drive inequalities.

Acknowledgements

We would like to thank everyone who has contributed to this output, including Alex Kennedy, Tim Gardner and Leo Ewbank. Errors or omissions remain the responsibility of the authors.