The prevention green paper – Advancing our health: prevention in the 2020s – begins by setting out the background and rationale for taking a prevention approach to health, citing the wealth of existing evidence behind the environmental factors that are known to shape our health. These factors are summarised into three overarching themes, which are the focus of the green paper:
- The services we receive – the 2020s will be the decade of proactive, predictive, and personalised prevention
- The choices we make – empowering people to make the decisions that are right for them
- The conditions in which we live – viewing health as our most precious asset, not just a problem to fix
The paper makes a number of specific proposals and announcements under each of these themes – services, choices and conditions. These have been summarised below.
Chapter 1: Opportunities (the services we receive)
This chapter focuses on intelligent public health and the roles that technology and data have to play in the delivery of more proactive, predictive and personalised services. This builds on existing social marketing campaigns from Public Health England (PHE) that already personalise lifestyle advice to different audiences.
This part of the paper announces the following proposals:
Starting this year, PHE will work with NHSX and other partners across the public health system, academia, industry and the voluntary sector to build a portfolio of new innovative projects to help evaluate and model predictive prevention at scale. This work on intelligent prevention will include sharing learning from opportunities and programmes that are developed locally to prevent ill-health using the latest predictive technology.
Focused support and advice: screening and intelligent health checks
In the 2020s, the DHSC want support and advice to be much more focused and tailored. This transformation will start with two of the largest existing prevention programmes: screening and NHS Health Checks.
Screening: There are challenges in the existing screening arrangements that need reform, and the paper sets out a vision for future screening. This includes better use of technology, data and AI, allowing the incorporation of genetic testing into screening and diagnostics – for example, using next generation sequencing to confirm cases of cystic fibrosis in children (currently being tested in the new born bloodspot programme). Recommendations from a September 2019 review of cancer screening will help shape the DHSC’s plans for change. This will be accompanied by an NHSX strategic review of the IT required to enable the screening strategy.
Intelligent health checks: The NHS Health Checks national programme offers people aged 40 to 74 a free check-up of their overall health, every 5 years. The government will commission an evidence-based review of the NHS Health Checks programme to maximise the benefits it delivers in the next decade, including ways of increasing uptake and options for making it more focused.
Early results from the 100,000 Genomes Project show one in four rare disease patients previously without a diagnosis now receive one. The paper cites the Next Generation Children Project at Addenbrooke’s Hospital which has showed that the diagnosis and treatment of some of the most critically ill babies can be improved by sequencing their whole genome.
In autumn 2019, the DHSC will publish a National Genomics Healthcare Strategy. This will set out how the genomics community can work together to make the UK the global leader in genomic healthcare and support the ambition to embed genomics in routine healthcare.
Opportunities to understand how best to realise the benefits of genomic approaches will be explored as part of plans to sequence 5 million genomes by 2023 to 2024, through collaboration between the NHS, UK scientists and industry. And this year, seriously ill children who are likely to have a rare genetic disorder, children with cancer, and adults suffering from certain rare conditions or specific cancers will be offered whole genome sequencing as part of their routine care.
Tackling current and future threats: AMR and immunisations
Antimicrobial resistance: The UK government has already set out its longer-term vision of a world in which AMR is contained and controlled by 2040, which includes the commitment to develop a real-time patient-level data source of patients’ infection, treatment and resistance history that will be used to inform their treatment and the development of interventions. It has also announced the intention to incentivise the development of new medicines by testing new models to pay companies for antibiotics based on their value to the NHS, not volumes used. To maintain the UK’s position as a world leader on AMR, Professor Dame Sally Davies has been appointed as the UK Special Envoy on AMR to support the delivery of both the 5-year AMR action plan and of ‘One Health’, which co-ordinates action on AMR in all sectors across the world.
Immunisations: By spring 2020, the DHSC will launch a Vaccination Strategy, to maintain and develop our immunisation programme, emphasise the preventative value of vaccines and address vaccine misinformation as effectively as possible. This will include: action to increase uptake of all recommended vaccinations across all communities and areas; enhanced use of local immunisation co-ordinators and primary care networks to ensure the right mechanisms are in place to increase uptake; and evolution of our immunisation programme to incorporate new, more effective and cost-effective vaccines and create new uses for existing vaccines across the life course. This will support the government’s medium-term aim of reaching over 95% uptake for childhood vaccinations and support implantation of the UK measles and rubella elimination strategy, which aims to increase uptake of the second dose of the MMR vaccine to at least 95%.
Chapter 2: Challenges (the choices we make)
This chapter focuses on the challenges that the modern world presents when it comes to living a healthier life, announcing a focus on empowering people to make the decisions that are right for them to live happy, healthy lives.
This part of the paper announces the following proposals:
The government are setting an ambition to go ‘smoke-free’ in England by 2030. This includes an ultimatum for industry to make smoked tobacco obsolete by 2030, with smokers quitting or moving to reduced risk products like e-cigarettes. Further proposals for moving towards a smoke-free 2030 will be set out at a later date. Smoking rates remain high in certain groups, and tackling these inequalities is the core challenge in the years ahead. To achieve the vision of a smoke-free future, action is needed to both discourage people from starting in the first place, and to support smokers to quit.
Help to quit is mostly delivered by the NHS or local authorities, paid for through general taxation. Given the pressure on local budgets, the government is considering other ways of ensuring people can get the help they need, aiming to use any funds to focus stop-smoking support on those groups most in need, such as pregnant women, social renters, people living in mental health institutions, and those in deprived communities. Inserts in tobacco products giving quitting advice will also be considered as part of a later review of tobacco legislation.
A call for independent evidence will also be run to assess further how effective heated tobacco products are, or are not, in helping people quit smoking and reducing health harms from smoking. The evidence on e-cigarettes will remain under review.
Maintaining a healthy weight
Proposals build on the existing government commitment to reduce childhood obesity by 50% by 2030. Work towards this has so far focused on making the food and drink available to families healthier, with a number of consultations in chapter 1 and 2 of the childhood obesity plan.
DHSC have used the green paper to outline their response to some of these consultations, including an announcement that the government will end the sale of energy drinks to children under the age of 16. The government response to other consultations on calorie labelling in the out-of-home sector, promotions of foods and drink high in fat, sugar and salt (HFSS) and restrictions for advertising of HFSS products on TV and online will be published later, outside of the green paper.
Chapter 2 of the childhood obesity plan also committed to deliver a Childhood Obesity Trailblazer Programme. The green paper announced that five authorities have now been selected (Blackburn with Darwen, Birmingham, Bradford, Lewisham and Nottinghamshire). These areas will test the potential for existing local levers to promote healthier diets and inform future action across the country.
In recognition of the need to go further, Chapter 3 of the childhood obesity plan has been published as part of the green paper, setting out plans for infant feeding, clear labelling, food reformulation improving the nutritional content of foods, and support for individuals to achieve and maintain a healthier weight.
Infant feeding: The paper announces the intention to commission an infant feeding survey to provide information on breastfeeding and the use of foods and drinks other than breastmilk in infancy. It also recognises the negative effects on babies and young children of added sugar in foods and announces plans to challenge businesses to improve the nutritional content of commercially available baby food and drinks. Progress will be monitored, and other levers considered if insufficient progress is made. This will be led by PHE with guidelines for industry in early 2020.
Recognising that nutritional information for early years food needs to be improved, DHSC commit to exploring how to improve the marketing and labelling of infant food. Inclusion of baby food within the Change4Life Food Scanner app will also be considered by PHE to support families with healthier choices.
Clear labelling: DHSC will consult by the end of 2019 on how to build on success of existing traffic light front-of-pack labelling schemes once we have left the EU to fully consider the evidence underpinning the many forms of front-of-pack labelling.
Improving the nutritional content of food and drink: Reformulation to make products healthier has been hugely successful thanks to the Soft Drinks Industry Levy (SDIL). It doesn’t currently include sugary milk drinks, and, pending further evidence on industry progress in reducing sugar, DHSC may extend the levy to include sugar milk drinks.
As well as sugar intake, more needs to be done to reduce the amount of salt we consume, and the green paper announces an ambition to reduce the population’s salt intakes to 7g per day. Revised salt reduction targets will be published in 2020 for industry to achieve by mid-2023, reporting on progress in 2024. Further options will be explored if this voluntary approach doesn’t work. A urinary sodium survey will be commissioned in 2023 to measure progress towards the ambition and understand how much salt individuals are consuming.
Government will also continue to examine growing evidence for use food technology to change the nutritional content of food to improve health, for example enriching milk with omega 3.
Support for individuals to achieve and maintain a healthy weight: Evidence shows that patients are receptive to brief interventions for obesity and on average lose weight in the year following the intervention. The green paper outlines plans to work with NHS England to develop approaches to improve the quality of brief advice given on health issues, including weight management, in general practice, as well as explore the use of quality improvement approaches through the NHS primary care network. It also outlines planned work with NHS England, PHE and NHSX to review the current digital weight management offer on the NHS Apps Library. Further development of ‘Our Family Health’ will take place to support more families in the most deprived areas with children aged 4 to 7 years with lifestyle behaviour change.
The green paper also recognises the importance of the National Child Measurement Programme in supporting parents and families. Currently, there is no standard route to share NCMP information with healthcare professionals, so PHE will work with NHS England and NHS Digital to explore how NCMP data can be shared directly with digital child health records so that it’s consistently accessible for both parents, carers and health professionals. Alongside this, ‘Our Family Health’ will be embedded within the NCMP, and better communication with parents and health professionals on obesity will be looked at, using behavioural science.
In recognition of the importance of being active for both our physical and mental health, the UK Chief Medical Officers have been asked to review the current physical activity guidelines, which will be published in September 2019.
Alongside this, a number of other proposals have been announced:
- The autumn launch of a new ‘digital design challenge’ for strength and balance exercises, focusing on older people, those with health conditions and people on low income in deprived areas.
- A second phase of the national Moving Healthcare Professionals partnership programme led by PHE and Sport England, supporting healthcare professionals to promote physical activity to their patients.
- Encouraging local authority planning decisions to promote active lifestyles.
- Supporting more people to switch from driving to public transport, cycling and walking.
- Encouraging nurseries to build opportunities into their daily routine for physical activity such as energetic play, walking and skipping.
- Strengthening the evidence base about the social and economic value of physical activity
Taking care of our mental health
The NHS Long Term Plan (January 2019) and the green paper on Transforming Children and Young People’s Mental Health Provision (December 2017) have already announced significant additional spending on mental health to support access to psychological therapies for common mental health problems, access to perinatal mental health care and increased access to support for children and young people via mental health support teams in schools.
This green paper announces a focus on the foundations for good mental health, and the need for urgent action to tackle both the risk factors for poor mental health (such as adverse childhood events, violence, poverty, problem debt, housing insecurity, social isolation, bullying and discrimination) and the protection factors for good mental health (such as strong attachments in childhood, living in a safe and secure home, access to good quality green spaces, security of income, and a strong set of social connections).
Additional action on mental health from DHSC will include:
- Providing advice for children and young people on dealing with difficult emotions and situations that can lead to problems such as stress, bullying and self-harm, through the Rise Above programme in schools and online
- Encouraging all local authority areas to have mental health promotion plans and sign up to the Prevention Concordat for Better Mental Health for All
- Investing up to £600,000 to support local authorities to strengthen and evaluate their suicide prevention plans
- Providing £1 million for the Office for Students to run a competition to drive innovation in the way university students are supported with their mental health
- Launching the Every Mind Matters campaign nationally in October 2019 with the goal of making 1 million adults better informed and equipped to look after their mental health and support others. From 2020, the campaign will include advice to parents on supporting their children’s mental health and wellbeing
- Exploring the potential to launch a programme in 2020 to protect and improve people’s mental health and wellbeing by connecting them to nature-based activities through social prescribing, building on existing work by DEFRA in eight localities
This will be complemented by other action across government, including a statutory Breathing Space scheme to provide respite to those in problem debt, and statutory guidance and training for schools and staff to support with identifying and supporting children with mental health issues and in teaching about mental health and wellbeing, from September 2020.
Wider factors: alcohol, drug use, sleep
Alcohol: Focus will remain on the harm caused by problem drinking, following estimates that 200,000 children in England are growing up living with a parent who is dependent on alcohol. The paper announces an independent evaluation to identify what we can learn from the existing April 2018 programme that is testing innovative ways of finding and supporting children of parents dependent on alcohol in 9 local areas. This is supported by Department for Work and Pensions work on reducing parental conflict. This evaluation will be published in 2021 to 2022. DHSC also want to make alcohol-free and low-alcohol products more available to ‘nudge’ lower strength alternatives. They will work with industry to increase in the availability of alcohol-free and low-alcohol products by 2025 and review the evidence to consider increasing the alcohol-free descriptor threshold from 0.05% abv up to 0.5% abv in line with some other countries in Europe.
Drug use: Drug misuse can affect the health of children, family members and carers. Once PHE’s review of Prescribed Medicines has been published, DHSC will work with the Home Office, PHE and other partners to undertake further policy development around issues related to prescribed and illicit opioid use. DHSC will also develop a shared understanding of the current challenges facing the substance misuse treatment and recovery workforce. They will also implement an action plan to address the adequacy of responses to cannabis and related mental health problems.
Sleep: Sleep has received little policy attention in the past. The government will start with a review of the evidence on sleep and health, with a viewing to setting national guidance on the daily recommended hours of sleep for individuals in different age brackets, and to raise awareness of the key ‘sleep hygiene’ factors that can support healthy sleeping. Work will also be done with the NHS to improve rest guidance for those in care settings, for example a national roll-out of ‘protected sleep time’ in hospitals, where staff leave patients sleeping unless clinically necessary.
Prevention in the NHS
In the NHS Long Term plan, a whole chapter was devoted to prevention, looking in particular at obesity, smoking alcohol and inequalities. The next step is to move from a national treatment service (focused on illness) to a national ‘wellness’ service (focused on creating good health) by allowing people to connect their own data, giving people personalised advice, and giving people the tools and motivation to make informed choices.
A new Social Prescribing Academy is being set up to help to champion referral to activities or services in the community and support national plans to make social prescribing available throughout England. By 2020 to 2021, over 1,000 trained link workers will be recruited, so that over 900,000 people can benefit from social prescribing by 2023 to 2024.
From October 2019, the Community Pharmacy Contractual Framework will redefine the role that community pharmacies play in delivering healthcare over the next 5 years. This will see pharmacy staff trained to provide a wider range of health advice and support, including helping to identify and refer patients with unidentified health conditions. In addition, all pharmacies will become Healthy Living Pharmacies, which will require them to have trained health champions on site to deliver a wide range of lifestyle and health interventions. More services will be commissioned from community pharmacies to support them to become further integrated into local NHS provider networks.
Chapter 3: Strong foundations (the conditions in which we live)
This chapter focuses on good health as one of the country’s greatest assets, and on creating a solid foundation for everybody on which to build their health. In particular, it focuses on the early years and the ways in which children are affected in early life.
This part of the paper announces the following proposals:
The early years, including oral health
To support parents, the healthy child programme will be modernised to be more personalised in order to make use of the latest evidence on effective practice and to enable focused services where additional needs are identified. The modernised programme will: make better linkages to other health records, including the digital red book; add new components, including a digital support tool; and include new pathways for speech and language development and pre-conception and pregnancy advice. The upper age range of the healthy child programme will be extended (from 19 to 24-year-olds) for those young people needing extra support, and the programme will also look to improve support for perinatal mental health and the healthy social and emotional development of babies and young children.
The government will continue to prioritise improving early speech and language outcomes as a preventative measure with strategic leadership across education, health and social care to narrow inequalities. A key part of this will be involving health professionals in the ‘Hungry Little Minds’ campaign, looking to improve the quality and quantity of parent-child interactions.
Oral health: Two areas have been identified to address unwarranted variation in children’s oral health across the country. The first is a toothbrushing scheme in pre-school settings and primary schools, and proposals to reach the most deprived 3 to 5-year-olds in all areas of the country with the new scheme will be consulted on next year. The second is looking at removing the funding barriers to fluoridating water. NHS England will actively seek partnerships with local authorities, with councils rewarded for their fluoridation efforts by receiving a share of the savings from fewer child tooth fillings and extractions. This work will also examine the role that water companies can play in supporting fluoridation efforts.
Creating healthy places: safer communities, connected communities, green spaces and clean air
Occupational health: Looking beyond the Health is Everyone’s Business consultation on measures to reduce ill health-related job loss, the government will explore how to align support for people with mental and physical health conditions across the NHS, employers and occupational health. There will also be a focus on supporting musculoskeletal problems, given the prevalence in the workforce. All call for evidence on this will be launched later in the year.
Safer communities: The green paper restates the cross-government commitment to reducing knife crime and tackling serious violence. Work is also already underway to tackle loneliness and make communities more connected through better physical spaces and improvements in public transport. In order to support better homes and neighbourhoods for people living with a disability or with some frailty, a ‘Home of 2030’ design competition will be launched later in 2019, to explore how innovative design can work with new technology to create more energy efficient, accessible and adaptable homes for all generations. This will build on lessons from the 2015 NHS England Healthy New Towns Programme and support existing work across the NHS estate on the Changing Places toilets scheme.
Green spaces and clean air: Building on the Clean Air Strategy published in January 2019, DHSC will work with DEFRA on two priority areas. The first is improving public awareness about pollution sources to empower individual action to reduce their impact on and exposure to local pollution. The second is to improve data on health impact to support monitoring and evaluation of long term trends in health impacts associated with air quality. This will support PHE’s current five-year programme ensuring that government has the best possible advice on the health burden linked to indoor and outdoor air pollution.
As the population of England becomes older, DHSC want to change the negative discourse around older people and reframe the narrative to an asset-based model, making the 2020s a decade of active ageing. PHE are leading a Consensus Statement on Healthy Ageing to set out key principles and ways of working together, as well as carrying out a review of how we can focus more attention on older people’s issues.
National action: prevention in wider polices and value for money
Given the variety of factors that affect our health, many of the policies relevant to prevention sit outside DHSC, in other departments. DHSC want all of government to be ‘pulling in the same direction’ on prevention in the 2020s. Proposals include the development and launch of a new Composite Health Index to measure changes in health over time and be used by the government to assess the health impacts of wider policies. This will provide a visible, top-level indicator of health that can be tracked alongside our nation’s GDP, shifting the view towards health as one of the primary assets of the nation. PHE’s capacity to project and model the impact of future trends in health will also be expanded to produce an annual Health Profile for England. The quality and coverage of health impact assessments of non-health policies will also be improved across government.
DHSC also want to encourage a higher value for investment in prevention across society. Prevention is common sense, with a recent review showing that for every £1 spent on public health interventions, there was an average £14 of benefit to wider society. Currently in the UK we are spending over £101 billion a year treating disease, and £8 billion preventing it. No proposals are yet put forward, but as part of the green paper’s consultation they are asking how we can make better use of existing assets to promote the prevention agenda.
Transformative change needs to be underpinned by high-quality research, and a number of commitments to research have been made:
- Make clear ambitious goals and principles for the research community based on the future needs of the nation – for example, understanding how to create and maintain built and natural environments that support better health
- Increase input from disciplines such as engineering or education to co-produce research alongside the public, policy makers and practitioners
- Focus research on the areas in the country where the public health challenges are greatest
- Inspire the next generation of researchers by combining academic research with practice as a career pathway
Local action, including integrated care systems and sexual and reproductive health
The role of ‘place’ is integral to any prevention strategy and local authorities continue to have responsibility for public health. Local Health and Wellbeing Boards bring together local government with the NHS to assess local needs and develop strategies to meet them. Health and Wellbeing Boards should continue to form a key part of the local infrastructure on prevention, working with Integrated Care Systems (ICSs), in order to make use of tools that already exist, including the flexibility to pool budgets.
The NHS Long Term Plan committed the government to reviewing the commissioning arrangements for sexual and reproductive health, health visiting and school nursing services, to ensure that they can deliver the best outcomes for the people who need them. The green paper confirms that local authorities will continue to be responsible for commissioning these services, but that the NHS and local authorities must work much more closely together on these services to deliver joined-up care for patients and to embed prevention into the full range of health and other public services. This increase in collaborative commissioning should build on best practice from across the country at national and local level – ‘Our Dorset’ ICS is cited as an example of an NHS ICS with prevention at the heart of its plans.
Sexual health services are core to prevention. The move towards ICSs creates the opportunity to co-commission an integrated sexual and reproductive health service. DHSC are also considering calls to develop a new Sexual and Reproductive Health Strategy for England and will respond to the Health Select Committee on this in due course.
The green paper marks a shift in thinking from life span to health span, and a focus on the number of healthy years lived free from illness or disability. It focuses on health as a shared responsibility, outlining a new approach to public health that emphasises a personalised prevention model and making healthier choices for ourselves and our families. At the same time, the paper encourages both local and national government and the NHS to put prevention at the centre of decision-making.
These commitments will help the Government to get started on their mission of ‘5 more years of healthy, independent life by 2035 while reducing the gap between richest and poorest’.
A consultation on the specifics of the proposals is running until October 2019. Following this, the DHSC aim to publish a government response to the green paper by spring 2020, setting out their proposals in more detail.