In the recent review of the current woes of the NHS by Lord Darzi, Independent investigation of the NHS in England, public health was mentioned a lot. This is not surprising when you read the author’s appreciation of the importance of prevention:
“There is extraordinary power in getting public health right. We can reduce premature mortality, reduce social disparities, and reduce the absolute time in ill health. This in turn reduces the burden on the NHS and social care while enabling us to be more productive in our working lives so strengthening the economy. This is the desired outcome for individuals, families, the public purse. But it takes the political will and willingness to invest to achieve it, with the skills to successfully engage the public.” (Chapter 4, point 11)
The new Labour Government has already prioritised prevention. The Secretary of State, Wes Streeting, has said one of his three priorities for the NHS is a shift from “sickness to prevention”. But no one underestimates the challenge. If it was so easy, why have all recent governments failed to make much progress in this area? The next 10-year plan for health services is due to be published in spring 2025. After its publication, it will take time to bring about change, but there are increasing concerns that something needs to happen now.
A public policy lever immediately available to Streeting is to revitalise NICE’s public health role and to implement fully the extant NICE public health guidelines. A reset for NICE public health is necessary because although in existence in some cases for more than a decade, the NICE public health guidelines have never been comprehensively and fully implemented with the wholehearted backing of government.
Governments have been lukewarm at best, and in some cases actively hostile towards the public health recommendations made by NICE (the public health alcohol guideline for example, NICE at 25 – A quarter-centre of evidence, values and innovation in health ( see chapter 7 ).
Among other things, the prioritisation of pharmaceutical solutions for health problems, the fear of being labelled a nanny state, and the reduction of resources for public health in local authorities have stopped bringing fully to fruition, NICE’s evidence-based and cost-effective public health recommendations. However, this could be changed very quickly and easily.
The reset would require no new primary legislation or significant new money, and could begin immediately. The evidence of cost-effective interventions to reduce risk and prevent disease has already been collected, assessed, quality assured, and the key strategies and tactics needed for implementation, are all detailed in each of the guidelines.
The starting point could be the NICE public health guidance on smoking, obesity and unhealthy diets, alcohol harms, physical inactivity, poor air quality, mental health, and maternal and child health. These are all areas in which ARC South London researchers are active, testing interventions and providing much-needed evidence on how to improve public health in ways that are sustainable and acceptable to public, patients, service users and health professionals alike. You can read more about the impact of this research here.
As a whole, the NICE guidelines cover important population groups and describe in detail who needs to do what and which organisations should be involved. The recommendations are in most cases (subject to a small amount of updating for some) ready for full implementation.
In other words, the groundwork has been done. What is needed now is the political will to facilitate their full implementation on the ground, an area where ARC applied research can play a role. This will require a clear and unequivocal steer from Ministers that these issues and the guidelines to address them, are to be prioritised by public health teams, especially in local authorities. Directors of Public Health must be empowered to act on them.
In the long term, to achieve this, the confused public health organisational structures referred to in the Darzi report (and highlighted by us previously) will need to be addressed. However, a lot could be done immediately. A small working group could be established, chaired by an independent public health expert, consisting of officials from the Department of Health and Social Care (DHSC) and the Office for Health Improvement and Disparities, a small number of local directors of public health, and NICE staff with experience in public health.
This working group could rapidly assess those elements in the recommendations which should be immediately acted upon and where resources should be directed in local authorities. It could also identify those recommendations which may need tweaking because of system changes that have occurred since the guidelines were originally published or last updated. In some cases, it may be necessary to undertake a rapid evidence review, to ascertain if there have been any significant new developments in the evidence base. NICE has the tools and expertise to do this, as do various research teams in different universities.
It is vitally important that any public health subvention to local authorities to facilitate the implementation of the guidance is ringfenced, so that it is used for the purposes intended – disease prevention.
The Secretaries of State should make it clear that it is the duty of every local authority, as well as other actors identified in the guidelines and including NICE, to act upon them and by mid-2025 report back to Ministers about the degree of compliance and progress.
Where action is recommended which impinges on national policy (as in the recommendations about minimum unit pricing for alcohol, for example), these should be referred to the DHSC in the first instance. But there is much where the actions needed are local and do not require any new regulation. Ministers should make clear to local authorities that they have a duty to comply. In due course, the possibility of making NICE public health guidelines mandatory (which they never were) should be considered at policy level.
When the NICE public health guidelines were originally developed, there was a duty on NICE to pay particular attention to the degree to which the guidelines would help to reduce health inequalities. In due course, the new working group should shift its attention to considering the evidence about the degree to which specific interventions in the guidelines are differentially effective in different segments of the population, another area in which ARC researchers are active – see, for example, the maternity research team’s work on improving outcomes for women and babies at higher risk of complications during pregnancy and birth).
These data should help form a new part of the evidence base for NICE, to be considered as each of the public health guidelines are updated. Ministers should make clear to NICE that the updating of each of these guidelines should be a priority for future preventive efforts.
There is much to be done to improve the health of the nation, to prevent disease and to deal with health inequalities. The full and comprehensive implementation of the extant NICE public heath guidelines would be one small, but very important step in building a better, healthier more equitable future for the population.
Some of the relevant NICE guidelines are: