If 'prevention is better than cure', what more can be done to prevent rural ill-health?

A crisis-focused system has developed in health and care which is not only costly but also places enormous pressure on services. While efforts have focused on meeting immediate and acute demand, ill-health is not always inevitable and can often be prevented. In July 2019 the Government published a Prevention Green Paper setting out how it wants to prevent ill-health over the next decade. With Government prioritising prevention for the NHS and social care, what can we learn from our history of public health?
Jessica Sellick investigates.

If you watch the news, or read newspapers, coverage of health issues is prominent: with smoking, vaccines, obesity, cancer, strokes, stress and the funding of health services amongst the stories that you might come across. These health issues and their responses have their history. Public health has always been subject to change – from the way it has been defined to the activities it has covered.

What is public health?

In 1920 a bacteriologist named Charles-Edward Amory Winslow defined and shaped the discipline. His definition is still used today by academics and professionals alike:

“Public Health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health; organizing these benefits in such fashion as to enable every citizen to realize his birth right of health and longevity.”

Pathologist and surgeon Sir John Simon was instrumental in bringing about the Sanitary Act (1866), arguing that:

Sanitary neglect is mistaken parsimony. Fever and cholera are costly items to count against the cheapness of filthy residences and ditch-drawn drinking water…The physical strength of a nation is among the chief factors of national prosperity.

The origins of public health lie in the Elizabethan Poor Law of 1601 which laid out a framework for poor relief in England and Wales. The system was originally designed for small, rural populations in the 16th century and determined the way people of lesser means (including the sick, the mentally ill and the disabled) were treated in England.

In the nineteenth century public health was concerned with improving environmental conditions, for example by providing clean drinking water and safe sewage disposal. In the 1800s laboratory research – by Louis Pasteur, Robert Koch and their pupils – advanced our understanding of disease.  In 1854 surgeon and General Practitioner John Snow mapped cases of cholera in London’s Soho and identified a water pump in Broad Street as the source. 

Between the 1890s and 1950s public health concentrated on preventing and treating disease using vaccines and antibiotics.  Germ theory, for example, led researchers to focus on newly identified disease pathogens that resulted in new vaccines and antibacterial drugs (e.g. Alexander Fleming’s discovery of penicillin). 

From the 1960s public health focused on identifying the economic and social factors affecting people’s health. In 1988 the Chief Medical Officer, Donald Acheson, defined public health as ‘the science and art of preventing disease, prolonging life and promoting health through organised efforts of society.’ This definition is still used by the World Health Organization (WHO) today. While these definitions have centred on physical health, the Faculty of Public Health (FPH) has also defined public mental health as ‘the art and science of improving mental health and wellbeing and preventing mental illness through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.’

The Marmot Review in 2010, ‘Fair Society, Healthy Lives’, found people in England dying prematurely each year as a result of health inequalities would otherwise have enjoyed between 1.3 and 2.5 million extra years of life. Marmot described a ‘social gradient’ in health – where the lower a person’s social position the worse his or her health. While Marmot maintained that public health actions should be universal, he also described how actions should be of a scale and intensity that is proportionate to the level of disadvantage. Marmot proposed reducing health inequalities by focusing on six policy objectives: (1) give every child the best start in life; (2) enable everyone to maximise their capabilities and have control over their lives; (3) create fair employment and good work for all; (4) ensure healthy standards of living for all; (5) create and develop health and sustainable places and communities; and (6) strengthen the role and impact of ill health prevention.  Marmot is currently working with The Health Foundation and the Institute of Health Equity (IHE) to examine how health inequalities have changed and what progress has been made on tackling the social determinants of health.

Policy Navigator illustrates these successive waves through a timeline, tracing the discipline from 1600 through to 2015. This shows how these historical waves of public health all build upon one another – from tackling threats to health and longevity that were the result of insanitary conditions (e.g. sewage and waste disposal, over-crowded housing, food storage) to preventing disease and improving individual health once these ills were tackled.

The NHS Long Term Plan aims to move away from a system that simply treats, to one that also helps to keep people well for longer. A blog published by PHE provides an overview of the key public health priorities contained in the Plan. The Plan’s focus on predicting and preventing ill-health [to save 500,000 lives over the next 10 years] references smoking cessation; obesity and type 2 diabetes prevention; diet and alcohol-dependence; antibiotic reduction; cancer screening and diagnosis; reducing air pollutant emissions; mental health support for children, young people and pregnant women; and supporting people with serious gambling problems.

In July 2019 the Government published a consultation on tackling the causes of preventable ill-health in England. ‘Advancing our health: prevention in the 2020s’ outlines an approach for the health and care system to put prevention at the centre of decision making. The prevention vision sets out the 4 factors that shape our health: (1) the services we receive, (2) the choices we make, (3) the conditions in which we live and (4) the genes we inherit. Under the guise of targeted support, tailored lifestyle advice, personalised care and greater protection against future threats; the consultation looks at how improvements in life expectancy can be made and how inequalities or ‘people experiencing multiple disadvantage’ might be addressed. The consultation document moves away from seeing people as patients in receipt of care but rather as co-creators of their own health.

Communicable and non-communicable diseases do not respect national/administrative boundaries; the threats, impact and response are truly global. Coordinated by the World Health Organization (WHO), in 2018-2019 eleven health and development organisations have worked together to produce a Global Action Plan (GAP) for Healthy Lives and Wellbeing. The GAP aims to accelerate progress to reach Sustainable Development Goals by 2030, in what has been dubbed the “decade of delivery,” to make up for the shortfall on progress since the SDGs were launched in 2015. Importantly, the UK has leading public health expertise, data and insights in fields such as data, technology, surveillance and laboratory services which it harnesses to work with high, middle and lower income countries on global health issues.

This historical context, and more recent interest in public health, raises questions around whether public health is about preventing or treating, medication or lifestyle, and/or understanding the role played by social machinery and economic conditions in determining a person’s health (e.g. education, housing, communities). Is public health about preventing deaths (mortality ratios), achieving coverage (universal access to health care services or targeted according to need/disadvantage), research and development (vaccines and medicines) and early warning and management (of global health risks) – or all of the above and more? The definition of public health and what it should focus on has long been the subject of debate and discussion.

How is public health organised?

Between 1856 and 1974 the Medical Officer of Health (MoH) were doctors with responsibility for public health at a local level. Initially they were employed by local government to advise on public health matters and they focused their work on the control of infectious diseases and collating data on births and deaths; before moving to a wider remit encompassing maternal and paediatric health, sexual health and food inspections.

In 1974 NHS reorganisation led public health services to be taken out of local government and moved into the NHS. General Practitioners (GPs) took on more public health related duties (e.g. vaccinations) and Community Physician (CP) posts were created to offer the NHS advice on public health at the local level.

In 2012 the Health and Social Care Act saw public health returned to Local Authorities and the post of Director of Public Health introduced.

At a national level, Public Health England (PHE) is the agency charged with overseeing public health in England. Set up in April 2013, PHE ‘exists to protect and improve the public’s health and wellbeing and reduce health inequalities…through world-class science, advocacy, partnerships, knowledge and intelligence, and the delivery of specialist public health services.’ In its strategic plan (see page 7) PHE has renewed its commitment to work with others to tackle the wider determinants of health – citing the proportional contribution to premature death caused by: behavioural patterns (40%), genetic predisposition (30%), social circumstances (15%), healthcare (10%) and environmental exposure (5%).

NHS England works with PHE and the Department of Health and Social Care (DHSC) to provide and commission a range of public health services – this includes immunisation programmes and national cancer and non-cancer screening programmes.  NHS England also has consensus statements with fire and rescue services, policing, social care services and ambulance services to encourage local areas to develop joint strategies for prevention and health improvement.

Voluntary and community organisations play a vital role in public health – from their campaigning work through to the services they provide. Private organisations (e.g. pharmaceutical companies) also play a role in public health – while this has not traditionally focused on delivery services the Health and Social Care Act (2012) opens up healthcare provision to ‘any qualified provider.’

Over time, the range of organisations with responsibility for, or an interest in, public health has increased. The organisation of public health has been linked to the medical care of the individual and the whole community; and to the work of GPs, dedicated roles (CPs and Directors) and Local Authorities.  This opens up questions around whether it matters where public health resides; and if health bodies should be increasingly concerned with ‘population health’ – that is, the wider determinants of health such as planning, housing, education: service areas that are conventionally separate from health services. The increasing number of organisations also highlights an overlap between a medical (illness) model and a social (community wellbeing) model. How can we create a collective sense of responsibility for public health across many different organisations? How can we work with communities to co-design services in ways that recognise local neighbourhood/place challenges and wider issues?

What services do public health bodies deliver?

According to NHS Health Careers public health delivers its work through three main domains: (i) health protection – protecting the population’s health by ensuring that environmental risks are minimised; (ii) health improvement – helping people to improve their own health and prevent illnesses from developing in the first place; and (iii) health care – making sure everyone has access to high quality health services and medicines that they need. 

The public health workforce follows the Skills for Health Career Framework – with core public health roles requiring levels 5-9 level on the scale and the wider workforce (levels 1-5) encompassing some 170 occupations. In February 2019, PHE published a review of the wider public health workforce. This found organisations across a range of sectors had an interest or activities relating to public health and how they fitted into one of three broad categories: (i) leading and advocating for health; (ii) influencing the wider determinants of health; and (iii) having direct contact with individuals and communities.

Throughout history a range of technical fixes have been used to tackle public health issues – with services including vaccinations, improvements to infrastructure (e.g. clean water), adding fluoride to the water in some parts of the UK (to reduce dental cavities), advances in medicines and diagnostics (e.g. antibiotics for infectious diseases, vaccines, blood tests); and the use of statins (to lower cholesterol levels and reduce the incidence of heart disease and stroke). From the 1960s onwards public health practitioners have also looked at how to get people to change their behaviour:  through persuasion, nudging or coercion! In the 1970s, 1980s and 1990s health educators attempted to use shock tactics – such as presenting images of the consequences of drug use, medicines poisoning, rotting food or the lungs of a smoker.

Successive Governments have also sought to improve public health by making structural changes. For example, by restricting the use of certain products thought to cause harm. This includes prohibition (of psychoactive substances such as heroin, cocaine, cannabis; the smoking ban); licensing (such as needing to be a certain age to buy tobacco or alcohol); and taxation (e.g. on cigarettes and sugary drinks).

Since the 1960s emphasis has been placed on behavioural changes. PHE, for example, has a social marketing strategy which looks at how digital technologies can be used to target services more effectively, engage populations and support change. The strategy highlights achievements around Sugar Smart and Be Food Smart; Stoptober (a campaign to encourage smoking cessation in October each year); and ‘How are You?’ health quiz. PHE is currently working with partners to create a smoke free NHS; improve the quality of data provided at a local level; and enabling people to make healthier changes to their lifestyles.

For some critics, behaviour change, no matter how it is achieved, can only go so far. The context in which people live means that they may be limited in the changes that they can make. There has therefore been much interest in understanding and addressing health inequalities. Such debates can be traced back to the very establishment of the National Health Service (NHS) in 1948. In the words of Labour health minister and founder of the service, Aneurin/Nye Bevan, to “universalise the best” was seen to offer the hope of an end to inequality. In 1980 the Working Group on Inequalities in Health published the Black Report which not only confirmed the existence of inequalities in overall mortality related to class but also found that health inequalities were widening. More recently, in 2016, Danny Dorling (Professor of Geography at the University of Oxford) claimed that worsening health and declining living standards in the UK reflected growing economic inequality and the public spending cuts that have accompanied austerity.

PHE has a wider determinants of health tool. This fingertips profile provides a set of indicators which describe these wider determinants; highlights the relationships between wider determinants and other risk factors; and provides a series of resources (e.g. case studies, best practice, guidance). This takes up the findings of the Marmot Review and draws on other evidence which shows how wider determinants have a greater influence on health than health care, behaviours or genetics. In September 2019 PHE published its evidence review of dependence and withdrawal problems associated with 5 commonly prescribed classes of medicines in England. The review found prescribing rates and duration of prescription to be higher in some of the most deprived areas of England; a similar pattern is also seen for the number of medicines co-prescribed (for example, at least 2 of the drugs). For opioids and gabapentinoids, the prescribing rate in the most deprived quintile was 1.6 times the rate in the least deprived quintile; and the co-prescribing rate in the most deprived quintile was 1.4 times higher than in the least deprived quintile (30% compared to 21%).

How might we measure the effectiveness of technical, structural and behavioural fixes – and what core and wider workforce do we require to deliver services? What are the goals and outcomes of public health policy?  How/do preventive services lead to savings for the health system in the longer term? Importantly, are there some services or interventions that work well or less well in rural settings (and why is this?)

How much does public health cost and how is it funded?

In June 2012 the then Department of Health (DH) published a policy paper setting out three principal routes through which public health functions would be funded: (1) ring-fenced grants to upper tier and unitary Local Authorities; (2) through the NHS Commissioning Budget; and (3) PHE commissioning or providing services itself – with the DH also carrying out some public health commissioning or procurement.

The Public Health White Paper, ‘Healthy Lives, Healthy People’, gave a commitment to ensuring that Local Authorities would be adequately funded for public health responsibilities and that any additional net burdens would be funded in line with the Government’s New Burdens Doctrine.

In February 2012 the DH published its first estimates of baseline spending. This was based on returns from primary care trusts (PCTs) of actual spend in 2010-2011. It included mapping relevant PCT public health spending onto Local Authority geographies. This estimated, in 2012-2013, approximately £5.2 billion would be spent on the public health system – including £2.2 billion on services to become the responsibility of Local Authorities. Government commissioned the Advisory Committee on Resource Allocation (ACRA) to develop a formula to allocate a health budget to Local Authorities. ACRA’s approach was utilisation based (i.e., analysing current patterns of public health activity); outcomes based (using population health measures); and looked at cost effectiveness.    

ACRA recommended that public health funding be based upon:

  • A formula based principally on a measure of population health best meets the criteria by which resource allocation formulae are determined.
  • The standardised mortality ratio (SMR) for those aged under 75 years should be used as the population health measure. This has been applied on a small area basis to take account of localised health inequalities, and aggregated to local authority level.
  • To help reduce inequalities, the SMR measure be incorporated into the public health formula so that the decile of small areas with the highest SMRs have received a weight per head, three times greater that the decile of small areas with the lowest SMRs.
  • The adjustment used in the local government funding formula for unavoidable differences in costs due to geographical location should be included. ACRA recommended that an appropriate Area Cost Adjustment (ACA) be used.
  • The ONS projected resident population for 2012 is used as the population base. This is the same approach as followed in the local government funding formula.

The Government published technical guidance in December 2012. This took up ACRA’s recommendations – taking the resident population (adjusted for relative need, unavoidable geographical variation in the cost of providing services), age, gender, and drug services outcomes to provide target monetary allocations for each upper tier and unitary Local Authority.   The DH then published its allocation of public health grants to Local Authorities covering the periods 2013-2014 and 2014-2015. In addition, NHS England received £25.4 billion (2013-2014) from DH for directly commissioning certain services at a national level – this included £1.8 billion for responsibilities on behalf of PHE comprising immunisation, screening and health visiting.

According to The King’s Fund, spending on public health services by Local Authorities was 8% lower in 2017-2018 compared to 2013-2014 (on a like-for-like basis). While funding for public health services has increased in real terms over this period, this is partly due to budgets and responsibility for some children’s services transferring to Local Authorities. Once this is accounted for, the pressure on Local Authority budgets to provide services such as sexual health, and drug and alcohol misuse has increased.

For the period 2019-2020 the total public health grant to Local Authorities (to be ring fenced) is £3.13 billion. Appendix A (from page 14) lists allocations to unitary and upper tier Local Authorities in England. The 2019 Spending Round sets out the Government’s spending plans for 2020-2021. In addition to a five-year settlement for the NHS, the Government is proposing ‘a real terms increase in the public health grant budget to ensure Local Authorities can continue to provide prevention and public health interventions’. Analysis from the Health Foundation reveals a £900 million real terms reduction in funding between 2014-2015 and 2019-2020. In citing a 25% reduction in the core public health grant over this period they calculated an additional £3 billion a year is required. 

Our public health funding allocations are based on PCT baseline spending from 2010-2011. While this was intended to provide a starting point, with a pace of change component built in, to what extend does this system reflect current levels of need and rurality? Whilst it is recognised that investing in prevention now should reduce demand on services in the future, prevention budgets, public health initiatives and mainstream services have been experiencing real-term cuts to their budgets. Public health touches almost every area of policy – planning, transport, education, housing, leisure, economy and much more besides…so public health budget cannot be seen in isolation. Has this approach led to a more fragmented funding structure and/or has it enabled integrated forms of health and care provision? Have pressures on Local Authority budgets led ‘ring fenced’ budgets to develop holes and/or improved the integration of services? Are the accountability structures that we have in place ensuring proper use of the public health grant, as well as delivery of value for money and health outcomes? How much funding is required to deliver public health and how can we ensure this is sustained into the future? 

What do we know about public health in rural England?

In 2017 the Local Government Association (LGA) and PHE published a set of case studies on health and wellbeing in rural areas. While health outcomes tend to be more favourable in rural areas (i.e., rural residents tend to have higher life expectancy and a lower number of potential years of life lost (PYLL) from cancers, coronary health disease and stroke); as rural populations are older and ageing the prevalence of these conditions is higher. Rural residents also experience ‘distance decay’ whereby service use decreases with increasing distance –this means rural residents have further to travel to access a GP, dentist, hospital and other health facilities compared to their urban counterparts. Social and economic factors can also disproportionately impact upon people’s health in rural areas (e.g. poverty, housing, employment, access to transport). The way statistical information on health outcomes is collected can also mask deprivation and poorer health outcomes in rural areas.

With support from PHE, academics at the University of East Anglia (UEA) have developed a Rural Deprivation Index (RDI) using Norfolk as a case study. Rural deprivation may present in small pockets (for example a few isolated houses on the edge of a village) and the effect is that existing deprivation measures fail to account for or understand these small pockets in their analysis. This leads some rural areas to become ‘overlooked’ when measuring health service need. UEA’s RDI has four dimensions: (1) ‘Relative household deprivation’, which contains indicators typically associated with material and financial deprivation that are not polarised to either urban or rural areas. (2) ‘Locality related deprivation’ which includes indicators around mobility and opportunity deprivation. (3) ‘Population characteristics’, to account for an older rural population. (4) ‘Spatial scale’. The model provides a flexible method for grouping and weighting variables within the index. Their analysis of Norfolk found greatest variability within Lower Super Output Areas (LSOAs) classified as ‘rural town and fringe’ particularly the ‘sparse’ subcategory – giving some support to the theory that larger rural LSOAs are less homogenous and therefore are more likely to hide pockets of deprivation.

In August 2019 PHE published a review on coastal and rural inequalities. This highlights the drivers of health inequalities in rural and coastal areas such as social exclusion, isolation, infrastructure (public transport, high speed internet) as well as the benefits such as a strong sense of community, easier access to green space and lower crime rates compared to their urban counterparts.

These documents are significant because definitions and what we mean by ‘rural’ are the basis for identifying needs and targeting resources. The more we understand about the impact of where we live the more able we are to pinpoint local health issues and delivery. However, many of the existing indices used provide a measure of disadvantage for the whole population in ways that can be inflexible to specific rural context, geography and community circumstances.  How can we build on existing research to more accurately understand disadvantage in rural areas? Could we, for example, produce a rural statistical profile that brings together datasets on areas such as demography, health conditions, health workforce (GPs, dentists), access to health and care services, spend on health and care service provision, housing (condition, affordability), connectivity (mobile coverage, broadband, public transport) and levels of economic inactivity? If this information was collated and then mapped according to the Rural Urban Classification,  what might this tell us about the health and care needs now in rural England [according to type of rural area] and could it help us think about how these might be better met in the future?

While the past is not always an accurate predictor of the future; according to George Santayana ‘progress’, far from consisting in change, depends on retentiveness. Those who cannot remember the past are condemned to repeat it.  With Government wanting a health model that is proactive, predictive, integrated and personalised, what can we learn from the history of public health and apply to rural areas? There remain persistent challenges around infectious and communicable diseases, the environment and climate change, and around how people are living longer [which is a good thing] but with more complex and multiple health and care needs (including issues around social isolation and loneliness) that need managing.

Not only is there much to learn from the history of public health but an increasing need for us to do so if we are take public health seriously. And we need invest in public health in ways that go beyond prevention towards tackling the root causes of poor health.

Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC). The NCRHC is a Community Interest Company, national in scope with a Headquarters in Lincolnshire, that focuses on four principal activities: data, research, technology and workforce. The NCRHC and the Rural Services Network (RSN) have developed a Rural Health & Care Alliance (RHCA) - a membership organisation dedicated to providing news, information, innovation and best practice to those delivering and interested in rural health and care across England. More information about the RHCA – and how to join – can be found here: https://www.rsnonline.org.uk/page/about-the-rhca

Jessica is also a researcher/project manager at Rose Regeneration. Her current work includes evaluating two veteran support projects (in Cornwall and North Yorkshire); supporting public sector bodies to measure social value; and evaluating a series of community safety and crime reduction projects.  In her spare time Jessica sits on the board of a housing association.
She can be contacted by email jessica.sellick@roseregeneration.co.uk, Telephone 01522 521211, Website -  http://roseregeneration.co.uk , Blog - http://ruralwords.co.uk, Twitter - @RoseRegen


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