Intended for healthcare professionals

Rapid response to:


Hancock pledges to invest in prevention to tackle “root causes” of ill health

BMJ 2018; 363 doi: (Published 05 November 2018) Cite this as: BMJ 2018;363:k4684

Rapid Response:

Re: Hancock pledges to invest in prevention to tackle “root causes” of ill health

The Institute of Health Promotion and Education warmly welcomes the Secretary of State for Health and Social Care’s new vision 'Prevention is better than cure'.(1) It has much to commend it including seeking to put prevention at the heart of national and local government policy and prioritising investment in primary and community healthcare. However, we do have three major concerns: timescale; potential focus downstream; and funding.

The vision quite rightly highlights some of public health’s pressing issues including cancer, diabetes, mental health and obesity. We think these areas need robust and urgent action. However, the Government only plans to publish a Green Paper on Prevention in the first half of next year; setting out its ideas in more detail, and seeking views on what action is most needed. Therefore, significant action may be some time off.

In relation to accident prevention, for example, a national strategy has just been produced by the Royal Society for the Prevention of Accidents in conjunction with many eminent organisations such as the Faculty of Public Health and the Royal College of Emergency Medicine.(2) It includes well-considered evidence based interventions for all age groups. Accident prevention is just one topic where strong immediate government support could have significant impact on: preventable causes of ill health, early deaths, and on our overstretched health and care services.

In schools for example, a tremendous amount of research and theoretical knowledge has been generated; much is known about maintaining and promoting the health of children.(3,4) Concepts such as the Health Career, the Spiral Curriculum and Coordination can all be used to guide activities.(3) Children do need to become health literate. Through their education and schooling and with support, they need to make lifestyle choices that develop and maintain healthy lifestyles and ultimately good health.(5) Beyond PSHE in schools, immediate action could be undertaken; many teachers and school nurses could be trained and supported. However, national commitment is required.

Throughout the history of public health there has been a tendency for governments to focus on “downstream” individual behavior change approaches and there has been a neglect of social and environmental or “upstream” approaches.(6-9) We firmly believe that there is a need for both and the balance of activity should depend on the issue.

The World Health Organisation’s Ottawa Charter for Health Promotion has been influential in guiding the development of ‘settings’ based health promotion in sites such as hospitals and schools.(9-11) This moved interventions “upstream” away from merely focusing on individuals who are ill and towards organisations and the environment that can be used to prevent ill-health and promote health. We are pleased that the Secretary of State for Health and Social Care recognises the importance of settings in his vision, but would urge him to revisit health promoting schools and develop support for health promoting workplaces.

The third major concern we have is funding. Doctors and nurses potentially have tremendous opportunities to improve the nation’s health; however, they are less likely to be involved in prevention and health promotion where there are staff shortages: capacity issues still need to be addressed.

The mullti-sector solutions to many public health problems are indicated in the new vision, and besides doctors and nurses a wide range of professionals could be involved in prevention and promoting health. Teachers, police, trading standards and environmental health officers are but a few. However, for this to become a reality they will need galvanising into action and supporting.

Directors of public health and their multidisciplinary teams have the skills and potential to work across sectors, coordinate initiatives and drive forward public health campaigns, but they must be given the power and resources appropriate to the magnitude of the tasks.(12-14)

1) Department of Health and Social Care. “Prevention is better than cure.” London: DHSC, 2018.

2) RoSPA. Safe and active at all ages: a national strategy to prevent serious accidental injuries in England. Birmingham: RoSPA, 2018.

3) Campbell G. New Directions in Health Education. London: The Farmer Press, 1985.

4) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.

5) Lloyd, J. Improving health outcomes and health literacy for children and young people through Personal, Social and Health education in schools. Paper presented at the 17th EUSUHM Congress. 27th June 2013. Royal College of General Practitioners. London.

6) Whitehead M. Swimming Upstream. Trends and Prospects in Education for Health. London: Kings Fund Institute, 1989.

7) Raphael D. Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada. Health Promotion International. 2003, 18(4), 397–405.

8) Orton L, Lloyd-Williams F, Taylor-Robinson D, Moonan M, O'Flaherty M, Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011, 11, 821.

9) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84.

10) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.

11) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.

12) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013

13) BMA. Funding for ill-health prevention and public health in the UK. London: BMA, 2017.

14) Watson M C and Thompson S, 2018. Government must get serious about prevention. BMJ 2018;360:k1279.

Competing interests: No competing interests

12 November 2018
Michael Craig Watson
Associate Professor of Public Health.
Dr John Lloyd (Honorary Vice President, Institute of Health Promotion and Education,
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA