The NHS long-term plan is a missed opportunity on prevention. The Spending Review must not be.
In November Matt Hancock, the Secretary of State for Health and Social Care, called the additional £20.5bn announced for the NHS a “unique opportunity to radically change the focus of health and social care onto prevention”. But unfortunately, the newly published NHS England long-term plan is an opportunity lost.
Hancock’s ambition for the NHS and local authorities to work together at the community level, “tackling the root causes of poor health…and providing targeted services for those most at risk,” is essentially a description of good public health services – the responsibility of local authorities funded through the public health grant.
The long-term plan, including how the £20.5bn investment will be spent, states that “funding and availability of these services over the next five years which will be decided in the next Spending Review directly affects demand for NHS services,” seeming to acknowledge both the importance of public health and its failure to adequately address it, rather passing the problem on to HM Treasury.
Whilst prevention is not excluded from the 10-year plan, the focus is on earlier diagnosis, largely to the exclusion of prevention of disease. Planned actions to address health inequalities, whilst welcome, also focus only on treatment and care, not prevention. And investment in services such as alcohol support targeting people in hospital, is set against a backdrop of community-based drug and alcohol services which have been cut to their bare bones as a result of 4% year on year cuts to public health.
The impact of public health cuts on sexual health services is stark and the new long-term plan offers little reassurance. Rates of syphilis and gonorrhoea have dramatically increased. Last year, 63% of sexual health clinicians said they were turning away patients weekly, with 19% turning away more than 50 a week. One of the country’s busiest clinics, 56 Dean St, reported that 1,500 patients a day were vying for only 300 appointments. Many of these people are symptomatic. And these are just the services that local authorities have to provide under the law – In areas with a high prevalence of HIV spending on non-mandated HIV prevention was cut by nearly a third in the two years 2015-17.
While there has been success in reducing HIV diagnoses in England in recent years, the very services that achieved this are being decimated. Increasing STIs amongst men who have sex with men are a warning that the drivers of sexual health inequality have not been dealt with and could signal risk of a future rise in HIV.
For sexual health the 10-year plan poses more questions than it answers: “the Government and the NHS will consider whether there is a stronger role for the NHS in commissioning sexual health services…and what best future commissioning arrangements might therefore be”. This delay in decision making is despite the request of NAT and our allies, over several years, for consideration of future commissioning of sexual health services, not least because of the risks posed by the impending removal of the public health ring-fence and move to locally raised business rates. These questions must be addressed urgently.
The 10-year plan will not focus the health and care system on prevention. The best way to do this is to ensure that public health services are properly integrated into the system and resourced. We now await a Green Paper on prevention which provides another opportunity, but we are clear that local authority led public health has to be at the centre of this and that it can only reduce pressure on the NHS if given necessary investment - to this end HM Treasury and upcoming Spending Review must deliver.
 Sexually transmitted infections and chlamydia screening in England, 2017 (Department of Health and Social Care)
 BASHH clinician survey, 2018