Prevention in the 2020s: where is primary care?

THE ROLE OF PRIMARY CARE

Some public health interventions require no contact with the public (for example, legislation), while others require one-off or occasional contact (for example, breast screening), but many benefit substantially through delivery in primary care, drawing on the strengths of that setting where care is available unconditionally over the long term in communities. This is particularly true in communities that are underserved and marginalised, and where interventions are targeting health-related lifestyle risks.

In the Department of Health and Social Care (DHSC) 2018 report, Prevention is Better Than Cure, which preceded the green paper, primary care is recognised as a ‘central part of our vision’.⁶ The report endorsed ‘prioritising investment in primary and community healthcare’, where the majority of prevention activity in the health and social care system is likely to occur. It highlighted the need for expansion of the GP workforce, retention of experienced GPs, and GPs working more closely with other professionals. It also recognised the significance of multimorbidity and highlighted that people living with long-term health conditions are the main users of health and social care services in England. In this context, a prevention agenda addresses not only primary prevention, but also includes prevention of complications, slowing progression of illness, and supporting recovery — all staples of good primary care.

Disappointingly, the current green paper all but ignores primary care, with no strategic role beyond rolling out social prescribing (previous policy) and in relation to brief interventions for weight management.

WIDER DETERMINANTS OF HEALTH

The report starts with tokenistic references to the social determinants of health in its ‘Introduction’ section. For instance, it acknowledges that women living in the 10% most socioeconomically deprived areas can expect to live 18 fewer years in good health than those in the 10% least deprived areas. It goes on to acknowledge that those living on low incomes and people with problem debt are at higher risk of mental health problems, and that multimorbidity is more common in deprived communities.

Yet it is notably silent on ‘upstream’ responses to these issues and pays little attention to them throughout the three main chapters (‘Opportunities’, ‘Challenges’, and ‘Strong foundations’). In the ‘Challenges’ chapter, for instance, there is a section called ‘wider factors’, in which the report neglects all of what most of us would consider to be the wider determinants of health — poverty, food insecurity, unemployment, poor housing — and includes only alcohol, drug use, and sleep. The verdict from the Royal College of Physicians was that ‘… the biggest omission from the paper is a clear understanding of the link between poverty and ill health’.⁷ Clear action is woefully absent.

TARGETING MARGINALISED GROUPS

The 2018 DHSC report promotes targeting and coordinating services for groups that are most at risk, emphasising the need to ‘get better at adapting support to meet the needs of vulnerable groups’.⁶ The example of smoking is presented, where 40% of adults with a serious mental illness are smokers compared with just under 15% across the whole adult population.

Again, in contrast to this, the more recent green paper pays lip service to targeting resources for marginalised groups and does so only in relation to smoking. It is now well recognised that the four main modifiable risk factors for the major non-communicable diseases (NCDs) — smoking, obesity, physical inactivity, and alcohol consumption⁸ — often coexist within individuals, and are concentrated among the most socioeconomically deprived groups where they exert greater levels of risk.^9–11 It follows, therefore, that if the approaches to prevention proposed are to be targeted at individuals, at the very least those efforts should be targeted to where needs are greatest, in keeping with the principle of proportionate universalism.¹² Recent examples in Scotland include investment in urban renewal¹³ and the targeting of community-links practitioners to practices in areas of high socioeconomic deprivation.¹⁴

BOLD ACTION REQUIRED NOW

The prevention strategy for England is still in the consultation stage, with the government response not expected until October 2020. Attention to the role of a properly resourced health and social care infrastructure, legislation, and regulation as examples of ‘upstream’ prevention interventions are notably absent from the government’s green paper. These are important, but meeting the challenge of clustering of unhealthy behaviours, which are strongly socially patterned and often concentrated among particularly marginalised groups, requires action that is targeted, coordinated, and addresses the social determinants of health.

If we are to take anything positive from this green paper, it is encouraging that it acknowledges ‘prevention in wider policies’: that illness prevention is enacted from many and wide-ranging strands of government action. However, the fragmented approach of the whole green paper reduces its ability to communicate what that should mean. This green paper needs to provide clear strategic direction to address social determinants while also acknowledging the role of primary care in working with individuals and communities to improve health and wellbeing.