Comment / Population health – one step backwards

March’s spring statement takes a lot of unpicking. Clearly the public finances are not in great shape post Covid. And the steep rises in inflation, partly driven by soaring energy costs, have been exacerbated by the war in Ukraine. So, with the economy still very much in recovery, this was a statement about sharing the pain, rather than a give-away.

The NHS’s unchanged cash settlement means its real additional purchasing power is significantly reduced. And cuts to core NHS funding to support the government’s living with Covid plan will increase cost pressures even further.

But one confusing aspect of the spring statement is how at odds it seems with calls for the NHS to focus increasingly on population health, health inequalities and the wider determinants of health. Ministers, Parliamentary committees, think-tanks, and auditors often extol the virtues of working holistically – across government, across local public services – to make populations healthier, but should the Treasury be exempt from this?

As the Office for Budget Responsibility pointed out in its economic and fiscal outlook document, published alongside the spring statement, the UK faces a historic fall in living standards over the coming year.

Higher earners, rightly, are the biggest losers from new tax changes. And the statement does deliver changes that help those on lower pay – raising the threshold at which national insurance is paid, for example. But the chancellor has done very little for those on universal credit. Benefits are set to rise by just 3.1% this year compared with inflation averaging 8% over the year.

There is no reason to doubt the commitment of the Department of Health and Social Care or NHS England and NHS Improvement to population health and addressing health inequalities. But the Treasury’s limited support for the poorest in society does appear to undermine the approach.

As the former Public Health England’s Health profile for England 2021 says: ‘Many physical and mental health outcomes improve incrementally as income rises. Income is related to life expectancy, disability free life expectancy and self-reported health.’

The Joseph Rowntree Foundation has warned that the failure to increase benefits in line with inflation – along with the national insurance rise and threshold changes – will pull around 600,000 people into poverty – with a quarter of them being children. And there have been increasing concerns that some families are having to make choices between heating and eating.

There are close links between nutrition and health. But the inability to adequately heat a house can also have major health consequences, with the cold or damp exacerbating some respiratory problems.

In many ways, this is nothing new. Public health grants saw major real-terms cuts from 2015/16 and even the improved recent settlements only maintain these budgets in real terms.

The government did double the household support fund for local authorities to support vulnerable households as part of its spring statement measures. But, while welcomed, this is widely seen as an insufficient response to the needs of these groups with costs rising so sharply.

There are already concerns that the financial pressures on the NHS and the focus on clearing waiting lists will distract new systems from their population health focus when they come on stream in July. This is despite an almost universal recognition that systems need to work in partnership to address the wider determinants of health, rather than focus on treating the consequences.

But it seems unrealistic to expect systems to make progress and improve the broader conditions that promote better health, if wider government policies are simply making the problem worse.