Climbing ladders: From treatment to prevention (2025)

Mick comes from a family where the previous generations of men worked in shipbuilding, and he followed this tradition by pursuing a career in construction. This was not the only tradition that Mick inherited from the generations before him. He, like his dad, and grandad, had smoked since the age of 14, and drank a few cans of beer every evening. Sometimes, he drank more heavily at the weekend.

This started to change when Mick's working life was cut short by a serious back injury which permanently affected his mobility.

Being out of work really changed Mick's life. He lost his identity and things became tense at home when he could no longer support his family financially. This affected his mental health, and he began to become withdrawn and irritable with Carol, his wife, especially if he had been drinking.

As a proud man, Mick wasn't one to ask for help, but he eventually attended an appointment with his GP practice with Carol's encouragement.

During the appointment, Mick was able to discuss further treatment options for his back pain and was offered a health check due to his age. At the check, Mick was screened to assess the health risks from his continued regular drinking. The result showed him that his consumption of alcohol was at harmful levels, and by making changes, he could significantly reduce the risk of serious diseases like cancer. He was also encouraged to stop smoking and given details of the local Stop Smoking Service.

The healthcare professional recognised that Mick's low mood and increased drinking were linked to not being able to work, and the social connection his job provided. He was referred to a Social Prescribing Link Worker, who talked to him about a local Men's Shed support group. Initially Mick was reluctant, but due to the trusting relationship he had built with the link worker, he decided to give it a go.

Joining the Men's Shed didn't just give Mick his social life back - it also provided a renewed sense of purpose, which helped motivate him to make other changes.

Mick went on to cut down on his drinking and successfully switch from smoking tobacco to using a vape from the Stop Smoking Service. It took him a few attempts, but he stayed positive and always tells people that if he can do it, anyone can.

The snakes and ladders in Mick's story

Snakes

Employment: The type of work Mick did contributed to his physical health problems. Each year, approximately 300,000 people in the UK suffer from back pain due to a manual handling accident, resulting in extreme pain, and temporary or permanent injury due to damage to the back, neck or spine.¹ Studies of musculoskeletal disorders in male construction workers in the UK show significant raised standard incidence rate ratios.²

Decent work boosts mental health by providing income, purpose, confidence, routine and meaningful social connection amongst many other benefits. (WHO, 2024)³ When Mick became unemployed, he experienced poor mental health as a result of a of these factors.

Income: People in poorer communities face greater alcohol related related harm, even though they often drink less than those in more affluent areas. Unemployed people and those in routine and manual occupations have a higher proportion of current smokers than other professions (ONS 2024).

Ladders

Access to services: Mick used free stop smoking smoking support, helping him improve his health and save money. Quitting smoking significantly reduces the risk of cancer, heart disease and stroke, COPD and dementia. Vaping - while not risk free free - is far less harmful than smoking and can help adults quit (freshquit.co.uk).

Mick was also given Alcohol Identification and Brief Advice (IBA) during a GP appointment. IBA is a quick intervention proven to reduce drinking by 4-8 units a week, with 1 in 8 people cutting down after receiving it. This early advice helped Mick make changes before his drinking became harmful or required specialist treatment.

Upping prevention

With alcohol harms at record highs, prevention and early intervention are essential to reverse the impact on our communities and to support population approaches to ensure people in Gateshead are better informed. We also need strong national action to shift the culture of drinking at harmful levels - making alcohol less desirable, acceptable, affordable and accessible, drawing on what we've learned from tobacco control.

Public health and prevention

Public health is a field of study and work which takes a population (rather than individual) level focus on improving health, tackling inequalities, and promoting equity through collective responsibility and action. The Faculty of Public Health defines it as:

"... the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society."

 

LA role of public health in driving prevention

Public health teams within local authorities have a statutory responsibility to improve population health and reduce inequalities. This leadership role is pivotal because prevention requires system-wide coordination across health, social care, and community partners.

Why public health leadership matters

• Strategic vision:
  Public health undertakes surveillance of population health, provides the evidence base and sets the strategic direction for prevention, ensuring alignment with national frameworks (such as the Marmot Review, NHS Long Term Plan) and local priorities.
• Whole-system approach:
  Prevention is not solely a healthcare issue; it spans housing, education, employment, transport, and environment (the building blocks). Public health teams lead on embedding "Health in All Policies" across council functions and influencing partners.

Prevention can be viewed at various levels. This includes broad actions at population level that aim to strengthen the building blocks of health and wellbeing and so prevent problems arising in the first place. This work is complex as it requires action at different levels across multiple organisations over longer time periods. Then there are more specific interventions that seek to minimise existing harm and provide early diagnosis and treatment, for example the provision of community sexual health services. This prevention work tends to be more distinct and measurable, and this often leads to much more effort and resource being focused here. This is important of course, but without sufficient action at primary level the root causes will continue, and demand will keep growing. This is itself a form of inequality.

In 2024/25, the Department of Health and Social Care (DHSC) budget was £192bn. This funds the delivery of health care and public health services in England. Of this budget, 86% (£165bn) goes to NHS England to cover the breadth of NHS clinical services as well as NHS public health responsibilities like screening and vaccination. The rest of the DHSC budget is allocated to capital spend, the department's arm's lengths bodies - such as the UK Health Security Agency, the National Institute for Health and Care Research - and the ringfenced public health grant to local authorities .

In 2024/25, the total public health grant was £3.6bn - equivalent to 2.2% of the NHS England budget, down from 2.9% in 2013/14. Although public health services funded through the grant have been de prioritised relative to other parts of the health system, they generally offer excellent value for money - costing an average of £3,800 for every additional year of good health in comparison with NHS treatment, which costs £13,500 for the same.

Overall, estimates suggest around 5% of health care spending is allocated to funding prevention¹³.

Exploring prevention

Prevention is sometimes classified into different 'levels,' based on acting at different points: 

Health creation - action to prevent exposure to risk factors in the first place by ensuring the building blocks are in place and are robust. This tends to focus on population-wide interventions on a range of social determinants of health, such as poverty reduction, taxes on unhealthy food, or ensuring access to parks or other green spaces for exercise or relaxation.

Primary prevention - action to reduce exposure to risk factors, such as stopping smoking, improving the food on offer, and limiting alcohol advertising. This is also about mitigating the impact of risk factors once exposure has occurred- for example, vaccinations to increase resistance to disease if exposure occurs.

Secondary prevention - emphasises early disease detection by identifying disease before symptoms have progressed and stopping the disease worsening, if possible. For example, a hospital-based mammogram following a GP referral for symptoms. Tertiary prevention - action to help people manage symptoms and prevent further disease progression once the disease has already developed. This can be thought of as harm reduction and helping people manage their disease. For example, a specialist-led cardiac rehabilitation in a hospital setting for someone who has already had a heart attack. In this sense, certain types of health care treatment are a form of prevention¹⁴.

This diagram gives examples of different types of prevention for lung disease across the spectrum of prevention:

Health creation is a recent addition to this framework, which has been added to take account of the social factors that impact on health and wellbeing. Of course, these levels are not set in stone as this is a complex picture, and the course of ill health is variable. However, the framework provides a useful way of understanding prevention and where action can be taken. As mentioned previously, most of the resource goes towards the secondary and tertiary levels which more closely align with the traditional clinical focus.

Preventing inequalities is about more than fairness. It is about social justice. In all aspects of inequality, it is those with less that suffer more. This causes shorter lives which are more likely to be lived in ill health. This causes suffering for individuals, families, and communities, and increases stress and social anxiety, which promotes isolation and affects our ability to build relationships and therefore, functioning communities.

Disadvantage gets passed from generation to generation where children inherit the inequalities and lack of opportunity experienced by their parents, resulting in an endless cycle. There is a wider societal impact in economic terms as people are less able to work and earn an income which would normally increase social mobility. However, the legacy of austerity, benefit system reform, and the cost-of-living crisis makes that less likely.

Equally, as people live shorter lives in worse physical and mental health, the demand on public services increases. Where there is economic inequality in a society, everyone in that society is affected.

This all makes a conversation about prevention timely, and thankfully this is recognised within the NHS 10-year plan which calls for a pivot from treatment to prevention, and for care to be focused within communities rather than hospitals. These are bold ambitions, but the headline message doesn't begin to convey the complexity of making this a reality. At a time where savings need to be made and where the demand continues to increase, services designed to react to acute need at the tertiary end of the prevention spectrum are being asked to get 'upstream' into primary prevention. However, they are still accountable for delivering what they always have, and this is how their performance is measured.

There is strong evidence that more effort on prevention can improve the health of our population, and there has often been enthusiasm about the potential of prevention. But action hasn't fulfilled this potential so far. There are various reasons for this:

• as mentioned above, there is a lack of clarity and understanding about what we mean by prevention - this means it can be used as a solution to different complex issues, and gain support, but that complexity often means there is limited subsequent action
• another issue is political - spending and performance measures are often focused on short-term, more acute goals, such as emergency care or the NHS waiting list. And the benefits of some prevention activities are more likely to occur in the medium term - outside of short-term budget considerations and political or electoral cycles¹⁵
• finally, prevention is invisible because the benefits of spending or activity may not be felt directly by the organisation that undertakes it, meaning it is difficult to measure impact, to coordinate, or to make the case for investment - our organisational confines don't always recognise that we serve the same population

To achieve prevention requires the different parts of the public sector, and crucially, our Voluntary, Community and Social Enterprise partners (VCSE), to work together in a meaningful way to act on the building blocks of health and wellbeing. A useful model to visualise this system led place-based approach is the the Population Intervention Triangle.¹⁶

 Whilst the building blocks of health shows what we need to change, the Population Intervention Triangle helps us to understand how we can change things. It shows three types of action that, when combined, can make a bigger difference than any one on its own. In turn this requires organisations to work differently and be freed up from project-based planning and performance management norms to encourage innovation, collaboration and learning over longer time periods. If this occurs, primary prevention may become more mainstream and turning down the pressure on secondary and tertiary service provision.

The shift from treatment to prevention requires strong senior leadership and a shared commitment to action, but there is also a need to enable flexibility within traditional organisational practices to make it possible. For instance, the pooling of budgets to provide resource and relaxing of the requirement for all work to be subject to short term operational key performance indicators (KPIs) which are more suitable for transactional services but can't take account of longer-term efforts which have complexity, collaboration, and transformational aims. These are better evidenced by the monitoring of longer-term trends and changes in the lived experience of people.

The risk is that this remains secondary to individual organisations' priorities, targets, and governance, and to the services they presently supply. This is after all how organisations are measured and judged, and the time and effort to unravel complexity isn't incentivised in systems driven by results and performance. This means that the default position when change is required, is often to pour more focus, energy, and resource into making existing services better or building new structures and services at pace using existing principles and practice. This leaves little room for the high level, well evidenced, and agreed collaboration that is needed to ultimately improve population health and wellbeing and to reduce demand in a sustainable way. Admittedly this is complex and relies on policy change nationally as well as action at regional, sub-regional and local levels, but that doesn't reduce the moral and economic imperative of 'getting upstream.'

Moving prevention upstream

By shifting our focus upstream, we can prevent harm to health and wellbeing before it occurs or reduce it as soon as possible.

Some prevention activities don't fit neatly into just one category. For example, a community project that offers social groups, activities, and advice can deliver:

• primary prevention: it helps stop problems before they start by boosting confidence, reducing stress, and helping people feel connected
• secondary prevention: it also helps people deal with problems early by building skills, support networks, and resilience to face challenges like money worries, mental health, or finding work so reducing the need for tertiary services