A Plan to Improve Population Health in England That Could Set an Example for the World

A Vision for Population Health: Towards a Healthier Future By David Buck, Alex Baylis, Durka Dougall, and Ruth Robertson

London: King’s Fund; 2018 87 pages ISBN-10: 1-909029-90-4 ISBN-13: 978-1909029903 Available at: https://www.kingsfund.org.uk/sites/default/files/2018-11/A vision for pop health summary online version.pdf.

A Vision for Population Health: Towards a Healthier Future presents the King’s Fund vision for advancing population health in England. The King’s Fund is an endowed philanthropic foundation that has been prominent in evaluating and formulating health policy in the United Kingdom for more than a century. The report is motivated by the observation that health indicators in England lag behind those of many high-income peer countries, and it states its vision simply as “Health outcomes and inequalities in health in England will be on a par with the best in the world. This will be achieved by a consistent and coherent focus on population health locally, regionally and nationally.”^(p18) Buck et al. suggest that this can be achieved by focusing on four pillars: the foundational determinants of health, health behaviors, places and communities, and an integrated health care system.

The fundamental thesis of the report is that health indicators in England have suffered from a disinvestment in the first of these three pillars, that health spending has been strictly health care spending, and that even that spending—mostly on the National Health Service (NHS)—has not been undertaken strategically to maximize an integration of service delivery with creating healthier communities or that prioritizes prevention over cure. Therefore, the report argues, England needs a reconceptualization of how it thinks of health, a recognition that health is produced through far more than health care, that the country needs a realignment of its priorities to generate health, and that doing so will need to extend well beyond the country’s ongoing investment in the NHS.

ENGLAND LAGS BEHIND

Structurally, the report first presents the data, showing that England lags behind on health compared with other high-income countries and that the health gains of past decades have slowed in recent years. It then moves on to present a vision for a healthier country, the four pillars of action that can get there, and specific actions that can move England in this direction. It ends with a strong call for leadership for achieving better health for the country’s communities and the country as a whole and for that leadership to be accountable.

In many respects, there is nothing novel about the material presented in this report; the material will be familiar to all who are careful readers of the population health science literature^1,2 or who peruse AJPH on a regular basis. It builds explicitly on, and synthesizes material previously articulated in, other reports^3–5 and presents a concise approach that is grounded in current realities.

A CLEAR, LINEAR ARGUMENT

But it is in synthesis and concision that the report makes perhaps its most important contribution. Buck et al. present a clear, linear argument, showing that health in England has been doing worse, explain why that change stems from underinvestment in the structures that create health to begin with, and argue, therefore, for an integration of efforts aimed at improving those structures, with the delivery of health care, toward creating a healthier world. Insofar as the audience for this report will likely be policymakers, politicians, and to some extent the general public, A Vision for Population Health is well written, builds effectively on what has come before it, and presents a clear path for action if there is political and public will to do so.

All of this is admirable and to the good. And it all has been said before. Why might saying so, then, in a different way matter? Two points here come to the report’s defense. First, the core idea that health is more than health care—while self-evidently correct—is so far removed from decades of medical domination of the health conversation that the idea needs repeating again and again to reframe a narrative that has long held the public’s imagination. To that end, the King’s Fund publishing a prominent new report is welcome and is another building block toward shifting a conversation that is long overdue for shifting. Second, this is a particularly unsettled time in the recent history of the Western world, perhaps nowhere more so than in England, where at this writing Brexit and its implications have occasioned a wholesale reexamining of questions of national identity and the political and administrative structures that emerge from that identity. If the moment can be used to galvanize a reconsideration of what creates health to the end of generating a healthier England, this report will have exceeded its most ambitious aspirations, and it will deliver on the promise portended by reports starting with the UK Department of Health and Social Security’s Black Report more than 40 years ago.⁵

NOT COVERED IN THE REPORT

There is much that this report does not cover that one would want to consider in the creation of a system in which health is “integrated with everything.”^(p48) Three areas in particular stand out. One, the report does not touch on the challenges of mismatched incentives for government departments, whereby particular departments responsible for some of the foundations of health, for example housing, see few benefits accrue to them for generating health. It is hard to imagine a true integration of health in everything without such a problem being comprehensively addressed. Two, the report does not touch on how one might go about shifting spending in the NHS from its curative focus to a more preventive focus. Doing so would require changes in spending priorities that would, inevitably, have implications and would meet resistance from the quarters most directly affected. Three, the report does not touch much on the tradeoffs that are almost certainly inherent in achieving better overall health and health equity, equity–efficiency tradeoffs that are difficult to make and uncomfortable to even consider.¹

And yet, in sum, we think these omissions reasonable to keep the report briskly readable, as it is now. At heart, Buck et al. aim to take decades of thinking in population health science, distill it, and present a compelling picture of an approach that is doable and that can lead to improved health. This report will not achieve that by itself—no report will—but it is a step in the right direction of a long journey. We look forward to a time when reports are written that look back at this period as having been an inflection point, when population health principles changed the health conversation and moved England—and perhaps with it other Western countries—to a direction of better overall health and narrowing of health gaps.