While some proposals in the Pathways to Work Green Paper aligned with the commission’s recommendations, including allowing people to try working without losing benefits in the short term, plans to reform eligibility for Personal Independence Payments (PIP) and the level of health-related Universal Credit will leave vulnerable people worse off, worsen health and make it harder for people with health conditions to move into work.
Policy action to strengthen prevention
The government needs to do more to prevent ill health and stop acute need arising. Deteriorating health impacts a range of social and economic policy areas, including homelessness and employment. This will require concerted action across government departments and a determination to reverse the trend of diminishing proportions of public spending devoted to prevention. In the 5 years before the pandemic (2014–19), UK government spending on prevention (based on the Office for National Statistics (ONS) categorisation) fell by 2% in real terms, and the share of UK government health spending allocated to prevention activities fell from just over 5% to 4.5%.
The Spending Review is an opportunity to make changes that promote action on prevention in two ways: firstly, tracking preventative public spending while shifting spend towards the most cost-effective interventions; and secondly, embedding a set of mechanisms to support cross-government working on health.
Preventative spending
The allocation of public spending is central to boosting prevention. A range of factors have meant past public spending frameworks have led to long-term underinvestment in prevention. These include siloed decision making, persistent short-termism and a lack of definition regarding what counts as prevention spending. These issues have been compounded by other political priorities taking precedence.
Current fiscal frameworksdo not distinguish between spending on acute services and prevention. Given the pressures on public finances, this risks prevention spending continuing to be squeezed.The Spending Review offers a chance to strengthen the fiscal framework by defining prevention spending and developing ways to track it across government departments, with a focus on cost-effective approaches that prevent more costly acute need arising in the first place. As an initial step, we recommend the Treasury establishes a review to make recommendations on how this could be done.
Such an approach could bring several benefits: it would better signal the importance of investment in prevention; enable departments to be held to account for spending on prevention; provide a baseline to track whether the balance of spending is shifting towards prevention; and strengthen the hand of budget holders to take a long-term view. But, ultimately, any technical changes in accounting rules would need to be matched with the political will to make long-term investments to improve the nation’s health.
Strengthening cross-government work on health
The Labour government has made mission-based working central to its political project, with its health mission aiming to build ‘a fairer Britain, where everyone lives well for longer’.
The health mission needs DHSC to work with other Whitehall departments, local government, other public service organisations, the voluntary and community sector, and others. But we are concerned at the slow progress on the missions, which appear to have been sidelined, with attention focused on the most urgent issues facing the government. This risks repeating the short-termism that a mission-driven approach was designed to address. We believe three actions are needed to embed a long-term focus on improving health across government:
- introduce independent advice and accountability for national action on health, taking inspiration from the Climate Change Committee
- establish ambitious – but carefully calibrated – targets on health and health inequalities to focus decision making in the most impactful areas and to help track progress
- embed the importance of improving health and tackling health inequalities across all missions and government departments, with support, oversight and constructive challenge from the health mission board.
