Delivering Triple Prevention: a Health System Responsibility

The aphorism that prevention is better than cure continues to grow in relevance.

As populations become progressively plagued by multimorbidity and avoidable long-term disorders, the need to prevent illness is increasing. In England alone, almost one in five adults smoke, a third of men and half of women do not meet recommended levels of physical activity, and almost two-thirds of adults are overweight or obese.

The pressures on health systems are clear; for example, obesity costs the National Health Service in England almost £5billion, and diabetes almost £10billion, annually.

As policy makers and administrators attempt to achieve fiscal sustainability for health systems, drastic upgrades in prevention to improve population health and moderate service demand are essential. A cross-sectoral approach is needed, as outlined in the upcoming Government Childhood Obesity Strategy, from improved education, to active support from industry, and robust lifestyle modification.

The NHS is launching a triple prevention strategy, which includes initiatives for patients, staff, and the public.  This strategy aims to set an example for other sectors in England, as well as for other health systems worldwide.

  1. Patients: Targeted Prevention Programmes

The first focus of triple prevention is patients. Although broad lifestyle recommendations such as sensible diet, ideal bodyweight, frequent exercise, and not smoking are helpful, targeted approaches in at-risk patients with specific long-term disorders can yield the greatest results. For example, targeted efforts to prevent type 2 diabetes have been widely supported. In 2002, a randomised controlled trial by the US-based Diabetes Prevention Program Research Group showed that lifestyle modification could reduce the incidence of type 2 diabetes by 58%, compared with a 31% reduction with metformin, over an average follow-up of 2∙8 years. The intervention was shown to be both safe and cost effective, and randomised controlled trials of similar interventions in several other countries have showed similar results.

The challenge of implementing such programmes has been politico-economic. Prevention requires health systems able to capture the benefits of reduced disease prevalence and service demand, with robust primary care services able to deliver it—unfortunately a rare combination worldwide. However, the single-payer nature of the NHS, coupled with policy alignment generated by the NHS Five Year Forward View—our roadmap for the health system—has enabled a national Diabetes Prevention Programme to be established, set to enroll 10,000 people this year and then be scaled up.

  1. Staff: Workplace Wellness Programmes

The second focus of triple prevention is health-care staff. As efforts to improve system productivity and performance increase, so should the emphasis on staff health and wellness. When health-care organisations prioritise staff health, performance is enhanced, patient care improves, staff retention increases, and absence due to sickness is reduced. However, more than 700,000 NHS staff are overweight or obese, the rate of sickness-related absence in the NHS (4∙1%) is 27% higher than the UK public sector average, and three quarters of hospitals do not offer healthy food to staff who work night shifts. The financial implications are substantial, with the annual cost of sickness-related absences in the NHS alone exceeding £2∙4 billion.

Health systems should lead by example to improve workplace wellness. Advocating prevention while hosting an unhealthy food environment on hospital premises is unacceptable. To address this problem, we have launched a national £600million incentive to drive delivery of workplace wellness. This incentive will be included in NHS commissioning contracts to encourage NHS hospitals and providers to prioritise the health of staff. We have also established a staff wellness programme, starting with 12 hospital trusts and covering more than 70,000 employees. Board-level leads at each organisation champion this agenda, visibly building engagement across their organisations. Training is offered to line managers to equip them to deliver health and wellbeing changes for staff. To support individual staff, the NHS Health Check has been made available to staff aged 40 years or older, and staff have been given access to services such as physiotherapy, smoking cessation, and evidence-based weight management services.

  1. Visitors & the Public: Healthy Ecosystems

The third focus of triple prevention is visitors and the public.  Health systems have a responsibility to create healthy environments for visitors and the public, encouraging evidence-based lifestyle modification while setting an example to other sectors. In the UK, sugar-sweetened beverages are the largest source of added sugar (roughly 30% of all added sugar) for children, and the second largest in adults. Consumption of sugar-sweetened beverages is an important contributor to obesity in children and adults, and has also been linked to an increased risk of type 2 diabetes. However, sugar-sweetened beverages are widely sold on NHS premises, together with foods high in fat, sugar, and salt.

To address this issue, the NHS is taking drastic measures to create a model environment for visitors and the public. The NHS is the first health system to consult on the introduction of a sugar tax, possibly in the form of a fee to be paid by vendors for each sugar-sweetened beverage sold. We are also introducing a rolling programme of contract renegotiation with food and drink providers on NHS premises. As contracts and franchises approach renewal, efforts will be made to restrict or remove the unhealthiest foods from vending machines and shops, to offer healthier, affordable alternatives, and to eliminate promotions of unhealthy products.

Finally, we are consulting on the content of new, enhanced mandatory hospital food standards for patients, staff and visitors, enforced through the NHS standard contract, including phased food reformulation to systematically reduce added sugar.

These interventions have been established in the past year. Effective delivery and robust assessment of cost-effectiveness and outcomes will be essential to ensure success.

Delivering Triple Prevention

Conceptually, the benefits of preventative strategies should be captured across the system, in practice however, fragmented pools of funding have somewhat limited this. There are five strategies that are and will be key to delivering Triple Prevention:

Funding: dedicated funding is essential to rapidly introduce momentum to an otherwise neglected objective: prevention. NHS England has invested up-front in its Diabetes Prevention Programme and Workplace Wellness initiative nationally, enabling prioritisation.

Policy alignment: because effective prevention needs to involve multiple stakeholders and be built into local communities, relevant delivery partners and advocates of prevention should work in alignment. The Diabetes Prevention Programme is being implemented collaboratively by NHS England, Public Health England, and the patient charity Diabetes UK, with expressions of interest from local NHS clinical commissioning groups, local government, and primary care practices, building alignment between local, regional, and national partners.

Integration of care: downstream rewards of prevention such as alleviation of operational demand and conservation of fiscal supply, are only realised in an integrated system. The third strategy is therefore to dissolve boundaries between primary and specialist services, and between health and social care. A parallel shift from individual organisation accountability to accountability spanning all service providers in a locality is needed, with mutual, fixed responsibility over their population cohort and capitated, pooled budgeting. Such architecture, similar to an accountable care organisation, disincentivises unnecessary use of health services and rewards payers and providers for preventive efforts.

Clinical prioritisation: infrastructure and culture should be improved in tandem. Without effective clinical engagement, enrolment into employer wellness programmes and referral of patients to relevant preventive initiatives will be poor. Changes in professional education, accreditation, training, and guidelines should be introduced to ensure clinicians are incentivised and enabled to drive prevention efforts.

Scale: efforts are needed to scale-up triple prevention initiatives. Although our Diabetes Prevention Programme is due to enrol 10,000 people in its first year and our Workplace Wellness initiative covers more than 70,000 employees, almost five million people have prediabetes in England, and there are 1∙3 million NHS employees in the country. Robust approaches to roll-out should be in place at the start of design and delivery to ensure appropriate scale-up.

Delivery of triple prevention is essential. Health systems are facing unprecedented demand due to growing, ageing populations burdened by increasing long-term disorders. Health systems have a responsibility to improve the health of patients, staff, and the public, to lead by example, and to achieve sustainability.

Prevention is the primary means by which these ambitions can be simultaneously achieved, enabling populations to enjoy the improvements in health and longevity that they have rightly come to expect.

Dr Mahiben Maruthappu

Dr Mahiben Maruthappu is a practicing doctor and Senior Fellow to the CEO of NHS England. He advises on NHS England’s innovation, technology and prevention portfolio, co-founding the NHS Innovation Accelerator and the NHS Diabetes Prevention Programme.

He has advised a range of organisations, from start-ups to multilaterals, including the Swiss government and the Experiment Fund and the WHO.

Mahiben has a strong interest in research with over 80 peer-reviewed publications and 50 academic awards. His work has been featured by BBC News and the international press.

He is Chairman of the UK Medical Students’ Association (UKMSA), and has written three medical books. Mahiben was educated at Oxford, Cambridge and Harvard universities and was the first person from British healthcare to be included in Forbes’ 30 under 30.