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The government recently published its prelude to the forthcoming major conditions strategy – a policy aiming to address the six groups of conditions that together result in the lion’s share of morbidity and mortality in England.  

It arrives just as Britain seems awash with ill health. Almost 2.6 million people of working age are not in work due to ill health and 7.5 million people are on NHS waiting lists – both the highest figures on record. Trends in levels of obesity and young people’s mental health are going in the wrong direction. Healthy life expectancy has been near static for a decade and there are significant health inequalities across populations. Some things are improving, for example smoking rates are declining – now at 13.9% for adults in England – and (for most) life expectancy is improving albeit at a slower rate than before 2011. 

Are we getting sicker?  

But it is the future that looks most concerning. Recent modelling by the Health Foundation projects a profound rise in the burden of morbidity between now and 2040: 80% of the growth will be because more of us will be older, as the baby boomers retire. By 2035, two-thirds of adults aged 65 years and older will have two or more long-term conditions. By 2040, across the wider population, nearly 1 in 5 people will be living with major illness (meaning illness roughly equivalent in impact on quality of life and need for health care as cancer). And soberingly, the number of people living with major illness (37%) will grow nine times faster than the working-age population (4%) in this period. These trends will have very profound effects on society, the public sector (in particular health and social care and welfare), the economy and future prosperity.  

This is a far cry from the seemingly heady days of the launch of the Office for Health Improvement and Disparities in 2021, under Secretary of State Sajid Javid, when it seemed ambitions to improve health and reduce inequalities had firm national political backing. In contrast, current political interest has reverted to ‘wan’, reduced even further by mounting challenges elsewhere, not least in the NHS. Despite the need for bold and radical measures, ministers have opted for a timid and limited approach. Spare a thought for the motivated civil servants in the Department of Health and Social Care, trying to make a difference on health in such an unpromising environment. 

For some time it has seemed that the original aim of having a robust cross- government strategy to improve health and reduce disparities, tackling the wider determinants of health, would at best be paused. The mood music instead has been to justify action on health that is (a) focused on the NHS and (b) with a realistic chance of demonstrable effects in the near term. Far more limited, of course, but more pragmatic given the circumstances. 

This is indeed the approach heralded in the government’s major conditions paper published in mid-August. No favours were done to the paper by the related launch announcement on during Number 10’s ‘health week’ about the intention to insert more information in cigarette packets to warn of smoking’s harm. Many misconstrued this as the main new element of the final policy. The paper, in fact, only explains the framework used and rationale for the forthcoming policy. Interesting that publishing the approach in advance was thought necessary – perhaps to manage expectations, running hot in the face of health trends and an overwhelming perception in health circles of government inattention. 

So what is the approach?  

The focus is on the ‘big six’ conditions causing death and ill health – cancer, cardiovascular disease and diabetes, musculoskeletal disorders, mental ill health, dementia and chronic respiratory disease. The timescale for action is the next 5 years, with the action a mixture of primary prevention, early diagnosis and secondary prevention and attention to how the NHS can develop its services to manage growing numbers of patients with multiple conditions. Very important for sure given trends in multimorbidity, but also very medical and NHS-y. In fact, the document reads like part of a (very slightly) revised NHS Five year forward view without the chutzpah. Elsewhere there is still a prevalent and disappointing emphasis on individual behaviour and choice, personalised prevention rather than government action. Yes, still, despite the evidence the document pointedly claims to follow. 

Although clearly not the main focus, perhaps the more interesting section is on primary prevention. There is due recognition ‘that our physical, social, and economic environment has a significant influence on our health’. And a reminder of the government’s healthy life expectancy targets (increasing healthy life expectancy by 5 years by 2035) and the role that local government can play.  

In terms of action we can expect in the final policy, the focus is on further food and drink reformulation and healthy food sales and increasing school sports activity. The language, however, is very soft: ‘we are working with stakeholders and industry to…’, ‘we will encourage industry to…’, ‘ we will help children be more active in schools through a school sport and activity plan…’. Stronger action is proposed (‘setting legally binding targets’) to reduce the most harmful air pollutants, improve the quality of rented housing through new legislation and invest to increase cycling and walking. There is also reference to levelling up investment but nothing specific on health. And despite mentioning the important role of local government and devolution, the paper is silent on this except for passing reference to integrated care systems. 

In short, an extremely limited and cautious approach looks on the cards for the final policy when it is eventually published. In the context of the current political reality – probably pragmatic. In the context of growing and concerning health issues – timid, disappointing and rather incredible given the overwhelming health trends. Completely leaving aside the moral case for health, and considering only the value of health as a crucial intangible asset for our economy now and in the future, we will surely pay a huge price. On this basis previous Foundation analysis estimates that the government’s target to improve healthy life expectancy will be reached nearer 2235 than 2035. This is surely what drift looks like. 

Jennifer Dixon (@JenniferTHF) is Chief Executive of the Health Foundation.

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