Part one: tackling population health challenges

Gerry McCartney and colleagues argue for a new model of equitable, holistic and sustainable public health

CREDIT: This is an edited version of an article that originally appeared on The BMJ

No amount of positive spin can detract from the numbers; the UK has not done well in the pandemic, whether measured in terms of mortality, economic performance, or social protection.

This should not have happened. In 2019, the UK came in second place in the Global Health Security Index; yet, when the pandemic arrived, decision-making was confused and slow, existing structures were side-lined, and new ones, exemplified by the ‘eye-wateringly expensive’ test and trace system, were flawed by design, paying inadequate attention to the needs of those isolating. Weak social safety nets offered little support.

Other countries also struggled, but the UK was especially vulnerable as the pandemic exposed deep societal and health problems that had been neglected for years. In marked contrast to many other high-income countries, the UK’s long term upward trend in life expectancy stalled after 2012; existing inequalities in mortality had widened, and death rates among working age adults had been rising in some places – with drug-related deaths a major factor, mirroring trends in the US. Here we set out three key population health challenges that the UK must now tackle and embed in government strategy.

Pressing population health challenges

Ongoing infection control

Firstly, we are not yet out of the woods with the pandemic, and cannot depend on vaccines alone to beat it. The combination of many adults still being unvaccinated (especially globally), incoherent messaging on childhood vaccination and waning immunity risks the emergence of vaccine-resistant variants.

The UK lacks a comprehensive control strategy for the long term. It needs an effective contact tracing system and vaccination strategy, built on increased investment in local in-sourced public health systems, as well as sufficient financial support for people to isolate, improved ventilation of buildings, more home working and consistent encouragement of mask-wearing.

Strained health services

The NHS saw a steep decline in the use of many non-urgent services in the initial wave of the pandemic – partly because of reduced need, but also because of reduced service supply and postponement of public demands on services. For example, counts of confirmed cancer diagnoses in Scotland dropped by around half in the first months of ‘lockdown’ before slowly recovering to close to 2019 levels, with 16% fewer diagnoses made during 2020 than in 2019. Cancer incidence cannot have changed so quickly and this, therefore, represents substantial unmet need in the system.

Health services – delivered by an exhausted and depleted workforce – face increased waiting lists and the consequences of delayed care, additional needs driven by lockdown experiences – such as increased mental ill health and obesity – continuing COVID-19 cases, and the burden of long COVID. Physical distancing requirements, and the use of personal protective equipment, place additional strain on healthcare workers, who already had high levels of work-related stress before the pandemic.

The social care system needs radical reform, professionalisation and increased funding to provide sufficient levels of quality care. Although more resources have now been committed to the NHS and social care, further increases are likely to be needed to prevent avoidable morbidity and mortality.

Wider policy challenges

Women, young people, disabled adults and ethnic minorities have disproportionately borne the economic and social brunt of the pandemic. Young people, especially those already disadvantaged, may struggle to make up for lost opportunities in education and social development, and these are likely to have lifelong consequences for health. Although massive state intervention, including the furlough scheme, has avoided some of the mistakes of the financial crisis, and increased prospects for a rapid economic recovery, many people have not benefitted. Withdrawal of the temporary increase in financial support through universal credit, coupled with continuation of pre-crisis policies to cut social protection (e.g., the two-child limit and benefits cap), is a particular risk when many families cannot compensate for these losses by increasing earned income.

The reversal of policies aimed at narrowing inequalities, together with other factors including neoliberal economic policies such as austerity, Brexit, increases in the power of the executive (such as curbs on judicial review), a failure to tackle racism (exemplified by the heavily criticised report of the Commission on Race and Ethnic Disparities), and repeated breaches of parliamentary standards point to widespread governance failures; these will make change more difficult.

Perhaps the biggest policy challenge affecting health is the threat from climate change. At the root of climate change is the design of the global economy, driven by consumption in high income countries, and fundamental change is needed to achieve rapid and extensive reductions in greenhouse gas emissions.