Now auditors understand health better than government

When we find ourselves in times of trouble, might it be worth listening to the wisdom of auditors? “We support Parliament in holding the government to account,” says the UK’s National Audit Office about itself, “and we help improve public services through high-quality audits.” Unfortunately, as consistently insightful as the NAO is, it tends not to receive the attention it deserves. Exhibit A: our coverage of its review of integrated care systems has, by the time of writing, been shared by eight people on social media (doi:10.1136/bmj.o2482).1 Sadly, not everything that is worth reading is read, and not everything that is read is worth reading.

The NAO says that England’s integrated care systems will struggle to deliver (with “deliver” being a word that can’t be repeated enough in political circles) long term improvements in people’s health because of extreme pressures on funding and staffing (doi:10.1136/bmj.o2481).1 This isn’t news—and is underscored by alarm over an exodus of consultants (doi:10.1136/bmj.o2465) and by a questionable proposal by the General Medical Council to redirect non-training grade doctors to primary care (doi:10.1136/bmj.o2505).23

The NAO’s verdict deserves more than eyebrow raising, not least because it goes on to urge ministers to take the logical next step of tackling workforce shortages with a measurable plan and ensuring sustainable NHS finances. It argues against short termism and says that the immediate pressures on health and social care must be tackled in tandem with a mid to long term plan. These are familiar themes for England’s new chancellor, but whether Jeremy Hunt lives up to his own recent rhetoric of bolstering these areas is an open question (doi:10.1136/bmj.o2496).4

More interesting still, the NAO seems to understand that success cannot be achieved without coordinated measures across government to tackle wider determinants of ill health, specifically the drivers of poor health outcomes, such as education, employment, benefits, and transport. Around 80% of integrated care system staff sought to invest in prevention, but only about 30% had capacity to do so. The government, says the NAO, has made little progress in matters beyond clinical care that contribute to poor health.

The UK isn’t alone in these glaring oversights, misjudgments, and unsatisfactory trade-offs, but England in particular is earning quite some reputation for an absolute abdication of state responsibility for the population’s health and wellbeing (doi:10.1136/bmj.o2482),5 from smoking to social care (doi:10.1136/bmj.o2472).6 As Nick Hopkinson puts it (doi:10.1136/bmj.o2492), if these policies are driven by libertarianism then a more useful way to look at it is to consider freedoms that are restricted by ill health and how to liberate people through better health and wellbeing.7

Even in times of trouble, progress is being made. A new study finds that shopping vouchers encourage women to give up smoking in pregnancy, although there is a tendency to relapse after six months (doi:10.1136/bmj-2022-071522, doi:10.1136/bmj.o2443).89 Other studies offer reassurance about the use of computed tomography to assess heart disease in women (doi:10.1136/bmj-2022-071133) and confirm concerns about hypertension in pregnancy and its effect on mortality in offspring (doi:10.1136/bmj-2022-072157).1011

There is the promise of a new malaria vaccine (doi:10.1136/bmj.o2462),12 of next generation covid vaccines (doi:10.1136/bmj.o2422),13 and a new funding round for the Global Fund to Fight Aids, Tuberculosis, and Malaria (doi:10.1136/bmj.o2320).14 The World Health Organization is learning from a failure of its policies that allowed private funding by formula milk manufacturers (doi:10.1136/bmj.2470),15 while clinical learning networks established during the covid pandemic might be usefully applied in other areas of emerging evidence (doi:10.1136/bmj-2022-070215).16

What this mixed bag of developments tells us, however, is that unless we think about prevention when we are under pressure to find treatments or think about the long term when we’re worrying about the short term, or about social care when our focus is on health, or international health when immersed in our local struggles, or policies outside the health sector when our heads are in the health system, we are condemning ourselves to an accelerating hamster wheel of health crises.

When your national audit office is urging you to improve people’s health by producing clear plans and taking a broader view, it would be negligent not to.