Last week’s ruling on Pre Exposure Prophylaxis (PrEP) for HIV prevention has put NHS England’s role in prevention at the centre of national media.
Given the Five Year Forward View’s statement that the NHS ‘needs to get serious about prevention’ one might think that the question of a responsibility to prevent would be relatively simple to answer. But returning to the document two years after publication, it seems slightly less straight forward.
The Five Year Forward View places prevention squarely in the context of creating ‘a sustainable NHS’ and ensuring ‘economic prosperity in Britain’. It emphasises the need to take prevention seriously to avoid a ‘sharply rising burden of avoidable illness,’ and the associated, unsustainable costs of such a burden. Prevention in the Five Year Forward View is discussed in the context of too much alcohol consumption, not enough exercise, smoking and an overweight and obese population. In this narrative, costly NHS intervention is connected with a failure to prevent. Diabetes is highlighted as an area where a lack of disease prevention has led to the NHS spending approximately £10 billion a year on intervention.
However, the Five Year Forward View fails to consider what happens when prevention, even if it would result in long term savings, comes at a substantial cost. An estimate quoted in a recent HSJ article, notes that for every pound PrEP costs, it would save the NHS over £30 in treatment costs. However, the annual cost of PrEP would be between £10million to £20million. The existence of PrEP fundamentally challenges the assumption of the Five Year Forward that prevention is a cheap option. In this case prevention of disease places an increased demand on services in the short term.
With regard to PrEP, NHS England contends that it does not have the power to commission the service because such prevention is a function of councils, which play a leading role in public health measures including reducing smoking, family planning and HIV prevention. However local authorities, whose budgets faced an in year cut of £200 million in 2015/16, say they do not have the money to pay.
On Tuesday 1st August, Mr Justice Green ruled in the High Court that NHS England did have powers to commission PrEP and in fact had broad prevention powers. The ruling mirrors the Five Year Forward View’s own statement that ‘while local authorities now have responsibility for many broad based public health programmes, the NHS has a distinct role in secondary prevention.’ NHS England will be appealing the decision but, at bottom, the suspicion remains that the case is more about lack of funding than the old dictum that prevention is better than cure.