In practice, health systems focus on immediate demands of health care services with, at best, only 3% of the total health expenditure in Organisation for Economic Co-operation and Development (OECD) countries committed to prevention (WHO, 2012a: para. 101). Evidencebased preventive services have not been implemented on the scale required and often fail to reach those most likely to benefit: a wealth of evidence on the health impact of unequal distribution of the social determinants of health has not resulted in effective cross-sector policy action to address inequity, while the tendency to associate public health with population-based preventive services has deflected attention from public health impacts of action in other sectors.

This chapter begins by reviewing arguments for prioritising investment in prevention and then describes initiatives for investing in health developed by the Labour government over the period of the study. It considers views of local stakeholders on enablers for and barriers to investing in prevention and the extent to which interviewees considered that prevention was prioritised in practice. Commitment to principles of ‘good governance’ is only meaningful if it is reflected in decision-making and priority-setting processes and the chapter assesses approaches to priority setting and decision support in the context of investing in health and addressing health equity. Finally, the impact on priority setting of the relocation of public health to local authorities is discussed.

Prioritising investment in prevention

While the reasons for preventing ill health, reducing health inequalities and increasing healthy life expectancy are primarily ethical and cannot be reduced to an economic balance sheet, costs of avoidable illness to health and other sectors and the scale of action required need to be constantly restated. The World Health Organization (WHO, 2002) quantified more than 25 preventable risks to health and assessed cost-effective measures to reduce them. It showed, for example, that one-third of the disease burden across Europe was caused by tobacco, alcohol, high blood pressure, cholesterol and obesity, and estimated that, in some European countries, life span could increase by about five years if preventive measures were implemented.