The impending financial squeeze makes it more important than ever to invest in preventing ill health in communities, rather than simply spending more on treatment

The NHS faces a prolonged period of financial constraint, and some primary care trusts are already having difficulty planning for it. While there has been much improvement for patients in terms of treatment, our record on closing the health inequalities gap has been dismal and the percentage of the health budget going into the cultural changes required to transform the health and life chances of the population remains minuscule.

Progress has been made on the big killers - cardiovascular disease and cancer - but we need both to compare ourselves with best international standards, against which we could do better, and look internally, where health inequality between communities is increasing.

There are no excuses: we have the resources. PCTs are funded to reflect the greater needs of populations and if we channel that all into treatment we will never break out of the cycle.

PCTs should be required to put significant resources derived from needs weighting into prevention. Too often spending on prevention has been squeezed out when the going gets tough.

The sort of changes required to bring about real reductions in health inequalities are not quick-fix, small-scale initiatives. We need to be in this for the long term and keep faith that if we keep doing the right things, we will see the results.

Work in disadvantaged communities needs to start way upstream of our current public health messages. Individuals and families need purpose and ambition in their lives before they are ready to hear these messages and act on them.

We need to raise the self esteem of the individual and their community. It is a myth that disadvantaged communities lack social capital; there are for example around one thousand community or community of interest groups in Liverpool and we need to harness those assets.

The NHS cannot take on all shortcomings of society and should concentrate on doing things that only we can do, including a culture change in primary care to interact more fully with their communities.

Sound civic leadership is called for, and the ability of the PCT chief executive and director of public health to influence others greatly needed.

Our job is to ensure local strategic partnerships are committed to health improvement and provide facilitation, expert advice and resourcing where we can. This is Liverpool’s approach.

We have influenced the city council to take up the smoke free, alcohol harm reduction, obesity and child health agendas. Through Capital of Culture and regeneration, the city has developed a sense of place and this has helped greatly in the civic and individual will to do better.

Courage needed

Liverpool led the way on smoking policy, the city council petitioning for a local Act of Parliament before government took on the mantle, and the council has agreed to designate 2010 the Year of Health and Wellbeing.

We have backed our approach with resources for large scale intervention and engagement through social marketing, local licensing enforcement and workers on the ground.

Our investments over 2008-11 run into tens of millions of pounds. Smoking prevalence has fallen by 20 per cent in three years; the rise in child obesity has been halted; alcohol-related hospital admissions have fallen by 1 per cent in the past year; we are ahead of trajectory for reducing cardiovascular mortality and on target for reducing cancer deaths. There is evidence we are closing the health inequalities gap.

Public buy-in to our programmes is increasing. The Liverpool Challenge to lose weight has signed up around half the adult population and around 90,000 people have already lost weight and even more are making changes to their lifestyle such as exercising more. Our Healthy Homes initiative, which brings together a number of agencies to work with tenants, has targeted excess winter deaths by enforcing minimum standards for heating.

We plan to draw together the resources we and partner agencies have in neighbourhoods of about 20,000, to bring about greater change supported by experts on tap, not on top.

If the case is to be made for spending on primary prevention from 2011, we need evidence. We have invested £2m through Liverpool University to establish research to give us some of the answers.

Prioritisation of primary prevention over treatment will need courage. It needs to become well evidenced and less a leap of faith.

Together we have a narrow window of opportunity to invest in community-based innovation and observe the results before the financial curtain comes down. Every second counts and we all need to play our part. Are you doing your bit?