Professor Richard Parish,
Chief Executive, Royal Society for Public Health
Published with permission from www.onmedica.com
Governments come and go, but there are always challenges to public health. The health consequences of modern day society and associated lifestyles, the emergence of new communicable diseases, such as pandemic influenza and HIV, or the re-emergence of those from the past, such as TB, combine to ensure that the need for an effective public health system will always be there. Add to these the growing impact of climate change on population health and it is clear that any government, irrespective of political colour, must keep public health high on the agenda or face the consequences.
The White Paper, Healthy Lives, Healthy People (1), was published by the Coalition Government on 30th November 2010. It sets out a framework for population health, reflecting the three major domains of health protection, health improvement, and the quality of health services provision. It follows the earlier White Paper, published in July 2010 (2), which focuses predominantly on the wider issues of health and social care. The Health Bill to be presented to Parliament in January 2011 will provide the necessary enabling legislation for both White Papers.
Healthy Lives, Healthy People is driven by a philosophy of individual responsibility for health, although it acknowledges the importance of wider social, economic and environmental factors. It acts as the Government’s response to the Marmot Review on the social determinants of health (3), accepting the thrust of Sir Michael’s recommendations. It remains to be seen whether the Government will implement the full range of actions necessary to address the wider social influences on health, given the emphasis on individual responsibility.
The public health White Paper embraces a number of principles. Strong emphasis is placed on professional leadership and the use of evidence. The application of evidence, however, is likely to become more apparent in the translation of policy into practice, and a number of more specific supplementary papers are promised for 2011. The White Paper adopts a life course approach, focusing on the most appropriate interventions at each stage of life. The early years are a particular priority, with an investment in health during childhood and adolescence viewed as delivering the potential for a lifelong dividend. Unlike some previous Conservative Governments, there is a demonstrable commitment to reducing inequalities in health. Healthy Lives, Healthy People reaches out to all sectors of society and recognises the essential contribution of both private and voluntary sectors. This latter theme reflects the Coalition’s emphasis on the ‘Big Society’. Local government will have a particularly important role to play. The White Paper adopts the Nuffield Intervention Ladder (4), which argues for the minimum level of intervention to achieve the desired outcomes. As such, voluntary agreements with industry are preferable to regulation, although the ‘big stick’ remains an option, if needed.
‘Localism’ pervades the new public health strategy. Public Health Departments will be transferred from PCTs to local authorities by 2013. Where a two tier local government system exists, the upper or County authority will become the new home for the Director of Public Health (DPH) and his or her colleagues. Elsewhere it will be the unitary authority. Although the County level makes more sense in terms of population size, this will divorce the DPH from Environmental Health and local planning services located at the District level. Despite covering the full range of local authority services, some unitary authorities may serve too small a population for effective public health action, unless they combine to provide a joint service across District boundaries. Priorities will be identified through a Joint Strategic Needs Assessment and democratic accountability will be managed through statutory Health and Wellbeing Boards, subject to the successful passage through Parliament of the Health Bill.
The current Ministerial Team is clearly passionately committed to public health. Alongside the role for local authorities, Ministers will establish a new body within the Department of Health, Public Health England, to co-ordinate those functions that require national leadership. The expectation is that health protection in particular will be led nationally, whereas health improvement programmes will be determined locally, reflecting local government’s close relationship with other health related services, such as education, transport and social care. On health protection matters, the Secretary of State expects a direct ‘line of sight’ to his office. Public Health England will incorporate the Health Protection Agency and the National Treatment Agency, thereby improving political accountability in the eyes of Ministers. Progress will be managed through an ‘Outcomes’ framework and associated indicators, already published in draft. The means for achieving these outcomes will be a much more devolved responsibility than has previously been the case and the Quality and Outcome Framework (QoF), introduced in 2004, will reinforce the focus on public health outcomes.
Ministers have recognised the importance of resources, so often the downfall of public health in the past. The current spend on public health will be protected through ringfencing, one of only a handful of Government areas where this will apply. The estimated total sum could well be in excess of £4 billion, a sizable proportion being used to support national work; not all will be devolved locally. In practice, it is extraordinarily complicated to identify the precise spend on public health, dissipated as it is across so many services. In addition to the ringfenced allocation, a local Health Premium will also apply. This will reflect a combination of relative disadvantage and progress in achieving improved health outcomes.
Healthy Lives, Healthy People undoubtedly creates opportunities for better health. Most importantly it does recognise the wider societal determinants. This is reflected in the creation of a special Cabinet Sub-Committee, which is looking at the contribution across all Departments of State. But will the new commissioning arrangements, both national and local, make the leap from concept to effective action? Engaging the business sector will depend on voluntary Responsibility Deals. Should these fail, however, Government must be prepared to deploy the full range of policy instruments at its disposal, including legislation, regulation, and fiscal penalties and incentives. A better integrated national health protection service could be one noticeable benefit stemming from the White Paper. However, the expertise of the Health Protection Agency must itself be protected upon transfer to the Department, as should its independent role in surveillance.
The potential is there, but implementation will be the crucial test. Almost four fifths of the NHS budget will be placed in the hands of GP commissioners. Will they have the sophisticated understanding and the capacity to commission effectively for better public health? Although there is a laudable attempt to ringfence public health resources, will these be sufficient in a world of ever growing health challenges? And will devolved decision-making to local government lead to a postcode lottery when it comes to health improvement?
The Coalition Government is determined to achieve a World Class Public Health system for England, but there are inherent contradictions to overcome. The current capacity of the Public Health Service is already too small, and diminishing, without the added challenge of supporting GP commissioning. Moreover, lines of accountability must be clarified, not least between local government and the DH. And in rightly strengthening the role of local authorities, Ministers must ensure that the NHS itself does not lose sight of its own leadership responsibilities. The quality of partnership working will be the acid test of success. The Third Sector, academic institutions, and the private sector must genuinely become equal players alongside Councils and NHS Trusts, to say nothing of the local community itself. They own many of the determinants of health and the services needed to promote and protect peoples’ health. The ability to move beyond political rhetoric and adopt evidence-based solutions will be the fundamental criterion for success. Population health is too important to be left to the whims of political philosophy.
References
1. Department of Health (2010) Healthy Lives, Health People: Our strategy for public health in England. London. (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121941)
2. Department of Health (2010). Equity and Excellence: Liberating the NHS. London. (www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm)
3. Marmot, M (2010). Fair Society, Health Lives: Strategic Review of Health Inequalities in England. London. (www.marmotreview.org)
4. Nuffield Council on Bioethics (2007). Public Health: ethical issues. London. (www.nuffieldbioethics.org/public-health)
