The Department of Health has unveiled plans to pass the public health baton from the National Health Service to local government, creating a new service - Public Health England - to better tackle premature death and illness and healthcare inequalities.
In a rather radical move, the government’s new White Paper Healthy Lives, Healthy People, sets out proposals to create a new public health service that essentially gives more power to local people over their health, “whilst keeping a firm national grip on crucial population-wide issues such as flu pandemics”.
At a national level, Public Health England will be comprised of experts from existing public health bodies such as the Health Protection Agency and the National Treatment Agency as part of the DH, pulling together expertise, advice and influence under the same roof.
The plans include ring-fenced funding from the NHS budget to spend on public health, with early estimates suggesting this could be around £4 billion, under a move to embed the motto prevention is better than cure and thereby reduce the future strain on health resources.
“For the first time in a generation, central government will not hold all the purse strings”, the DH noted, as public health services will largely be commissioned by local authorities from their ring-fenced budget, or by the NHS, all funded from Public Health England’s new pot of cash.
“Too often in the past, public health budgets have been raided by the NHS to tackle deficits. Not any more. The money will be ring-fenced to be used as it should be – for preventing ill health,” promised health secretary Andrew Lansley. “Directors of Public Health will be able to champion local cooperation so that health issues are considered alongside housing, transport, and education,” he added, further explaining the new strategy.
While specific details are still thin on the ground, the government has stressed it will take a less intrusive approach, “staying out of people’s everyday lives wherever possible”, employing instead a range of evidence-based approaches to boost health, such as providing information to educate people into making the right individual choices, and enabling choice, by giving people a ‘nudge’ in the right direction to change behaviour.
Directors of Public Health will be employed by local governments to be ambassadors of health issues for the local population, leading discussion on how funds can be best spent to improve health, and ensuring public health “is always considered when local authorities, GP consortia and the NHS make decisions”, the government said.
In addition, in order to better tackle health inequalities a new health premium will reward progress on specific public health outcomes, with disadvantaged areas receiving greater premiums for their progress because of the greater challenges they face.
Response to the plans has been a little mixed. “Moving public health to local authorities should have many benefits as councils have greater potential to impact on the causes of ill health,” noted acting chief executive of the NHS Confederation Nigel Edwards. But he also stressed that it is “important to get the implementation right, otherwise a good idea can do more harm than good”.
In addition, he points out that the relationship between GP consortia and local authorities “is really crucial”, and that “GP consortia and local government need a shared plan for health social and public health so we can prevent the lack of co-ordination that has bedevilled this area in the past”.
Welcoming the white paper, the National Institute for Health and Clinical Excellence said: “It’s clear that prevention is better, and also cheaper, than cure,” and it stressed that its “cost-effective evidence-based advice on what works to prevent ill-health is a good way to help the NHS provide the best outcomes for the limited resources available”.
But while applauding the government for publishing its plans for public health so early, Professor Tim Lang from City University London also warned of “some dangers” within the white paper. “The hype around 'nudge' as the best way to change behaviour should be treated warily,” he said. “It's an individualised approach to what ought to be addressed at a population, society-wide level [and] no substitute for public policy. There is a danger that the nudge will become a fudge”.
He also argues that handing the public health baton to local government “sounds good, but the reality is that local decisions have next to no power over the determinants of health. Problems are manifested locally, of course, but leverage and power mostly operates far away”.
Vivienne Nathanson, Chairman of the BMA’s Public Health Committee, said: “We agree that ‘nudging’ people to be healthy may be more effective than only telling them how to live their lives. However, if people live in an environment where they are surrounded by fast food advertising and glamorous alcohol marketing, nudging will have a limited effect.
And while Richard Jarvis, Chairman of the BMA’s Public Health Committee, also welcomed the government’s commitment to improving public health, he noted that public health doctors “will be worried about some aspects of the government’s proposals”, and cited concern “that plans for local terms and conditions of employment may fragment the workforce”.