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Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- White Paper - Healthy lives, healthy people:
Our strategy for public health in England
- Deadline for response:
- 31 March 2011
Background: Executive Summary
- This is a new era for public health, with a higher priority
and dedicated resources. This White Paper outlines our commitment
to protecting the population from serious health threats; helping
people live longer, healthier and more fulfilling lives; and improving
the health of the poorest, fastest.
- It responds to Professor Sir Michael Marmot's 'Fair Society,
Healthy Lives' report and adopts its life course framework for tackling
the wider social determinants of health. The new approach will aim
to buid people's self-esteem, confidence and resilience right from
infancy -with stronger support for early years. It complements 'A
Vision for Adult Social Care: Capable Communities and Active Citizens'
in emphasising more personalised, preventive services that are focuses
on delivering the best outcomes for citizens and that help to build
the Big Society.
- The goal is a public health service that achieves excellent
results, unleashing innovation and liberating professional leadership.
This White Paper builds on 'Equality and Excellence: Liberating the
NHS' to set out the overall principles and framework for making this
happen.
- Subject to Parliament, local government and local communities
will be at the heart of improving health and wellbeing for their
populations and tackling inequalities. A new integrated public health
service - Public Health England - will be created to ensure excellence,
expertise and responsiveness, particularly on health protection,
where a national response is vital.
- During 2011, the Department of Health will publish documents
that build on this new approach, including on mental health, tobacco
control, obesity, sexual health, pandemic flu preparedness, health
protection and emergency preparedness, together with documents from
other government departments addressing many of the wider determinants
of health.
The proposals in this White Paper apply to England but the Department
of Health will work closely with the Devolved Administrations on shared
areas of interest.
COMMENTS ON
DEPARTMENT OF HEALTH
WHITE PAPER: HEALTHY LIVES, HEALTHY PEOPLE
- OUR STRATEGY FOR PUBLIC HEALTH IN ENGLAND
The Royal College of Physicians of Edinburgh welcomes the opportunity
to respond to the White Paper on Healthy Lives, Healthy People – the
strategy for Public Health in England.
This College has as many Fellows and members working in England as
in Scotland, and its content will therefore be of interest to many. In
addition, several public health measures contained in this strategy
are reserved matters and therefore affect the whole of the UK. For
this reason, the strategy relates to interests of this College across
the Government’s remit for the UK in these respects. The
strategy proposes a radical departure from previous approaches to public
health strategy. It addresses many current public health challenges
and shifts the balance of emphasis towards individuals and communities,
a crucial element of any public health strategy. However, the
strategy must recognise the leadership role of Government, and of political
will, in facilitating change and improving health and the social determinants
of health. Therefore, while the general direction of strategy
is welcome, a number of questions are left unanswered.
A welcome set of proposals:
- The RCP Edinburgh strongly welcomes the cross-Government, life-course
approach to public health and the establishment of a Public Health
Service with a ring-fenced budget.
- It also welcomes the strong emphasis on public health. However,
it would be reassuring to see the standard definition of public health
stated early in the document:
Public health is "the science and art of preventing
disease, prolonging life and promoting health through the organized
efforts and informed choices of society, organizations, public and
private, communities and individuals".
- It supports the commitment to improving the health of the poorest,
fastest. This includes broad interventions to decrease poverty,
because over 90% of ill health is attributable to factors outside
the NHS. Furthermore, dedicated interventions and awareness
campaigns are needed for those who suffer disproportionately from
cardiovascular disease, including some black and minority ethnic
groups
- To protect population health, particularly children and young people,
and to create an environment that supports and enables healthy choices,
behaviour change approaches and voluntary action by industry must
be part of a much wider government strategy that includes regulation
and legislation.
- While the College supports the commitment to empowering communities,
national oversight and accountability are essential. Independent
and open access to performance data, including the Public Health
Outcomes Framework, will be crucial to enabling scrutiny and accountability
and facilitating the sharing of best practice and effective innovation
- Directors of Public Health (DsPH) must have the independence, authority
and resources to be effective local leaders and to drive improvement
in all policy areas that have a bearing on health and health inequalities
- It agrees that close partnership working will be essential between
Public Health England and the NHS Commissioning Board, and between
DsPH in local authorities and GP Commissioning Consortia
- Patients, the public and voluntary sector organisations should
be involved in needs assessment and throughout the commissioning
cycle.
The College’s Concerns:
- to what extent is the Government diminishing its own role in leadership,
regulation and legislation for health?
- to what extent is it weakening the public health function by, once
again, reorganising, while simultaneously highlighting the need for
a strong and integrated set of arrangements?
- what is the relationship between the current strategic intentions
and reduction of health and inequalities which still is a prime policy
objective?
The strategy has not addressed these issues, while the whole breadth
of Government action influences the public health of the country. This
strategy does not bring together the Government’s commitment
to fiscal and other legislative matters that could be vital ingredients,
and that are so important in this area.
Detailed comments on the Government’s Strategic Proposals:
Background: Discussion of structural
changes to public health organisation in England inevitably follows
the Government’s proposed reforms to the rest of the NHS in England. These
will generate major disruption.
Some discussion of concerns regarding the wider NHS forms is therefore
necessary.
History is repeating earlier mistakes: Early
in the days of the last Labour Government, in the late 1990s, Primary
Care Groups (PCGs) were established in England; these were commissioning
bodies largely run by general practitioners (GPs). Very
soon they were found to be too small to be able to commission effectively,
as NHS hospitals were much larger and more powerful organisations. So
these PCGs were amalgamated into larger PCTs in 2002, and employment
of public health staff passed from health authorities (HAs) to these
new PCTs. In turn, these PCTs were also shown to be still too
small, and in 2006 were amalgamated into much larger PCTs, which looked
rather similar to the original HAs of the 1990s! So public health
departments had to reform themselves within new organisations twice
within five years. Their performance was substantially impaired
on each occasion.
Each previous NHS reorganisation produced substantial disorganisation
and demotivation that lasted at least two years. The negative
effects on the organisation’s efficiency and morale of the NHS
were therefore considerable. The NHS is one of the most effective
and efficient health care systems in the world. The idea of simultaneously
trying to extract £20billion savings while uplifting the biggest
reform in three decades defies logic.
The current coalition government intends to abolish PCTs, and to devolve
commissioning of most health services to consortia of GPs. These
emerging consortia are already becoming recognisably similar to the
PCGs of 12 years ago. We appear destined to be forced to tread
the same path again, to re-learn that commissioning bodies have to
be larger than is being proposed. An even earlier cycle of such
reform was initiated by the Conservative Government of the early 1980s,
when larger Area Health Authorities (AHAs) were abolished, to make
way for very much smaller District Health Authorities (DHAs). These
were in turn found to be much too small to be effective, and they were
required to merge to form much larger HAs.
If it is now planned that PCTs should be abolished, public health
departments will therefore need a new home, as “commissioning
groups” will be too small to provide this (as were PCGs before
them). So PCTs are to be transferred to local authorities
(to the larger tier, where there are two tiers of local government),
taking their budgets with them, supposedly “intact”. However,
various PCT chief officers are concerned that PCTs, before they give
up their public health departments, will have relieved them of responsibility
for as many funding streams as possible, so that these can contribute
to PCT “savings”. The Public Health White Paper
describes how this should occur, and indicates some of the main public
health challenges which the Government envisages will face the new
local government-based departments, and how they might be structured
to deal with these. It also indicates some of the public
health solutions which the Government hopes may be adopted in the future.
Pros and Cons of Locality based Public Health: There
are both positive and negative aspects of the proposal to move public
health to local government. The positive aspects are
about the advantages of a local authority base – not a new idea
for public health, as this is where public health was based until 1974. NHS
PCT-based public health departments had to collaborate closely with
matching local authorities, as so many public health and local government
services interact with each others. Indeed, several directors
of public health have, for some years past, been appointed to joint
posts that straddle local authorities and PCTs. Such relationships
should become much easier in the future proposed arrangements, and
services may be able to collaborate more efficiently than hitherto.
The negative aspects surround the break-up of established
PCT-based departments. These departments, operating since
2006, have just begun to function effectively, and with funding increases
to support adequate public health data analysis and health promotion
(or health improvement, as it is often called nowadays), have become
able to achieve adequate critical mass to enable them to work really
well. Their destruction will be a significant loss
to effective health improvement in England.
However, the change will not “set public health free”. Public
health departments in PCTs were often fairly criticised for too readily
adopting NHS agendas. This was often at the expense of ignoring
more major challenges outside the immediate reach of health services. If
the proposals are enacted, Public health departments will now inevitably
be dragged into the adoption of agendas that are set in the context
of local government, its problems, perceptions, and services. It
will probably be no easier for directors of public health to demonstrate
independence of thought and action than it was within the NHS.
The Public Health Function needs an Independent Voice: The
White Paper proposes that they should share accountability to both
the local authorities which employ them, and to the Department of Health
(or perhaps to new “wholly-owned subsidiary” to be called “Public
Health England”). Ironically, this is proposed by a Government
supposedly supportive of the “devolution of power and authority” away
from the centre! Furthermore, will DPHs (or DsPH?) be free
to lead their departments in practising genuinely science-based public
health? There are inconsistencies and paradoxes in this approach.
The current Secretary of State has stated his opposition to what he
calls “nannying legislation”. This is what others
might call effective public health leadership. Previous impressive
examples include clean drinking water, effective public sanitation,
legislation to ban tobacco advertising, smoke-free indoor public areas,
compulsory wearing of seatbelts, plus elimination of asbestos from
workplaces, and arsenic from food etc. Health education itself
was found to be largely ineffective over forty years ago (eg the people
kept on smoking). It only became effective when supported by
environmental changes (often legislative ones) which made healthy choices
easier. However, the current Secretary of State opposes all
such modifications of the physical and social environment in the interests
of public health. His White Paper instead advises public health
departments instead to “nudge” populations towards healthier
lifestyles. On its own, this is a flawed and ineffective strategy,
lacking supporting evidence and much criticised in recent papers in
the BMJ and Lancet.
Conflicts of Interest: Another very
worrying sign is the willingness of the Government to invite major
food industry firms to work with the Health Department on “healthy
nutrition initiatives” as part of the Responsibility Deals. There
are clear worries about blatant conflicts of interest, based on past
business loyalties.
Evidence Based Policy: The
recent NICE CVD Prevention report reviewed extensive evidence. The
most effective policy levers are legislation, regulation tax and subsidies.
These have all been explicitly ruled out as “Departmental Diktats”. Instead,
voluntary agreements are being developed. These were evidently
ineffective during forty years of failed tobacco control. More
recently voluntary agreements have been proven equally ineffective
in promoting healthier diets in the USA and in Europe. Public
health science runs a grave risk of being left outside the new public
health service in England. This is reminiscent of the Conservative
Government of the early 1980s and its suppression of the Black Report,
that potently exposed social inequalities in health.
Recent events are worryingly similar. In December 2010, the
Government cancelled over a dozen ongoing and planned NICE Public Health
reviews. These covered key topics such as work
on obesity.
The UK government has also told the National Institute for Health
and Clinical Excellence (NICE) to suspend its work on the prevention
of obesity using a ‘whole-systems’ approach at local and
community level.
NICE has also been told not to start work on several programmes that
were being prepared, including:
- Increasing fruit and vegetable provision for disadvantaged
communities
- Identification and management of overweight and obese children
in primary care
- Developing transport policies that prioritise walking and
cycling
- Using the media to promote healthy eating: guidance for
policy makers, food retailers and the media
- Identification and weight management for overweight and
obese children: community based interventions
The Role of Government in Protecting Vulnerable Groups: In
times of hardship, affluent communities can move ahead while those
serving deprived communities will have less resilience to cope with
the substantial cuts in public services. This is no time for
the Health Department to neglect its Governmental role to protect the
weakest in society. Furthermore, when ministers try to justify
their radical reform proposals (eg in other documents supportive to
the White Paper), they construct an image of poor health in England,
but often using very misleading statistics. In fact, several
health indicators have improved markedly over the last 10 years. Ministers
alleged that the mortality rate from coronary heart disease is twice
as high as in France. In fact, John Appleby of the King’s
Fund has shown that, if current trends continue, England will soon
have a lower coronary mortality rate than France {BMJ 2011}.
Proposals for the Public Health Function: Service
public health in UK has three main sub-specialties: health promotion,
health protection, and planning and evaluation of health services. Consideration
of each of these in the context of the reforms proposed:
- Health promotion: “health improvement” departments
will move to local authority departments, and directors of public
health will retain responsibility for these services; here the future
seems reasonably clear.
- Health protection (mainly environmental health and
communicable diseases control): most of the consultants
(and other staff) working in this field are employed by the HPA. This
however is to be disbanded; how services will be reorganised accordingly
is far from clear.
- Health service planning and evaluation: this will be the
field of the new GP-led “commissioning consortia”. Will
they invite the assistance of those individuals with a mass of experience
and expertise: public health consultants, hospital consultants, and
other stakeholders, into their work and discussions? Again,
the future is far from clear.
CONCLUSIONS
This public health White Paper has some merits, but it does appear
to preface:
- Uncontrolled marketing and consumption of damaging amounts of junk
food and sugary drinks;
- Major disruption of currently effective public health departments
and services;
- Impoverishment of successor departments through pressure and erosion
of their budgets;
- Reduction of local accountability of public health departments
and their directors;
- Removal of parts of the scientific basis for public health practice
from practical application;
- Slowing the rate of improvement of health status in English communities;
- Increasing inequalities in health.
In response to the Questions of the White Paper
- Role of GPs and GP practices in public health – are there
additional ways in which we can ensure that GPs and GP practices
will continue to play a role in areas for which Public
Health England will take responsibility?
This College
welcomes the central engagement of primary health care as an influence
in public health. The governance of GP commissioning and GP consortia
will influence the extent of the real engagement with the public and
services users, with patients as co-producers of health. This
line of accountability for the performance of GP consortia, their priorities
and delivery of care together with influence and determinants of health,
is a crucial aspect of the strategic proposals. Additional ways,
therefore, must include governance and accountability, harnessing all
available skills for pollution-based health; secondary outcome-based
objectives for GPs and GP practices in respect of public health; including
the many objectives in the reduction of specific inequalities that
are relevant to national policy and local circumstances; harnessing
around GPs and GP practices core public health capacity and skills,
with suitable expertise. Public health specialists should be
at the core of primary care organisations, GP practices etc.
- Public health evidence – what
are the best opportunities to develop and enhance the availability,
accessibility and utility of public health information and intelligence.
The best opportunities
should be enshrined in clear strategy, sustained investment which bears
the fruits of political courage and reasonable resources. Strategic
leadership should be in touch with networks of many stakeholders including
the academic and public health leadership communities, interested lay
organisations and civil society. There are firm foundations and
engage a vibrant capability across the UK with respect to public health
research. It is always a challenge to shorten the distance between
the knowledge creation, evidence, implementation, policy and then practice. The
White Paper must respond to the challenge that public health science
presents, and seek to apply it.
- Public health evidence – how
can Public Health England address current gaps such as the using
of insights of behavioural science, tackling wider determinants of
health, achieving cost effectiveness and tackling inequalities?
The pursuit
of improved public health is not exclusively a matter for Government,
or the individual or community. It is an integrated and sustained
endeavour. The role of the individual in community could well
be enhanced through this strategy. However, cultural change,
empowerment and involvement at local levels are more important than
structural change which, by itself, will not achieve the ambitions
of this strategy. Public debate on evidence, and shifting consensus
to take the UK into the environment of “pro-health culture” could
be the vital contribution forward for public health at this stage. This
will require concerted efforts of Government, the public health community,
NHS leaders including those in general practice, and the wider society
in order to achieve these gains. These are where the important
current gaps lie, in our view.
- Public health evidence – what
can wider partners nationally and locally contribute to improving
the use of evidence in public health?
The text that
follows – on “Our vision for the Public Health workforce” – is
central to answering this question. If there is a positive and
confident vision for the public health workforce, then they will be
in a position to engage with wider partners to produce an environment
that will improve the use of evidence in public health. There
is always the risk that use of evidence is selective and partial, that
interpretations vary and forward movement towards improving public
health is lost in debate away from the main purpose. Public
health specialists have the skills and the common knowledge and understanding
of evidence and its limitations that can allow wider engagement and
debate across civil society in health improvement. In their new
local setting of local authorities, there are many opportunities to
improve the use of evidence, and its influence, on the public health. Education
alone is insufficient to change behaviour. This is an example
of selected use of evidence that the “responsibility” deal
must tackle.
- Regulation of public health
professionals – views on Dr Gabriel Scally’s report.
In the previous
paragraph, the text states that “professional regulation is a
devolved matter” – we disagree and believe it is not. Registration
should be a function of professional life that is kept separate from
standard setting and the pursuit of professional interests. As
such, voluntary regulations should not be the function of any of the
Academy of Medical Royal Colleges or their faculties. Recent
experience with the professions of psychology and pharmacy highlight
the need for separation of responsibilities, and it would be inappropriate
for the speciality of public health to take on this role. Any
voluntary regulation scheme should be closely associated with the Council
for Professional Health and Regulator Excellence, eventually self funding
but closely allied to an organisation that is robust and independent
in terms of governance. If the public health function is of central
importance to Government, any strong and durable regulatory environment
should be in its interest. Therefore the eventual answer to this
question is in the Government’s core interest.
The Royal College
of Physicians of Edinburgh is an organisation closely associated with
the Faculty of Public Health in the UK. The College endorses
both the advocacy and the concern of the Faculty that will be represented
to Government on the subject of the strategy and will follow closely
the extent to which their concerns are addressed in future arrangements. The
long term health of the public health function as a bedrock for the
delivery of better public health in the UK, as in England.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[30 March 2011]
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