05 March 2004
When the NHS was established in 1948, Nye Bevan believed its effect on the nation's health would be so profound that future governments would not have to increase its budget greatly.
But far from becoming the national health service of Bevan's dreams, the NHS developed into a national ill-health service, which fights to cope with ever-growing demands on an ever-increasing budget. Health promotion initiatives have come and gone without making a lasting impact – but last week the NHS was challenged to end this cycle.
The report by former NatWest bank chief executive Derek Wanless has put public health firmly at the top of the agenda, not just for health service organisations but also for local government and the voluntary sector. A survey this week – showing that working-class families north of Watford and in Wales are the most likely to get type 2 diabetes – will increase the demands for action.
It is significant that the Wanless report, Securing good health for the whole nation, was commissioned by the prime minister, chancellor and the health secretary. This triumvirate is clearly hoping for a more collective approach to tackling the nation's ill health.
As Wanless noted, the NHS and local authorities are involved in many initiatives to encourage healthy eating, exercise or smoking cessation but they are uncoordinated and unsuccessful.
Wanless's prescription for a healthy nation includes a national framework of objectives for all the key risk factors, such as smoking and obesity. These were two of the main preoccupations of the government's public health consultation launched by Health Secretary John Reid this week.
Wanless added that primary care trusts and local authorities should agree joint local targets after considering the national objectives and local needs.
These targets should be reinforced through the NHS and local government performance management and inspection systems. Local government and NHS public health targets, enshrined in the Comprehensive Performance Assessment and the Priorities and Planning guidance respectively, should be the same.
Understandably, health service organisations are wary of more targets, especially as the Wanless report was published barely a week after Reid apparently promised fewer targets for the NHS.
'Our view is that we are not going to be able to achieve what Wanless wants to achieve if the NHS has to concentrate entirely on the things it has had to focus on in the past, like waiting lists. Public health targets must not be crowded out,' says Janice Miles, NHS Confederation policy manager.
Faculty of Public Health president Professor Sian Griffiths agrees the government will have to tread carefully when setting targets. 'There is a need for a balance between government regulation and individual responsibility. Emphasis needs to be placed on achieving this balance to avoid victim blaming. As the report indicates, many of the issues it raises have been made before – now is the time to act.'
She adds that, to succeed, public health specialists will need a framework for action as suggested in the report.
Local authorities and NHS organisations have been collaborating more in recent years through Local Strategic Partnerships, pooled budgets and joint staff appointments.
Joint performance assessment and management in public health will only increase this trend, but Miles does not believe a merger between health and social services is on the cards. The agenda set by Wanless means that collaboration with local government must now be much wider than just social services, she argues.
'There is a greater realisation now that the joint approach is better for many services, particularly between health and social services but also with a broad range of local government departments,' Miles says.
This is reflected in the report. Wanless called for a national strategy to develop the public health workforce, which could include the creation of new jobs, such as smoking cessation officers. But he adds this strategy must include workers whose duties can help promote good health.
Jonathan McInerny, Local Government Association education and social policy project officer, agrees with this analysis. 'We need to draw on the skills and experience, not just of doctors and clinicians but of all staff who can affect people's health, including social workers, housing officers and people working in transport and environment. This is particularly true of deprived areas.'
A renewed focus on improving public health through collaboration is clearly welcomed by those on the front line. Ministers are serious about health improvement and will publish a white paper later this year. There have been many false dawns before but, like a GP advising an overweight man to adjust his lifestyle, public health professionals will be hoping they take Wanless's recommendations to heart.