Public health needs to move out of the lecture hall and into the living room, according to Anne Milton MP, Parliamentary Under Secretary (Public Health), speaking at The King’s Fund last week. She is right in one sense. Public health is everybody’s business; it is shaped in part by the actions and behaviours that we undertake every day at home, at work, at play. But it is also more than that.
Our health is also influenced by our immediate environment and social circumstances. The government’s decision to strengthen the role of local authorities in public health allows for an inter-sectoral approach to improving health at the local level.
This mirrors the approach being adopted nationally through the Cabinet sub-committee on Public Health. Policies on housing, crime and education all impact on health. Local authorities also have the power to create healthier environments to support behaviour change, for example by promoting and developing leisure facilities and parks, and using planning laws to limit the number of fast food outlets and betting shops.
Emerging lessons from Total Place – now being re-branded as place-based budgets – also suggest there may be some genuine opportunities to use place-based approaches to tackle local health issues. Having the voice of directors of public health at the heart of these decisions is vital.
But there is a real danger that the proposed separation of public health from the NHS, both financially and organisationally, will mean the NHS no longer sees ‘health’ as its responsibility, only health care, and it will focus on treating ill health, not preventing it.
The NHS has a critical role to play in promoting health not just in secondary prevention, but also in primary prevention. A wide range of health professionals, including GPs, practice nurses, pharmacists, midwives, consultants and specialist nurses, have many opportunities to offer brief interventions to support behaviour change, such as smoking cessation or reducing alcohol consumption. They encounter patients at times when they may be open to change – before an operation, after a health scare, when they are feeling ill, or are pregnant.
However, these opportunities will be taken only if the NHS sees health as its core business, and that means training health professionals in the skills and techniques that work, ensuring they can direct patients to appropriate help and support, and encouraging them to value these activities.
GP-commissioning consortia should have incentives to invest upstream. But if public health funds are held separately and the responsibility for health improvement and prevention sits with local authorities, it is not clear who will make such investments, particularly at a time when funding will be under pressure. The mismatch between the geography of local authorities and GP consortia could make establishing partnerships difficult. The new Outcomes Framework will ensure that consortia are accountable for commissioning high-quality health care, but they must also be accountable for improving the health of their population. GPs will need help with this.
Research by The King’s Fund to be published later this year, including our GP Inquiry and work on the Quality and Outcomes Framework (QOF), suggests that GPs do not prioritise their role in promoting public health; they are focused more on the patient in front of them. The approach of QOF, which reduces care to items of activity and individual targets, does not help GPs stand back and see the big picture. It can prompt them to identify and manage someone with asthma effectively, but does not help them see that there is a cluster of children with asthma on a local housing estate. They will need access to the data and skills that public health specialists currently bring to commissioning in primary care trusts.
The public health White Paper, expected in the autumn, will need to address these issues and ensure they are not overlooked in the rush to reform the NHS.
Dr Anna Dixon is director of policy at The King’s Fund. This blog also appears on www.kingsfund.org.uk
