The new public health strategy for England

The government’s new public health strategy for England, Healthy Lives, Healthy People,1 is a welcome commitment to protecting and improving health and reducing health inequalities. Action is clearly needed. Although people are generally living longer, the overall burden of chronic physical and mental ill health is increasing,2 and the poor are worse off than the rich. If, as some have predicted,3 the recent comprehensive spending review affects the poor more than the rich, this is likely to be exacerbated⇓.4

• Download figure
• Open in new tab
• Download powerpoint

The strategy, which promises to be radical and new, is evidence based and rooted in an approach that engages and integrates the efforts of national and local government, the NHS, charities, schools, higher education, voluntary groups, businesses, and employers. The strategy accepts a place for government leadership and, albeit when other approaches have failed, for regulation. However, it takes the view that the balance of responsibility and action should shift from central government to local communities, and that people should be “nudged” towards taking on more responsibility for their health by living more healthily. A cabinet subcommittee has been established to engage relevant government departments, and the strategy includes an encouraging list of related initiatives.

In the spirit of national engagement, county and unitary local authorities will employ the local directors of public health and their staff and will be given increased powers and responsibilities for health, supported by ring fenced public health budgets. Local authorities will be required to set up multiagency health and wellbeing boards to review local needs and coordinate responses, informed by their director of public health’s independent annual report. A new organisation, Public Health England, will be established within the Department of Health and will combine the current functions of the Health Protection Agency, National Treatment Agency, and regional public health teams and observatories, together with some existing national policy and response functions. Directors of public health will be “jointly appointed” by and accountable to the local authority and the secretary of state for health through Public Health England, and they will work at the interface of national and local agendas.

The aim of these reforms is to place public health leadership and expertise at the heart of local and national decision making. Opportunities for making a sustained impact on health exist but the risks are high. Local authority budgets are under pressure, and the current changes must take place alongside what is arguably the biggest NHS reorganisation since 1948. Successful public health work depends heavily on effective working relationships between key local players and on a clear understanding of local contexts. The new arrangements will take a while to achieve their full potential, during which time serious disruption to public health activities could occur. The implementation timetable extends over more than two years. Local authorities’ budgets will not be ring fenced until 2013, and despite the government’s expressed intent to protect public health, cost reductions that are currently being implemented through existing systems could result in a greatly depleted public health workforce before then.

Public health is “the science and art of protecting and promoting health and wellbeing, preventing ill health, and prolonging life through the organised efforts of society” (www.fph.org.uk/what_is_public_health). It takes a multifaceted approach and a societal perspective, and it must be rooted in coherent coordinated action that is focused on the population rather than the individual. Some public health initiatives, such as slum clearance and ensuring clean air and water, work exclusively at a population level. Others, such as those targeting smoking or infectious disease, require a suite of synergistic interventions from government regulation to clinical advice and treatment. The good health of the population requires action in each of the three “domains” of public health: health protection, which is concerned with infectious disease, disasters, and environmental hazards; health improvement, which deals with lifestyle and the wider determinants of health and wellbeing; and the provision of effective, appropriate, and accessible health services.

Although the new strategy acknowledges the importance of the healthcare domain to public health it makes few solid proposals. A public health outcomes framework which is, as proposed, separate from those for the NHS and social care, is unlikely to stimulate collaborative working unless outcomes are common to all three. The strategy recognises and encourages primary care’s contribution to the public health agenda but says little about the enormous potential contribution of other medical specialties. The new general practitioner commissioning groups will need public health advice, and directors of public health will be expected to support them. Detailed arrangements will have to be negotiated soon, at a time when the local public health landscape will be far from clear.

The director of public health, sitting at the local authority’s top table and working closely with colleagues from the NHS, other authorities, and the private and third sectors, should be a powerful force driving changes that improve people’s health. However, they will have limited power if their position is too junior and if they have few supporting staff. The strategy is, so far, silent on the nature and scale of the infrastructure likely to be available to directors of public health. The success of local initiatives could be enhanced greatly if the proposed national “responsibility deal” between government and the private sector has tangible relevant outcomes. Precious time could be wasted and confidence lost however, if—as seems to have happened in the United States5—industry does not take its voluntary agreements seriously.

Will the strategy achieve its overall objective of streamlining the system and providing a “clear line of sight” from the government to the front line in emergencies? As yet, it is not clear who is accountable and who will be in charge in the new system, particularly regarding health protection issues, where success depends so heavily on clarity of responsibility. Further discussion is urgently needed.

Healthy Lives, Healthy People has huge potential. But the step changes it is hoping for will depend on determined implementation and strong leadership, sustained over time, and on each individual being inspired and enabled to make his or her own contribution.