Public health: why GPs need to see the full picture

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 – introduced in the NHS White Paper, Equity and Excellence: liberating the NHS – allows for an inter-sectoral approach at local level to improving health. 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 inquiry into the quality of general practice in England 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.

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Comments

#209 Charlie Mansell
Research and Development Officer
The Campaign Company

A very useful summary of the current situation and the uncertainties around how public health will be delivered in future. There clearly needs to be a proper debate.

One of the issues is innovation in behaviour change. Do we (or GP's on the front of the latest Observer newspaper) just keep rationally telling generally poor people they are "wrong" and behaving badly when perhaps we need to appeal to their emotions or develop new local social norms within their community? The "telling off" approach is hardly a two-way conversation that those in the least well off communities (often with values that fear or switch off to telling off) will automatically want to start off listening to? This is why many PCT's have adopted the deep insight and segmentation approach of social marketing to get their messages across and from my experience, that local level communication doesn't tend to ever start with moral grandstanding on the front of the Observer!

Research in social psychology and other fields tells us that perhaps we should start testing out in effect "immunising" people and their communities from some of the worst aspects of health inequality they suffer through their deeply embedded behaviour. This requires building more social capital and better social networks at a local level to increase local community resilience and greater personal motivation. Indeed, in the current financial situation, it may be an approach that delivers better outcomes, which we won't know until we allow more local innovation to test and properly evaluate at a local level the increasing academic research.

For the many years the focus has been quite rightly on supporting people's "abilities" (through providing universal education, health care and safety and security welfare services) when the future may be much more about investing in supporting people's "motivations" which will often be about people's emotional state and the state of those who surround them and wider social networks they all reside in. Funding more support for services to support peoples' "abilities", as is understandably argued through the Spirit Level or the work of Danny Dorling, is inevitably expensive and may be beyond the tolerance of taxpayers even in future good days, let alone the current financial situation? Convincing the wealthy that they will live a year or two longer if the worse off are treated better, may be a good moral case and an excellent rational argument to make to someone with the intrinsic values of myself, but rather a poor incentive to those who are healthier, but whose values may actually differ and whose financial, rather than health behaviour, it is we need to change!

Which organisation is better placed to deliver new approaches at a local level that might build local social capital and better social networks? Health providers or local authorities?

Is the caring culture of health service, set on individual health improvement, the culture where this innovation will thrive?

The commitment to ring-fence public health spend is important. How much did that happen when PCT's and their predecessor bodies delivered public health? Local authorities, already used to ring-fencing across a series of discrete services with a range of cultures and a long record in behaviour change across a number of fields, should perhaps be given the opportunity to deliver innovation here? Local authorities are also used to commissioning a much wider range of providers and that itself should drive improvement and innovation. However I cannot believe local authorities are also going to suddenly ignore the knowledge, or ability to deliver, that local health providers will be able to offer. And will suddenly health providers react badly when an organisation they have worked closely in Local Strategic Partnerships for a decade, tells then they wish to commission in a certain way. I doubt it.

We gave the health service the opportunity from 1974 to 2012 to lead on public health. They did a good job in raising health outcomes for the population as a whole, but we all recognise health inequalities generally widened. Much of the reasons for this were wider social factors clearly beyond their control, (and discussed in detail in the books I refer to above) but were they also the organisations, rightly culturally committed to a strong form of universalism, that were unable to deliver on the local segmentation and targeting that local authorities are much more used to managing. Perhaps it is time for a change?

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