Questions to ask about the public health White Paper

The coalition government will shortly be publishing its public health White Paper, which should tackle the major public health problems – including obesity, alcohol-related hospital admissions and rates of liver disease – that remain in our society.

How will the new policies fit with the wider reforms of the health service? Here I set out some key questions that I think the White Paper should address.

1) What will the Public Health Service look like?

The coalition government has announced the creation of a new Public Health Service, which will take on a number of responsibilities, formerly under the remit of the Health Protection Agency (one of the many quangos to be abolished). Given the increasing diversity of providers and freedoms that NHS providers have what powers will the Public Health Service have over hospitals and other providers to make sure they comply with current regulations – for example, in relation to emergency planning? Will the new Public Health Service sit within the Department of Health or will it operate more independently?

2) Who will be accountable for improving health and achieving health outcomes?

Local authorities are to be given responsibility for improving health and for assessing the needs of the local population. It is expected that the White Paper will set out an outcomes framework for public health. How will local authorities be held to account for achieving those outcomes and by whom?

It is important the NHS is also held accountable for public health outcomes. Currently the NHS Outcomes Framework for assessing the performance of the NHS Commissioning Board is focused on clinical outcomes. Not including public health and health improvement in the framework risks diluting the roles of the NHS and general practice, and may give GP consortia little motivation to engage in public health. How will this be addressed?

3) How will funding for public health be defined?

Funding for local health improvement will transfer from primary care trusts to councils, and this budget will be ring-fenced. How does the government propose to calculate funding for public health? Will the new formula for public health spending adequately compensate deprived areas with higher health needs? What services will be defined as 'public health'? And which ones will fall to local authorities to fund and which to the Public Health Service or the NHS?

While bringing together health improvement with other local authority responsibilities is a good opportunity to join up locally, there is a risk of costs being shifted within local authorities and between local authorities and the NHS. For example, will GP consortia or local authorities be responsible for commissioning smoking cessation support and weight loss programmes?

4) How is the government proposing to tackle health inequalities?

The Marmot Strategic Review of Health Inequalities in England post 2010 sets out a wide range of proposals to reduce health inequalities. The coalition government are committed to reducing health inequalities, so the public health White Paper will need to explain how the government proposes to implement the recommendations set out by Marmot and improve cross-government working to tackle health inequalities. There is a real danger that in the current economic climate, with many government departments facing significant cuts, their commitment to investing in these priorities will be found wanting.

5) To what degree will the government co-operate with industry to improve public health?

The government has already set out its plans to abolish many arm's length bodies, such as the Food Standards Agency, that currently play a key role in the regulation and monitoring of industry. Will the government leave it to the food industry to standardise food labelling? Ministers were quick to dismiss recommendations by NICE for minimum alcohol pricing. Will they act to regulate the availability of cheap alcohol and introduce stricter regulation of smoking such as plain packaging for cigarettes?

6) What will the Big Society mean for public health?

Current coalition government policy emphasises the need for individuals to take a greater responsibility for their health. There is good evidence that empowering patients to take a more active role in managing their health and health care is good for outcomes and can reduce costs. The evidence on how to support behavioural change is mixed. Financial incentives and other 'nudges' are attracting attention, but there is mixed evidence of their effectiveness. Our report, Commissioning and Behaviour Change: Kicking Bad Habits, found that the use of multiple strategies, including individualised support, are required to promote behaviour change and encourage people to improve their health.

The public health White Paper needs to set out how the government will support individuals to change their behaviour and improve their health. Will the government's emphasis on personal responsibility mean there will be consequences for individuals who choose unhealthy behaviours? Will the government signal a greater role for the voluntary sector in supporting people to stay healthy or encourage greater use of lay volunteers and health trainers?

7) What will the public health workforce of the future look like?

The NHS also has an important role in promoting health and preventing disease. The public health White Paper needs to set out how others working in the NHS, including GPs and staff working in secondary care, will be trained and supported to encourage healthier behaviours. Will there be incentives for them and the organisations that employ them to undertake preventive activities?

There is a danger that the delivery of public health will become fragmented and the small workforce with public health expertise will be dispersed across multiple organisations and sectors. It is vital that appropriate training and support is available to maintain sufficient public health expertise. How will the White Paper ensure that this happens?

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#268 mandy

My concern about Public Health moving to the local authority, is that over time it will be diluted and subsumed into the authority which is politically is it possible to have a national Public Health service run by a local authority? How can it then be a National service if it is not nationally led......and if it is to be nationally led how can it sit comfortablly in local authority........confused public health worker........

#269 Charlie Mansell
Research and Development Officer
The Campaign Company

I'm interested to see whether the funding formula is based on local deprivation indices, or whether any historic local funding will transfer from PCT's to local authorities? What happens if a PCT is found to have spent above average on public health, but the formula for it is quite low?

#270 Philip Leech

It looks as if they are already planning to raid the PH pot to pay GPs - for QOF, which is already funded. Is this what the PH 4bn is for?

#271 stuart brown
Sing For Your Life

Will the funds given to Local Authorities be ring fenced?

Local Authorities are notorious for diverting funds away from the work they are intended to support

#273 Carol Hunt
Practice Manager
Howden Medical Centre

During this transitional stage of GP Commissioning many localities have identified a small number of GP's currently involved with Practice Based Commissioning to meet with their respective PCT staff to understand their functions and which of these are to be replicated by the Commissioning Consortia. Whether the same GP's will be chosen to sit on the GP Commissioning Consortia Board is another question. During this transistional stage it would be interesting to learn how many GP transition groups in the country are talking to local councils to discover what they are planning to do and how they intend to do it. Are the councils actions likely to match the intended outcomes of the GP Commissioning Consortia. I would also like to know what are the expectations of Practice Managers in this process, after all this is GP Commissioning not Practice Manager Commissioning.

#274 John Kapp
Secretary of SECTCo
Social Enterprise Complementary Therapy Company SECTCo

Well said. Health inequalities which are caused by the rich being able to afford complementary therapy, and the poor not. There are 6 such treatments which are NICE-recommended, to which every patient has the statutory right under the NHS constitution. They are the Mindfulness Besed Cognitive Therapy 8 week course, spinal manipulation for low back pain, and hypnotherapy for IBS. These are clinically appropriate for 3 out of 4 patients in primary care, but are provided at present in such small quantity that the waiting list is thousands of years. SECTCo exists to provide these free at the point of use on the NHS (see If replicated throughout the country, this could halve the public health statistics by 2016, which is what the changes in public health administration should promote.

#275 Mr Chris CCR Pa...
Managing Director
County Durham Furniture Help Scheme

The NHS is the envy of the world but it is not perfect. The provision of therapies is a ‘post code’ lottery. As a disabled ex-serviceman I have had to find my own therapies (Pioneer Care Centre) and create a non profit company (CDFHS) to provide a range of therapeutic work for people who have been unemployed due to illness (mental or physical) as well as ex-offenders and those who, for various reasons, have been long term unemployed, to return to employment by giving them work experience and the chance to learn new skills in a friendly non-judgemental environment.

#276 Charlie Mansell
Research and Development Officer
The Campaign Company

Now that it is published, it is clear that there needs to be more research into the effectiveness of Nudges and the Kings Fund has a key role.

Since Nudges are often expressed in terms of the percentage of people who comply with them, it is clear that there is a need for research into whether target groups of the least healthy will most benefit. I have blogged about going beyond standard demographics and utilising at motivational values segmentation here:
The Economist has published a good article on the White Paper. Is the new "stealth public health" of Nudges similar to the Blair/Brown era of "stealth taxation"? ie short-term gains, but long-term cynicism?

#277 Mr. Suresh Bhachawat

Nobody thinks much about the common things like reception staff's behaviour, difficulties in obtaining GPs' appoitments, referrals by the GPs to the specialists at the hospitals, effects of illegal migrants who are the greatest sources in making this country as 'poor'.

Patients do not appointments with their GPs due to inability to get connected to their surgeries telephone lines and if the ltheir lines get connected the no immediate appointments. The GPs also do not bother much to listen to their patients and help them to provide proper care. Most of the times,the patients are neglected by their GPs.

And if referred to a hospital for a specialist treatement, the hospital consultants also do not care properly.

And going to the A & E Department is not somuch helpful as the patients are either not attended and treated properly.
If a patient complaints about some kind of abnormal headache or bodyache, he is simply prescribed painkiller or aspirin tables while those complain about stomach or any kind of pain their colon are simply said to be suffering with constipation without making proper investigation.

Similarly, patients having chest pain are treated as if they are having a simple or common pain while no serious inestigation takes place.

The PCT centers for surgeries and PALS at the hospitals enter patients' complaints with zero results by defending their medical and non-medical staff.

These may be small matters but they certainly be more painful in future and increase the financial budgets of the hospitals every year. But who cares? Certainly, nobody bothers to such things

Why not surgery bookings are made through online instead of waiting a response from the receptionist and ringing the telephone bell for a long time which causes sharp rise in the telephone bills because many of the GP surgeries have now
changed their telephone numbers to premium call numbers?

Why consultants are not allowed to refer from one department to other in the hospital when it is necesary instead of referring the patients back to their GPs
surgeries and stretching the duration of treatment for a long time and more inconveniences to the patients?

There are matters that may seem or appear small and negligeble but resolving them in an approrpiate way could reduce the financial budget of the surgeries and the hospitals.

Transferring PCT services to the local Coucil as well as abolishing the posts of Practice Manager while imposing the financial liabilites on doctors at the Surgeries will not be helpful to the patients as they will create more complications.

Hope, these small suggestions will not be neglected but would be looked at without ignoring them.

There are still more ways to reduce the financial burdens.

(Mr.) Suresh Bhachawat
Greater London

#278 Mr. Suresh Bh...

The Prime Minister, Mr.David Cameron should ask and make the survey by asking to the citizens - especifically, the retired and pensioners - "How unhappy are they with the policies and working of the present Government instead of asking them: "How happy they are?"

The citizens should be invited debates on this and other subjects concerning their daily life instead of empowering the
officers of their various departments to harass the pensioners, retired, old and sick persons and blaming
them on taking benefits for a long time.

(Mr.) Suresh Bhachawat
Greater London

#288 Alison

To Mr Bhachawat:

I find your comment racist and offensive:

"effects of illegal migrants who are the greatest sources in making this country as 'poor'."

Do you have evidence to support this allegation?

#296 Anonymous

this is gonna be the start of corruption in the NHS

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