Public health: looking to the future

Responsibility for significant public health functions, including supporting behaviour change, is being transferred from the NHS to local government from 1 April. We ask David Buck, Senior Fellow at The King’s Fund, whether the public health reforms and introduction of health and wellbeing boards will address the public health challenges we face.

Most people are living longer lives, many of which are spent in good health. But a recent report in The Lancet hit the national headlines when it said there’s still plenty of room for improvement in the United Kingdom.

The challenge

While the report showed that the United Kingdom was doing well in some areas, such as lower deaths and injuries from traffic accidents and significant improvements in mortality in older men, overall it showed that we have slipped behind many of our European neighbours in terms of improving premature mortality in younger adults since 1990.  Heart disease remains the biggest cause of premature mortality, but cirrhosis and alcohol use disorders have leapt up the rankings.

‘The report clearly shows that public health needs to remain high on the political agenda,’ says David Buck. ‘With health and wellbeing boards coming into force on 1 April and a renewed role for local authorities in public health, the question is whether the reforms will give us the right funding and mix of levers to deliver improved public health outcomes.’

‘We are optimistic about the changes being ushered in by the boards,’ he says. ‘They offer real opportunities to join up local services, create new partnerships with GPs, and help local authorities make the most of their new public health role. However, a missing piece of the puzzle is where the accountability for delivering public health improvement lies.’

Ensuring accountability

‘Accountability is opaque, diffuse and arguably not strong enough,’ argues David. The public outcomes framework sets out the results the Department of Health expects but who will be held to account for delivering these, and how?

‘The reforms rely on committed citizens holding their elected officials in local government to account for public health outcomes,’ he explains. ‘Although a worthy ideal, citizens will need time, and the inclination, to understand how the actions of local authorities affect their health; relying on transparency alone is too weak.’ The reforms also depend on ‘sector-led improvement’, where local authorities assess other authorities’ performance, through a process of peer support and challenge. Are these mechanisms robust enough when there is so much pressure on public health to address inequalities, and at a time of huge financial pressure? David thinks not: ‘There doesn’t seem to be a clear answer to what happens – and in particular what will Public Health England do – if public health outcomes stall, drift, or worse if core elements of the outcomes framework, such as life expectancy, in some communities start to go into reverse.’

Others are taking an interest in this matter too. The Communities and Local Government Select Committee quizzed ministers on accountability in the last session of its inquiry into the role of local authorities in health issues. David gave evidence to the inquiry: ‘The committee’s report is due to published very soon and I hope that accountability is highlighted as a critical issue.’

A broader perspective?

David argues that, while The Lancet report offers a very useful benchmark on progress against our European neighbours, we should also look closer to home for ideas on improving public health: ‘The Welsh government is consulting on to what extent there should be more public health regulation in Wales,’ he explains. This includes considering whether all government departments in Wales should have a legal duty to undertake health impact assessments as they develop polices.

David explains the significance of this: ‘Health is determined by a complex interaction between individual characteristics, lifestyle and the physical, social and economic environment: the houses we live in, the way we travel, our education, our economic status. All these elements impact on our health. Understanding the impact of broader policies on public health outcomes is crucial, as the Marmot Review showed.’

‘It will be interesting to see where this debate ends in Wales,’ says David. ‘They could decide on a harder line approach with a greater focus on holding government departments to account for their impact on health and regulation, in contrast to the English government’s focus  on a more liberal approach to public health, with more reliance on voluntary agreements with industry. This will give us the opportunity for some interesting comparisons in the future.’ 

Find out more: