Blink and you missed it: the public health command paper

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Did anyone notice the release of the public health Command Paper? We were hoping that it would coincide with our recent public health summit, where Anne Milton gave the keynote address. In fact it came out the next day, with none of the fanfare seen for the consultation response to Equity and Excellence, or the response to the Future Forum.

The update is rather underwhelming. Even the biggest news – that Public Health England will be an executive agency of the Department of Health – has already been released as part of the government's Future Forum response.

The stated aim of the document is to reduce uncertainty and the update does clarify some of the funding routes (for sexual health services and immunisation for example), and reiterates some decisions, including an invite to the Future Forum to examine the role of the NHS in improving public health outcomes. However, it has now been eight months since Healthy Lives, Healthy People was released, and for those expecting answers to a torrent of critical questions raised during the consultation period – about the public health ring-fence, the size of the overall pot and how it will be allocated, and how the outcomes framework and health premiums will work in practice – the wait goes on. Instead, each of these subjects will be addressed in a series of publications due 'during the autumn'.

The Command Paper also misses a trick in failing to clarify other positive changes set out in the response to the Future Forum – the clear signal that integration is not simply links between primary and secondary care or health and social care, but should extend into public health, or that the quality premium payment to commissioning groups will now include an inequality criteria. Critically, it leaves us none the wiser on how the centre will hold local areas accountable for the use of billions of pounds of transferred NHS funds raised from national taxpayers. The nuance in the language is important here: at various points Public Health England is either 'driving' or 'supporting' improved health outcomes – how this plays out in its operating model will be critical to success.

Meanwhile time is marching on. Health and wellbeing boards are gearing up and local authorities and the NHS are discussing how local structures and decision-making will happen in the future. Those conversations are at risk of being hamstrung, since the key parameters of the debate – especially on funding – remain ill-defined. How can local partners begin planning in earnest if there is no white smoke from the Department on any of these issues?

As alluded to, the public health profession has half-won the battle for an independent Public Health England and the Department is also signalling, if not spelling out, that it expects directors of public health to be independent too. The other clear message from this update is that ministers clearly remain unconvinced about the other great concern of the profession, the case for statutory regulation.

The clear enthusiasm for many of the government's public health end-goals risks being dissipated in transition. The Department needs to step up and send stronger signals to local authorities and health bodies about the planning assumptions they can reasonably take in the run-up to the publications scheduled for the autumn. For as we all know, a Whitehall autumn could easily extend into winter, barely a year away from the system going live in 2013.


Bryan Yates

Surrey Link/Healthwatch
Comment date
01 August 2011
In August2010 I prepared an eighteen page resume on the Government's white paper for my local GP Consortia in response to the Consortia's, method of operational process.
within the past year the D.H. have changed tack on several occcisions with the result that very few Clinicians and public have a clear idear of theNHS direction.
Within the next two weeks our local Clinical Commissioning Group will be explaining their commissioning intentions to CCG and Patient Forum Groups.I await to be educated in the current mysteries of the Department of Health administration and commissioning.

Meanwhile I am heading up a Local survey on Patient/Public attitudes,opinions and wishes related to the kind of Health Services including social care,that they would require.

I fear that most of the public/patient participants of the Survey will have little knowledge regarding the current D.H. proposals.
We travel in Hope.

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