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.
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?
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?
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?
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.
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?
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?
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?