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A new approach to public health

Dominic Harrison, joint director of public health, engagement and partnerships at Blackburn with Darwen Borough Council, highlights the need to move towards a preference based social model of healthcare.

Joint director of public health at Blackburn with Darwen, Dominic Harrison, gave an empowering speech to the Local Government Association Annual Public Health Conference in February on the need to move towards a preference-based social model of health.

PSE attended the conference, and caught up with Harrison afterwards for more on the challenges and opportunities this transfer of responsibilities presents.

Despite huge amounts of funding and critical work on treatment of disease, the NHS has little impact on measures of life expectancy, only reaching around 15-20% of the health status of any population. An LGA delegate later pointed out that the NHS would be lucky to affect even that much of the UK; with a small amount of control difficult for any national organisation to achieve.

Harrison commented: “As soon as you get that, what constitutes effective health policy and health intervention becomes quite a different debate to the one we’re used to having.”

Investment in the NHS has generally focused on managing illness and, in public health, on lifestyle services. But this is only “a small part of what could make a difference”, Harrison said.

Changing hearts and minds

As responsibility for public health transfers to local government, Harrison described the need to move from an evidence-based medicine system in the NHS to a preference-based social model of health.

He said: “As we’re being exposed to local government decision making processes, what’s become more obvious to me is that there is another tier in local government decision making which is persuading, cajoling, giving evidence to and proposing options for elected members.

“It’s not simply a technical exercise in terms of changing public policy at local government level to improve health; there needs to be an understanding that hearts and minds need to be changed and we need to understand what drives elected members’ preferences for different policy options.”

A good example is 20mph speed limits – which if implemented could have a significant impact on child mortality.

Harrison said: “20mph is a choice of whether to allow people to die from predictable, acknowledged, known causes, or not.”

He told PSE: “We have the evidence but it isn’t implemented, so what’s stopping us doing that? It’s preference.

“Public health needs to understand some of that dynamic much more in order to have influence and to achieve the health outcomes it needs, to understand how to mobilise opinion.”

Symbols of care

This has also been evident in the hot topic of hospital closures that have seen public opinion flare against NHS decisions. Harrison noted it was another area where “we haven’t been sophisticated enough yet in helping to change public opinions”.

“People support and defend hospitals because hospitals symbolise for us our willingness to care for each other. Often when people defend hospitals they are defending that value.

“Everyone wants to hold on to their local hospital, even if that money would be better spent with their local GP who could keep them healthy and safe at home.

“We know that centralised care, with experts who do a particular clinical intervention every day, is safer and has better outcomes.

“But of course the trade-off is that you have to travel to get there and that trade-off – outcomes versus accessibility – is where a lot of those debates are hovering around.

“Genuinely, some people say, ‘I don’t care if it’s less safe, I want it nearer’ – that’s a value-based position, which is not unreasonable, it’s just a preference. We need to understand that.”

Loyalty and understanding

The NHS must really get inside this value, he urged, to allow managers to address the public in the most effective way when attempting service reconfiguration.

He said: “We have to create a narrative in public health capable of getting that level of loyalty and understanding.

“Because actually most of the things we might want to do in public health would have a much bigger impact and be much more caring.”

Harrison suggested that local government was in a better position to handle this, with “much better” connections with their communities and an ability to both reflect and influence attitudes to public health.

He said: “Real political leadership is an asset in communities that the NHS has never really had available to it to make a difference. There’s that opportunity to mobilise that resource around public preference and political leadership.”

Unallocated resources

The Government’s ring-fenced budget for public health means an increase for all councils on previous levels, presenting directors with “unallocated public health resource”.

This could be partly used to fund services facing cuts in other areas, but which directly impact on health and wellbeing, he suggested. “Those things which determine health and wellbeing are getting worse. Many authorities that already have poor health are going to struggle even to keep that level of poor health as it is.”

He added that safe transition of those services could significantly improve public health, although it may be difficult for councillors to show they are not simply re-labelling the existing spend instead of investing directly into health and social care services.

“Many local authorities are having to cut the very things that would affect health outcomes. That is not just rebranding public health – this is something else.

“Those priorities should protect and promote health and wellbeing. Some of those things will be things the council has been doing but is no longer able to. If they decide to put some of that money into rescuing those services, I think that’s entirely legitimate.”

This would be transparent and accountable to the DH, he explained.

“They have to defend that; it has to be open and transparent and it will be accountable back to the DH as it’s a ring-fenced budget. The idea of councils saying ‘thanks for the money, we’ll just pretend everything we’re already doing is public health’ – that’s not what I’m arguing for and I would be extremely concerned if anyone was doing that.”

The power of loneliness

One of the big ticket issues for public health is loneliness, the evidence for which is “extremely powerful and compelling”. Harrison described how the majority of NHS funding was spent in hospitals, and particularly on long-term conditions.

But this money could be better dealt with in primary care, he suggested. “In order to be more effective at dealing with those long-term conditions we need much better wellbeing services; much of which local government [is responsible for]. Not just health, but leisure centres and housing: those could be packaged together with the prevention spend as a wellbeing service. That’s a real opportunity.”

Evidence suggests that it is not the severity of a long-term condition that causes admissions to hospital, but the presence and amount of social support at home.

The biggest cause of adult social care dependence is in unmanaged long-term conditions.

Tackling fatalism

Another challenge is incentivising the public to work with the NHS and local government to improve their health. Blackburn with Darwen has the fourth worst life expectancy in England, and for some citizens, there is a complete lack of belief that there is any opportunity to change their health or behaviour, or that it would bring any benefit.

“That becomes almost a double challenge, because you need to raise expectations as well as outcomes.

“We need the public to challenge us and enable more democracy; putting things in the public domain in a way that people can understand and react to, that show both what the problems are and how people can become involved in the solutions.”

Although many would argue that the individual has responsibility for their own health, Harrison suggested that looking at the wider picture could often highlight society-scale determinants of ill-health.

“If people are ill from diseases that are avoidable, through behaviours they themselves have undertaken, you have to ask why those behaviours and consequent preventable illnesses happen in whole populations rather than just individuals.”

For example, advertising “allowed by government” to target the poor with lowquality, unhealthy food contributes significantly to obesity rates.

“To then say it’s that community’s fault for being overweight or obese seems to miss the context.

“We need to encourage people to be a little more active and angry at a political level; to be more demanding and have higher expectations of where they live – their community, their corner shop, the Government, the council – in helping create healthy environments for people to live in.”