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Bringing public health home

Source: Public Sector Executive March/April 2013

Responsibility for public health is transferring formally from the NHS to local government and Public Health England on 1 April – but is everyone ready? Kate Ashley reports from the LGA’s public health conference.

Local government is ready for the challenge of taking on responsibility for public health, delegates heard at the LGA’s annual public health conference on February 26.

The event in London, attended by PSE, saw a packed line-up of key speakers from both the health service and local government, including Duncan Selbie, chief executive of Public Health England (PHE), Mike Farrar, chief executive of the NHS Confederation, Professor Steve Field, deputy national medical director of the NHS Commissioning Board, and a number of councillors and cabinet representatives from local authorities.

With a matter of days until the transition, delegates were eager to discuss the obstacles and opportunities involved in “bringing public health home to local government”.

There was a sense of readiness in many of the councils, although there was still plenty of concern over the tight timescales in others. Some suggested that while it was the right thing to do, creating new relationships with NHS staff by April 1 was proving a challenge.

A number of case studies of local circumstances helped offer a taste of different areas’ preparation for their new responsibilities and a wide range of workshops allowed delegates to debate the hot topics, including tackling health inequalities, collaborative working between public health and CCGs and an introduction to PHE.

Chief executive designate of PHE, Duncan Selbie, voiced his belief that local government had effectively prepared for the switchover.

He said: “I have been astounded by the capability and commitment and a sense of purpose for these new responsibilities. I say that without any caveat – I think you are ready.”

In just three years, he said, the sector will be looking back on the “amazing shift we’ve made”.

Citing recent research on life expectancy, Selbie highlighted the UK’s progress as far behind that of comparable EU countries.

He said: “Our obsession as a nation with what we do in hospitals; it’s quite unique in this country. Yet we know that 80%, and that’s being conservative, of what will affect outcomes, isn’t about the NHS.”

This crucial 80% included having a job, somewhere to live, people to support and care for you, and something meaningful to wake up and do every day.

The issue of isolation in the elderly was another key point; with a huge number of people aged over 65 living on their own, with little human contact. This endemic loneliness can have a major impact on their health, and thus the NHS.

The role of PHE in disseminating knowledge and information to the relevant people in meaningful ways would help local government to make choices and judgements to prioritise at a local level, he said.

“We will share with you what we think. We’ll be looking at nudging, hugging, shoving – but the one thing we won’t be doing is smacking.”

Mike Farrar, chief executive of the NHS Confederation, saw the switchover as “a fantastic opportunity” and reiterated his support for local government taking on public health.

To really inspire change, this must be seen as a duty that goes straight to the top, he said: “It can’t be something that’s done on the side of organisations. The NHS has largely seen public health as something on the side, not mainstream and core.”

Reorientating the delivery of systems to support people to stay healthy was “a very sensible move”, he added.

“We’ve created a world which is about to disintegrate some of the commissioning spend. We had health improvement spend in one bit of local government, social care for adults and children in a different bit, primary care spend with the National Commissioning Board, communities and hospital spend in the CCGs, specialised care spend with another bit of the Commissioning Board.”

Farrar continued: “The way which we use that resource is critical. CCGs and HWBs have got to have primacy if this system is going to work in pulling the resource through to all those different areas. Not just seeing this as one small part of the health improvement spend is very important. We need to be radical and ambitious about how we take this forward and there should be no sacred cows.

“Our attitude right from the word go is that we see citizens and people as assets, not needs or problems. The health service has struggled with that concept, for benevolent reasons; we don’t see that person, that family, that support, that community. I’m really hoping that local government will effectively be able to bring that mindset to the big issues that we have.”

Professor Steve Field, deputy national medical director of health inequalities at the NHS Commissioning Board, believes there is the opportunity to make a big impact on public health – but “we can’t do anything without local authorities’ involvement”.

His role was to ensure that “in everything we do, we look at the opportunity to address health inequalities”, and invest to help the health of the poorest fastest, integrating health and social care with the community at the centre.

Having health at the table with public health and with local authority leaders will “make a real difference”, Prof Field said.

He warned that there were “very strong contracting mechanisms” in place with NHS staff and will not tolerate poor care, or people turned away from appointments as DNAs.

“Resistance is futile, we will make it happen,” he said.

‘The money is there – but it takes imaginative thinking’

Public health minister Anna Soubry MP said the return of public health to local government, where it used to belong, “is certainly one of the least controversial parts of an otherwise very controversial Health and Social Care Act. It was recognised, almost universally, that is was absolutely the right and the best thing to do.”

She spoke of her confidence in local government to take up this challenge effectively and noted the impact working in public health could have on them.

“There will be some councillors who will perhaps not be as excited by this as I know some of you are.

“When you become involved in public health, the first thing you do is take a look at yourself. It will have its effect on you as well as councillors, and that will be no bad thing.

“I’m getting healthier because of the job I’m doing. It is the most fantastic challenge and there are real rewards to be had.”

Soubry described her desire to “drill right down to ward level”, with simple, inexpensive action that could make a huge difference to residents’ health.

This included smoking, she said, where local government now have the power to designate particular areas as smoke-free.

The evidence against smoking was “overwhelming”, Soubry added: “We know that if we reduce smoking levels, more people give up smoking, more people will live long, happier, healthier lives. And full credit to the last Government who introduced what was a very controversial piece of legislation.”

Statistics on children’s asthma demonstrated the dramatic impact this has already had. Soubry called for local government to work with schools, GPs, pharmacies and HWBs to identify other areas for improvement.

Acknowledging the ring-fenced budget for public health for the following two years, she said: “The money is there.

“But actually it doesn’t take huge amounts of money, it does take imaginative thinking.

“Public health is not just about leaflets and posters.”

Despite noting that many people think “there really isn’t any room for party politics” in public health, Soubry outlined how politicising the issue could lead to competition, driving up services in much the same way as happened with recycling rates.

“Because recycling became a political issue, councils will look to their own successes and criticise those who haven’t reached the same level. It became a hot topic and everybody raised their game.

“As politicians, you will have that ability and you have the tools now in the various frameworks about public health outcomes, the great directors of public health, a lot of support to help you make this happen.”

She concluded: “If we do all those things, most importantly we will see the sorts of successes that we all want, for everybody to live longer, healthy, happy lives and in particular those who start their lives from the most disadvantaged of positions.”


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