Dr John Middleton
Director of Public Health,
Sandwell Primary Care Trust
UK Faculty of Public Health
John has been Director for Public Health in Sandwell for 21 years. His principal interests are environmental health and sustainable development, community safety, prevention of violence and human rights. He is Chair of the West Midlands Teaching Public Health Network, Honorary Reader in Public Health at Birmingham University and Honorary Senior Research Fellow with the Warwick University Business School
The English public health system is set to undergo a radical overhaul for the first time in nearly 40 years. The government's white paper Healthy people, Healthy Lives was a response, the government said, to policy failures in public health that mean:
But what is 'public health'? The white paper uses the definition from the UK Faculty of Public Health: "The science and art of the protection and promotion of health and wellbeing, the prevention of disease and the prolongation of life, through the organised efforts of society."(2)
This is clearly a very broad set of activities that includes the individual advice and health information provided in general practice as well as public education campaigns, practical preventive medicine such as immunisation and screening, and wider regulatory activities (eg, tax and laws) to create healthier behaviours in the whole population – for example by wearing seat belts and reducing public smoking.(3)
The strategy calls for an engaged, integrated, evidence-based approach in which the NHS, national and local government, schools, charities, industry and so on all play a part. It is very much about shifting responsibility and action to local communities and individuals.
A new service, Public Health England (PHE), will pull together functions such as the Health Protection Agency, the National (Drugs) Treatment Agency and the regional public health teams and observatories. It will be responsible for providing high-quality public health intelligence and the evidence base to drive new health improvements.
PHE will also oversee the allocation of ringfenced budgets to local authorities and delegate commissioning of health service public health tasks such as immunisation and screening to the NHS Commissioning Board. Top-tier local authorities will be given increased powers and responsibilities for health strategy: for public involvement (through HealthWatch) and public health improvement.
Directors of public health and their teams will be appointed and accountable both to the local authority and, through PHE, to the chief medical officer and to the secretary of state for health. Their teams will deliver health needs analysis, health protection and health improvement programmes, managed either by the team or commissioned from a range of healthcare services, voluntary and community providers and other agencies.
Local authorities will hold a ring-fenced public health budget and this will need to be deployed to achieve a series of public health outcomes. A health premium will be available for areas with the greatest health inequalities, with rewards for achievement and otherwise.
Health and Wellbeing Boards (HWBs) will be set up to review local needs, based on the independent annual report by their public health directors and the joint strategic needs analysis. Local authorities will lead these bodies, but clinical commissioning groups (CCGs) are members by right and given equal status in determining the agenda. The recent Future Forum report recommended that HWBs' role should be strengthened and that they "should agree commissioning plans".(4) This led to the government announcing in June that HWBs should have the right to refer back local commissioning plans that are "not in line with the health and wellbeing strategy".(5)
The Health Bill confirms duties of engagement, partnership, quality and reducing inequalities on NHS commissioners and public health. HWBs used well will be vital forums for determining local health strategy and agreeing joint commissioning in areas such as mental health services, learning disability and other services for people with disabilities and drug and alcohol problems.
They can also become powerful vehicles for agreeing important public health policy interventions such as housing and welfare rights, based on their local knowledge of primary healthcare. However, if they work badly the potential for arguments about cost shunting from health to social care and back will be considerable.
The companion consultations – on the outcomes framework and the funding and commissioning routes – show how difficult it will be to separate public-health functions for the NHS-funded streams. There are four pages of proposals for how different services should be funded. Screening and immunisation are problematic, as is the recruitment of the new health-visiting workforce for early years – they will be funded in part from the ringfenced PHE budget, delegated to the NHS commissioning Board to pay GPs and other NHS providers.
But currently much routine administration, for example patient registration, isn't 'commissioned' but is rather 'co-ordinated'. So arguments may arise in future about who pays for what.
PHE will also hold an element of Quality and Outcome Framework (QOF) money, which will be administered according to achievement of public-health outcomes. This will give HWBs and GP practices another compelling reason to work together.
The white paper uses a life course approach to improving health, which it attributes to recommendations made in the Marmot review of health inequalities in England, Fair Society, Healthy Lives. This highlights six main areas for reducing health inequalities: improving early years family support; improving opportunities for young people; improving health in the workplace and for people of working age; improving the quality of physical environments and housing; reducing inequalities in income; and providing health improvement interventions that reduce the gradient of poor health across society.(6)
Primary care can contribute the most to this latter area. Tudor Hart's 'inverse care law' described how the people who are most in need of good care are the least likely to get it.(7) The QOF has not changed this – the last 10% of the population in the target are likely to be the most needy.(8) Better use of information systems in primary care and partnership approaches with public health specialists and community agencies, to ensure take-up of services, will help to address the inverse care law.
The role of primary care in public health
There will be an ever-more-pressing reason for co-operation between the disparate arms of the new health system. Reducing the cost of healthcare will be necessary – either through efficiency savings or preventing ill health. To achieve this, primary care will have to work together with public health specialists: GPs providing clinical insight and public health specialists providing the population perspective.
Primary care has a key role in the direct management and support for preventive care in the surgery. GP advice, for instance, about stopping smoking works and GPs need to have available back-up from the public health lifestyle services to improve population health.(9)
From the commissioning viewpoint, GPs will need to take a more studied and systematic population approach to deliver preventive healthcare better. But public health specialists will need to listen to what GPs have to say and help them address problems in the community in more effective ways. GP commissioners will need more focused health needs assessments and plans to address problems in their communities, rather than merely those of the individual patient they see in the surgery.
This is already happening in many parts of the country. For instance, the cardiovascular risk stratification tools, developed by Tom Marshall for Sandwell PCT, combine a GP's insight with a systematic practice population approach to reach the people most likely to suffer heart attacks in the near future, and thereby to avert coronary events and save lives. This is a very real way to prevent the death and disability of premature heart disease. Risk stratification is also moving forward in relation to diabetes, renal disease and case management for chronic disease.(10)
GP commissioning is expected to deliver reduced hospital admissions with savings ploughed back into practice services. To help prevent illness and hospital admission, GPs will need to be more active in promoting lifestyle intervention for
For example, Brighton PCT has extensive lifestyle referral options on its website.(11) Sandwell PCT and council operate a 'one number' referral system linking GPs or patients directly to the lifestyle services nearest and most appropriate to them.(12)
The potential to reduce admissions from alcohol-related problems is already recognised, but the same could also apply with respect to 'stop-before-the-op' smoking cessation programmes,(13) exercise on prescription, accident prevention, gentle exercise and home-safety programmes.
Built in to clinical care pathways, lifestyle programmes, such as diet and exercise programmes before bariatric surgery, or exercise and smoking cessation before arterial surgery, are better for patient outcomes and reduce the cost of acute care. Lifestyle interventions also need to be built in to rehabilitation and regalement programmes after hospital discharge to prevent readmission.
For the first time we have some good tools in primary care that can tell us how well our local population is and how well they are being treated; not just the old public health data about what people died from! Data extraction tools such as the MSDi Information Manager, which can measure morbidity in a meaningful way in primary care, will be important in this process.
Sound information sharing will also be required between public health specialists and GP commissioners to prepare joint plans and joint commissions. National and local agreements about data sharing will be necessary – not only to protect patient confidentiality, but also to enable powerful presentations of what people in an area are suffering from and hot they can be treated better.
GP commissioners will also need the skills of public-health practitioners in the specialised role of analysing health service epidemiology and assessing the clinical effectiveness of the ever-expanding array of hi-tech drugs and equipment they will be asked to fund.
Public health, in its turn, will need to call on the expertise of the primary care team to ensure the continued high take-up of immunisations and screening programmes.
All parts of the health system will need to ensure they are willing and able to respond to major emergencies. Haggling over the price will not be acceptable to the reputation of the new national health system. We will have to maintain our collective professionalism in the face of whatever occurs: extreme weather events, terrorist attacks, foot and mouth outbreaks or the next great flu pandemic.
If primary care and public health make the most of the new health system, with a spirit of respect and a sense of purpose, we have a major opportunity to improve the health of our patients and reduce health inequalities in our population.
1. Department of Health. Healthy lives, healthy people: our strategy for public health in England. London: DH; 2010.
2. Davies L. The new public health strategy for England. BMJ 2010;341:7049.
3. Nuffield Council on Bioethics. Public health: ethical issues. London: NCB; 2007. Available from: http://www.nuffieldbioethics.org/go/ourwork/publichealth/introduction
4. Department of Health. NHS Future Forum recommendations to Government. London: DH; 2011.
5. Department of Health. Government response to the NHS Future Forum report. London: DH; 2011.
6. Marmot M. Fair society, healthy lives: strategic review of health inequalities in England post-2010. London: The Marmot Review; 2010. Available from: http://www.marmotreview.org
7. Tudor Hart J. The inverse care law. Lancet 1971;1:405-12.
8. Dixon A, Khachatryan A, Wallace A, et al. Impact of Quality and Outcomes Framework on health inequalities. London: Kings Fund; 2011. Available from: http://www.kingsfund.org.uk/publicationsimpact_of_quality.html
9. Aveyard P, West R. Managing smoking cessation. BMJ 2007;335(7609):37-41.
10. Marshall T, Westerby P, Chen J, et al. A controlled evaluation of a programme of targeted screening of cardiovascular disease in primary care. BMC Public Health 2008;8:73.
11. Lifestyle services information. Brighton: Brighton and Hove Primary Care Trust; 2011. Available from: http://www.brightonandhovepct.nhs.uk/healthyliving/index.asp
12. Sandwell Primary Care Trust and Sandwell Council. One number for lifestyle services. Oldbury: Sandwell Council; 2010. Available from: www.sandwell.gov.uk/download/2087/one_number_for_lifestyle_services
13. London Health Observatory. Stop before the op: a briefing on the short term benefits of preoperative smoking cessation in London. London: LHO; 2006. Available from: http://www.lho.org.uk/viewResource.aspx?id=10495