White Paper on public health examined

A new White Paper foresees a devolution of responsibilities in public health, with only a minor nod towards OH, John Manos argues.

National public health service for England to be launched by 2012

Publication in November of the White Paper Healthy Lives, Healthy People: our strategy for public health in England by the Department of Health, signalled the start of a radical reorganisation of state-funded public health activity in England, scheduled to be complete by April 2012, subject to the necessary primary legislation being passed. It follows the earlier White Paper, Equity and Excellence: liberating the NHS, that outlined how the NHS, and its funding, are to be reorganised, including dismantling of existing primary care trust (PCT)/strategic health authority structure and the establishment of a new NHS Commissioning Board.

While the public health White Paper makes only limited reference to occupational health, it is proposed that local directors of public health (who will be appointed jointly by the new national public health service and local authorities) should collaborate with local businesses on “health at work” issues. The rationale underpinning the proposals is similar to that employed by Dame Carol Black to support her proposals on work and health in 2008.

Among the Government’s key proposals is devolving responsibility for leading many local public health activities to local government, including allocating ring-fenced budgets for public health to upper tier and unitary authorities. Directors of Public Health, currently based in PCTs, will move to local government.

This devolution involves “radically shifting power to local communities, enabling them to improve health throughout people’s lives, reduce inequalities and focus on the needs of the local population”, the White Paper says.

Public Health England to be established within the Department of Health

A new public health service – to be called Public Health England and be an integral part of the Department of Health “will harness the efforts of the whole of Government to improve the nation’s health”. The new service “will have a new protected public health budget and will support local action through funding and the provision of evidence, data and professional leadership.”

Directors of public health, who currently exist within the health trust structure, will be appointed (jointly with Public Health England) within local authorities with responsibility for achieving public health outcome goals specified in local “strategic needs assessments” drawn up by local authority health and wellbeing boards.

Public Health England will absorb the majority of the current functions of the Health Protection Agency, including its regionally located Health Protection Units, its regional microbiology laboratories and its emergency response and chemicals, poisons and radiation protection centres. It will direct certain public health activities at national level such as: collation of disease monitoring and surveillance data; coordination of national “resilience” against public health threats – response to flu pandemics, emergency response preparedeness – etc.

Focus on lifestyle-driven health problems

The White Paper contains considerable discussion of the health improvement “domain” of public health – ie “positively promoting the adoption of healthy lifestyles”. It notes, for example, that two big threats to public health – obesity and diabetes – are amenable to lifestyle changes and discusses how nationally coordinated health improvement strategies on obesity, tobacco control and sexual health are to be the subject of further separate policy documents during the coming year.

In his foreword, health secretary Andrew Lansley refers to the “alarming” scale of lifestyle-driven health problems. “Britain is now the most obese nation in Europe. We have among the worst rates of sexually transmitted infections recorded, a relatively large population of problem drug users and rising levels of harm from alcohol. Smoking alone claims over 80,000 lives every year.

“Experts estimate that tackling poor mental health could reduce our overall disease burden by nearly a quarter. Health inequalities between rich and poor have been getting progressively worse. We still live in a country where the wealthy can expect to live longer than the poor.”

Examples are given to illustrate the extent of health inequalities (in England) that warrant locally tailored interventions: mortality from heart disease in the Birmingham area, for example, is shown to correlate strongly both with failure to register with a GP and with high levels of deprivation.

The White Paper notes that government proposals covering specific health promotion/protection areas are to be published during 2011, “including on mental health, tobacco control, obesity, sexual health, pandemic flu preparedeness, health protection and emergency preparedness, together with documents from other government departments addressing many of the wider determinants of health”.

As part of the economic case, the White Paper refers to the estimate made in Black’s 2008 report that up to £100 billion a year could be saved by reducing ill health among the working-age population.

Except for this reference to the Black report, the public health White Paper makes limited reference to the role of occupational health in the new arrangements. It is noted that a preventive approach to mental health could help reduce the near-10 million working days lost per year due to work-related stress, depression and anxiety.

However, a greater focus is placed on achieving health improvements among the young and old, including the cost benefits to be gained through: preventing many of the yearly excess winter deaths – 35,000 in 2008/09 – through warmer housing, and preventing further deaths through full take-up of seasonal flu vaccinations; avoiding a substantial proportion of cancers, vascular dementias and more than 30% of circulatory diseases; saving the NHS the £2.7 billion cost of alcohol abuse; and saving society the £13.9 billion a year spent on tackling drug-fuelled crime. The changes are to be enshrined in a health and social care bill, due to be published later in 2011.

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