Taking the Long View of Public Health

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School of Medicine Pharmacy & Health

Taking the Long View of Public Health: a new dawn or poisoned chalice? Presented by David Hunter Professor of Health Policy and Management 31st October 2013

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What is Public Health? Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. ∂ Sir Donald Acheson, former Chief Medical Officer for England (1988)

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Domains of Public Health  Health protection  Health promotion  Health service performance ∂

UK Faculty of Public Health

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A Tale in Two Parts  Looking back A not too Horrible History of Public Health ∂

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A Tale in Two Parts  Looking forward New dawn or poisoned chalice? ∂

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Looking Back (1) History tells us that local government played the greatest historical role in the sanitary revolution during Britain’s rapid industrialisation in 1800s  Improved housing ∂  Cleared nuisances  Introduced gas lighting  Provided public bathing and washing facilities  Implemented infectious disease control School of Medicine, Pharmacy & Health

Looking Back (2) Rediscovery of public health in more recent times  Rise of non communicable diseases: cause of 86% of deaths in the WHO European Region – 53 countries, 900 million people  Smoking  Obesity  Alcohol misuse

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 Communicable disease control: flu pandemics, sexually transmitted infections School of Medicine, Pharmacy & Health

Looking Back (3)  From 1974 - 2013 the National Health Service (NHS) had responsibility for public health  Clinical dominance of public health workforce  Multidisciplinary public health workforce becomes a reality (2003): ∂  Introduction of UK voluntary register for public health specialists  Faculty of Public Health Medicine becomes Faculty of Public Health  Joint Directors of Public Health appointments between NHS and local government School of Medicine, Pharmacy & Health

Public Health and the NHS: a difficult relationship While the NHS claimed from the outset to give high priority to the promotion of health…in reality this aspect of the service was never more than ∂ weakly developed, notwithstanding claims to the contrary, habitually made in ministerial speeches. Charles Webster (1996) (Official NHS Historian)

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Looking Back (4)  Brief renaissance of public health under New Labour: first Minister for Public Health (1997)  Wanless I (2002) and II (2004): 'fully engaged scenario'  Joint Directors of Public Health posts: recognition of local government's role in public health – 'multidisciplinary public health will become a reality' ∂(Blears, 2002)  NICE assumes responsibility for public health evidence (2005)  World class commissioning: focus on population health (2007)  The Marmot Review: focus on SDH (2010) School of Medicine, Pharmacy & Health

Wanless’s Critique Numerous policy statements and initiatives in the field of public health have not resulted in a rebalancing of policy away from health care (a ‘national sickness service’) to health (a ‘national ∂ happen until there is a health service’). This will not realignment of incentives in the system to focus on…tackling the key lifestyle and environmental risks. Derek Wanless (2004), Government Adviser

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Looking Back (5)  Persistent tension between focus on individual lifestyle change (nudge) and government action to improve health (shove): ‘lifestyle drift’ prevails over ‘nanny state’ ∂  Responsibility deals  Behaviour Insights Team (Nudge Unit)  No action on plain packaging for cigarettes or alcohol minimum pricing

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Where are we Now? The coalition programme…involves a restructuring of…public services that takes the country in a new direction, rolling back the state to a level of intervention below that in the United States – something which is unprecedented. Britain will abandon the goal of attaining ∂ a European level of public provision. The policies include substantial privatisation and a shift of responsibility from state to individual. Taylor-Gooby and Stoker, The Political Quarterly (2011)

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Reflections: the Negatives  Public health caught up in neoliberal agenda: from the welfare state to the market state  Continuing tension between the nanny state and the enabling state ∂ especially evident in  ‘Lifestyle drift’ policy bias, England  Medical resistance to non-medical specialists

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Evolutionary Trends: How far have we really come?

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Source: The Economist, 12 November 2003.

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Reflections: the Positives  Acknowledgement of wider public health and its multidisciplinary workforce  Smoking ban – example of government action with public support ∂  Example of evidence informed policy  Recognition of local government’s key role in public health

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Looking Forward

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Key Challenges  Return of public health to local government (April 2013): realising the potential  New organisation at centre to lead on public health: Public Health England ∂  Making the public health workforce fit for purpose with new skills  Changing leadership styles  Applying evidence and strengthening knowledge to action School of Medicine, Pharmacy & Health

Local Government: public health’s natural home Many people in local government believe it is their organisations, rather than health ∂ authorities, that are public health authorities. Tony Elson (1999) (former local authority chief executive and adviser to Department of Health)

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The Main Determinants of Health

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Meeting the Public Health Challenge  Investment in public health  Health spend per capita: £2000 per year  Preventive spend: £80 per year (4%)

 Using ring-fenced public health budget to unlock resources elsewhere in∂ local government  New partnerships: are Health and Wellbeing Boards the answer?  New skills and competencies required  Relationship building  Political astuteness School of Medicine, Pharmacy & Health

Concluding Reflections (1) Is the glass half-empty?  Demise of the public health profession as we know it: future of specialist-practitioner-wider workforce paradigm at risk  End of DsPH as we know them ∂  Emergence of a divided and fragmented workforce split between different cultures  Failure to recognise and invest in public health skills training  Devaluing the evidence base in political world of local government  Time of austerity: public spending cuts School of Medicine, Pharmacy & Health

Concluding Reflections (2) Is the glass half-full?  Transform the way public health is conceived and delivered  Break away from the shackles of a biomedical model and embrace a social model: from a deficit to an assets-based approach ∂  Develop new skills and competencies – not a case of preserving the old and familiar  Embed new leadership style focused on influencing others engaged in health improvement and wellbeing  Use of ring-fenced public health budget to lever in resources from elsewhere

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The Journey Continues– Thank you! ∂

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