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Forty wasted years?

It will also surprise many. The new Public Health England chief executive has a reputation for being a thoughtful operator, not fond of broadcasting his opinions. His new job requires him to adopt a higher profile, but few would have predicted his first interview to contain repeated attacks on the NHS’s stewardship of public health.

So, is Mr Selbie correct in his disparagement of the NHS and his view that local government will make a better fist of reducing inequality and boosting life expectancy?

Let us examine the case against the NHS. Over the last two decades Mr Selbie has been the chief executive of a mental health trust, an acute trust and a health authority, as well as being a Department of Health director general. He will know government rarely stresses about public health performance issues - when compared to, say, hospital waiting times or healthcare acquired infections. He will also know that, partly as a result, public health issues rarely creep onto the must-do lists of those running major provider organisations. In summary, he will understand public health has been the poor relation in the NHS family.

Despite this, there is little doubt NHS immunisation programmes have made a major contribution to the public’s health. Screening programmes too have had a positive impact, although their benefits are more ambiguous than previously thought. Some point to the ban on smoking in public places, but the NHS can claim little direct involvement in that. Fluoridisation remains controversial and patchy. There has been some important work on resource allocation - although regular debates about perceived unfairness shows this is still far from finished work.

There is also, of course, the significant - though often unrewarded and unrecognised - role GPs and community healthcare staff have on the behaviours and attitudes of the public.

Mr Selbie may be laying it on a bit thick to say the NHS’s attempts to improve health and reduce illness “haven’t worked”, but it is reasonable to suggest the NHS’s contribution to public health comes a distant second to its record in treating illness.

Public health professionals will also complain - with some reason - that their work has been underfunded for most of the last four decades. But the profession is not blameless in its failure to win more money or influence. Many local authority chief executives were shocked some public health directors appeared to be more concerned about who they would report to rather than what opportunities their new roles might give them. The sensitivity about status is a sign of a profession which has become marginalised within the NHS and, in some cases, has adopted a prickly isolationism as a result.

There is no doubting local government’s enthusiasm to pick up the public health baton. Combining traditional public health interventions with action on housing, employment and education may deliver the benefits of an integrated approach the NHS would have found it much harder to assemble. There is also reason to believe public health should enjoy a higher status in the council chamber than the NHS boardroom.

But two major issues remain to be resolved. Will local authorities have the money to realise the synergies joint programmes could release - especially after what is likely to be another brutal public spending round? Given that context, it is also necessary to ask what happens when a council decides public health, or an aspect such as sexual health, is not a priority. Local authorities are democratic organisations and do not expect to have their decisions second-guessed.

Finally it will be down to Public Health England to ensure responsibility is not simply “dumped” on local government, allowing the NHS to spend even more time focusing on the preoccupations highlighted by the newly outspoken Mr Selbie.

Readers' comments (11)

  • Great editorial. It's not LAs or NHS, it's LAs and NHS. The expertise of the National Support Teams, so hastily dumped by the Coalition, needs to be rediscovered and applied. My view is that on inequalities, the NHS has an awful lot to offer - but the new duties will need to be worked hard to pull it into line. There should be no excuses, under the last govt DH did not performance manage its inequalities targets hard enough - when it knew what the NHS needed to do to achieve them. That's a failure of the old NHS management culture in the DH, now in the NHSCB. I hope the new duty will open their eyes to their responsibilites, a good sign that Steve Field is there to pull them into line.

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  • It is a somewhat bizarre and crude statement to make and it would have helped had he had outlined in what specific way the NHS has failed public health. (If he did it was not reported or mentioned in the editorial) We should expect a national model of PH action from Mr Selbie which could be delivered according to local circumstances.

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  • Hello Patrick

    If you read the interview with Duncan (linked at the start of the editorial), you'll find Duncan gives quite a few examples.

    Alastair

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  • Public Health in PCTs has consistently punched below its weight ( a real value for money issue in management terms).This is partly due to its academic detachment and desire to not get its hands dirty. We can all recall countless repetitive mind-numbing presentations by public health consultants on SMR rates and awful health status gaps, going nowhere because of the lack of a resolving action plan: the culture is so inclusive and democatric, it has forgotten it needs to actually do something. What to do? Its obvious - funds need to be targetted to actions in the most deprived segments of urban populations, to raise the bottom 25% up to the local average, and then to raise the average to the upper quartile - only then is it worth thinking about narrowing the gap with a desirable England quartile or decile. This means planned diffential investment of interventional monies on a significant scale in deprived wards, over a 10 year period, and also by-passing the dead-hand of primary care contractors - policies which public health steadfastly refuses to take on board. It also means a more aggressive stance against manufacturers and purveyors of fast food, junk supermarket food and alcohol. What happened to the public health campaigning spirit? Come on, develop a spine, do a job!

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  • A quote from a local PH colleagure: "I'm absolutely fed up with writing reports for people who ask for them and then choose to ignore them."
    Effective routes to by-pass the selective hearing of commissioners are definitely needed at a local level, coupled with national-level action on alcohol, fat foods, sugar etc.

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  • Mr Selbie is no friend of the current regime. He was an acolyte of Nigel Crisp. Who could forget the infamous 'Selbie letter' to CEOs warning of the consequences for financial indiscretion? The letter followed the pasting Patsy Hewitt gave Crispy after she was dragged to the Commons to apologise for a record NHS deficit. Not long after, Crispy was put out to pasture in the Lords, from where he continues to submit the odd pathetic attention-seeking non-sequitur. Oh, those were the days........

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  • you only need to look at Change for Life to see that Mr Selbie is right about the centers ability to deliver on public health.... its a marketing construct with no product or utility whatever... every few months they pump another few million on advertising it on the telly, hits jump and then return to zero again ... local authorities could hardly fail to do better

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  • I wonder exactly how much ability to change public health remains in the hands of the NHS. The drivers behind the big preventable public health issues - smoking, alcohol abuse, obesity, inactivity - are the efforts of enormous companies.

    People aren't doing the same level of exercise as their ancestors, which to some degree is because the likes of BSkyB and Facebook spend huge sums and employ the finest minds of our generation to increase the amount of time we spend sat down looking at screens.

    The manufacturers of sugary, fatty, salty foods pay top dollar to sponsor things like the Olympics, because they know that this means people buy more of their products. These same companies have no interest in their wares being consumed in moderation - see how they resist things like the Traffic Lights labelling, which evidence suggests leads consumers to reconsider unhealthy products.

    These drivers of unhealthy behaviour can only be curbed by legislation which will make the current business models of very powerful organisations less lucrative. The smoking ban, and the current work around plain packaging, are rare examples of where lawmakers have the courage and public support to try this.

    In other cases we end up with Responsibility Deals - the equivalent of asking Jack the Ripper to stick to maybe one murder a week, and consider giving his victims 5 seconds' warning.

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  • Martin Rathfelder

    Expecting local public health staff to tackle problems which are rooted in economic inequality is entirely unrealistic. It isn't surprising most of them spend their time describing the problem, not doing anything about it.

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  • I am ex public health, now doing something completely different, but a lot more target/ outcome focused, and very hands on. I despaired of the culture and attitudes and found the lack of action immensely frustrating. I realised I could never progress my career or feel I fitted in a job until I left. I have some sympathy for dull reports because I've written my share of them in order to tick some corporate box. But equally, yes, every disease has a social gradient. There are still things that can be done to address inequalities and deprivation but while I don't know enough to go as far as Cassander and tackle big business, I don't think the skill set lies in public health. I've met some very driven, passionate health promotion managers who've had an impact and take pride in achievements for hard to reach groups, but I have to say that most of them were in LAs or the NST. In the NHS it felt like a career cul-de-sac because it was mostly about contracting. Yes, we could've made better use of people, e.g. by building the evidence for change and looking at clinical/ cost effectiveness but maybe the horse has bolted. Many good people have left. But that's just my personal experience.

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  • Patrick Keady

    While all of the comments are valid, Governments of all persuasions tend to carry out short-term tasks - such as white papers, organisational change (CCGs, SHAs, PCTs, PCGs, CHI, HC, CQC etc) which are easier to implement and usually meet with public support - and at the expense of medium and long-term action. Public health challenges however, need more than the life of one government - from implementation of policy to visible improvement in health outcomes. The way forward for public health seems to be about professionals demonstrating the value of Public Health in their Boroughs/Counties coupled with sustained longterm vision and support from Public Health England.

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