Alan Maryon-Davis is dreaming of a white paper

A bulging sackful of goodies - health improvement to be a statutory duty for local authorities; directors of public health to be embedded in local government where they truly belong; a new national public health service (Public Health England) to extend the kindly hand of the Department of Health to local level; a gift-wrapped ring-fenced budget for public health. Even a heavenly choir chanting about improving the health of the poorest fastest. It could all be straight out of Dickens.

But let’s not reach for the mulled claret and wassail too soon - there are a few reindeer in the room. For instance, the white paper says there will be “minimum constraints on how local government decides to fulfil its public health role and spend its new budget”. So will directors of public health have any real clout in the new set-up? Will they be on a par with chief officers reporting direct to the council CEO? What influence will they have over the public health budget? Just how “ring-fenced” will it really be - and for how long? We’ll have to wait for further guidance next year - but it looks as though councils will have pretty free rein.

Then there’s the crucial issue of joined-upness? How effective will the linkage be between local government, GP commissioners, the local Public Health England health protection unit, and other stakeholders? We know the instrument will be the local health and wellbeing board, using the joint strategic needs assessment as a blueprint - but how well will these boards work? We’ve had patchy experience with local strategic partnerships. The whole new public health edifice will stand or fall on how robustly these boards are set up. Again the blueprint is forthcoming.

And no details yet on how local authorities will be rewarded on their achievement of health outcomes - or not, as the case may be. The public health outcomes framework is still being worked on, as is the reward system. But the metrics of public health are notoriously complex and shifting. Populations don’t stay still. Mortality-based outcomes are far too blunt and sluggish to be used for real-time monitoring and performance rating. Health behaviours such as smoking, drinking, diet and exercise are too much influenced by externalities. Even risk factor prevalence has its problems. It would take an Einstein to come up with a fair approach to dishing out the “health premium” for good results.

The outcome of improving the health of the poorest fastest is a case in point. As the ex-public health director of a deprived inner-city borough I particularly worry about those areas struggling to reduce health inequalities. Even in times of plenty, the gap remained stubbornly persistent - the better-off have always tended to improve their health faster than the have-nots. If anything, the government’s drastic cuts look set to hit the poorest hardest, with negative consequences for health. It would be cruelly unfair to penalise local authorities for failing to close their inequalities gap when the cards are so heavily stacked against them. That would surely be an act of Scrooge-like heartlessness in these hard times. Dickens would turn in his grave.

Alan Maryon-Davis is immediate past president of UK Faculty of Public Health and Hon Professor of Public Health at King’s College London

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