Public health must be protected from short term raids on its funding by acute services
Public health recruits are cautioned that they must be able to work with “long time constants” to improve health.
Public health by definition requires the organised efforts of society. Hearts and minds have to be won, healthy public policies have to be formulated, needs have to be assessed, effective interventions have to be devised, tested and measured. Prevention is a great idea - prevention is better than cure, especially where there is no cure.
The target set by the last government had no evidence base but it galvanised action
Working with those long time constants requires patience and an ability to build relationships and partnerships - a long term strategy. The health secretary keenly cites the Hewitt debacle of 2006-07, when large sums of earmarked public health cash were siphoned off for the acute sector bail out. Indeed, it is a good example of how prevention has been failed in the NHS.
This still happens each year in smaller measure: planned public health investments take a long lead time to develop, during which the acute sector racks up more overactivity and the public health development cannot be funded for another year.
This is the problem the NHS creates for preventing ill health. The coalition government’s answer - a ringfenced budget and a new public health system - is therefore welcome.
But the new public health service will not be live and ringfenced till 2013. In the hiatus between the old system and the new one, jobs in public health are disappearing. As directors of public health play their corporate primary care trust roles they are contributing to reductions in management cost, cost cutting generally and seeing vacancies frozen and delayed.
And public health infrastructure is being lost, not just misplaced. The Guardian last week reported more than 100 specialists in public health areas such as obesity, alcohol and smoking are being sacked by the Department of Health in a move that casts doubt on health secretary Andrew Lansley’s improvement drive.
Public health must operate at national, regional and local level. Yet six out of nine regional tobacco control teams are being closed down. Tobacco control networks helped ensure the public smoking ban in 2007 was implemented with consistent delivery and interpretation of the law across neighbouring authorities. Because of this even the least healthy places, like Sandwell, are seeing rapid benefit in reduced acute coronary admissions. Tobacco control networks have also increasingly worked with HM Revenue and Customs to tackle cigarette smuggling, probably the deadliest crime in the country. Networks of this nature take a long time to become successful.
A huge amount of experience has built up in tackling teenage pregnancies, now decreasing. The target set by the last government had no evidence base but it galvanised action. Now the teenage pregnancy regional coordinators in all the nine government offices are being axed.
The new public health service will have to recreate some of these roles to ensure consistent standards and implementation of effective public health measures. Assign it all to local processes, and a postcode lottery in public health services will be created. It will be another three years before the infrastructure for effective health improvement strategies can be re-established, with years of effort wasted.
Even more fundamentally than specific policy areas, the teaching public health networks have offered the ability to develop training for all levels of the public health workforce. It is too easy to dismiss those that have failed and close them down rather than say “we need this function” and get it right. Their expertise will be dispersed while the new service has to build training across all community action to promote health.
These are exciting and potentially very positive times, but there is a danger that babies will be put out with the bath water, while the NHS moves forward with planned changes.
The new public health service will need to reinvent capacity for policy and delivery at national, regional and local levels. It would be wise to keep as much as possible now of what is a tiny part of the NHS budget in case it has to start from scratch.
Ahead of the public health white paper and the public health strategy it would be wise for NHS chief executive David Nicholson to issue guidance to “prospectively ringfence” public health roles and people, and public health spend.
The DH needs to issue instructions to NHS directors of finance about where the public health ringfence comes from. And, finally, the timetable for shadow local public health arrangements needs to be brought forward to give the people in it a chance to shape the new service before it goes live.