What will the new national public health service look like?
Health protection and the national drugs service are two givens. Other clear pointers from the Liberating the NHS white paper are health improvement, immunisation, screening and, more interestingly, occupational health and health visiting in children’s centres.
The promise of a ring-fenced budget protects a future for public health intervention, but it must be regarded as baseline funding
Local authorities have not tackled health inequalities in any meaningful way; their equivalent of the inverse care law generally applies - poor people get poor services.
The NPHS cannot be seen as the exclusive body responsible for public health. Public health duties should be enshrined in the role of the NHS commissioning board, in GP commissioning, in the role of hospitals and in social care.
Many hospitals are now embracing smoking cessation work and “stop-before-the-op programmes”. Social services are awakening to the preventive agenda in re-ablement and personalisation. GPs must access lifestyle services - exercise on prescription, mental health resilience, nutrition and weight loss, job support, welfare rights, housing and affordable warmth.
In Sandwell, GPs are still nine times more likely to prescribe Orlistat than they are to refer to our “Slimwell” service. Care pathways agreed with acute hospitals need to enshrine preventive interventions before resorting to complex clinical procedures like bariatric and vascular surgery. And GP commissioning organisations will need to invest in more lifestyle services, in joint programmes with directors of public health.
The promise of a ring-fenced budget protects a future for public health intervention, but it must be regarded as baseline funding and not the only money invested for the health of the public.
With the inclusion of the national drug service, there won’t be much change for anything else if the ring fence is only 4 per cent or even as I have suggested 5 per cent.
The vision is for an NPHS that can operate according to local circumstances. Public health, like general practice, is both a commissioning and provider function.
But there are not enough public health staff to fill the duplicate roles of commissioner and provider. The new NPHS will need to be able to deliver health improvement programmes and commission a mixed economy of other locally suitable services delivered to it by kitemarked contractors.
It will take considerable management skills.
The immunisation and screening functions need to be detailed. Most of the groundwork is done by NHS staff, but these require public health leadership. This could be problematic if institutional boundaries get in the way.
Directors of public health in local authorities still need to be appointed as NHS data custodians or users. There will need to be new national information governance permissions to facilitate information sharing. We have good morbidity data from primary care now and directors of public health need the right of access for joint needs assessment.
Public health specialists must still be employed by the NHS bodies. But they will need honorary status at least with the NPHS, and public health training needs to be delivered from a single place - the NPHS.
Clinical governance and Care Quality Commission registration need to be sorted out - the NPHS has to be able to give antibiotics, antivirals, vaccines and antitoxins and deliver health advice and information.
Resources will need to be expanded for training. Regional public health institutes should be developed and the excellent work of the public health observatories should be built on.
The localisation agenda should permit local variations. Sadly, Transforming Community Services does not leave much space for imagination or local negotiation. It has also added to the distorted centrality of hospital services in a health system which purportedly wants to keep patients out of hospital.
Locating public health with local authorities may be the romantic return to provenance. But local authorities have not supported environmental health over the years. Social care services consume care funds with the same reckless avarice as hospitals consume health service funds.
Public health brings a population health perspective that local authorities have not had for many years. There will be much work to be done in the meeting of cultures.