Published: 11/08/2005, Volume II5, No. 5967 Page 12 13

With impatience growing about lack of progress on firm proposals for delivering the aims set out Choosing Health, the role of the forthcoming white paper on healthcare outside hospitals in improving public health delivery will be crucial. Continuing our four-part series, Helen Mooney and Mary-Louise Harding look at what it must set out to achieve - and how

Health secretary Patricia Hewitt is clear that improvement targets will continue to take centre stage as 'family health services' come under the reform spotlight.

And last month NHS chief executive Sir Nigel Crisp reiterated this message in his latest central guidance, Commissioning a Patientled NHS.

At the same time, the government is keen to stress that health improvement will secure a key role in both the consultation and subsequent white paper on healthcare outside hospitals.

It is easy to pay lip service to the importance of the NHS crossing the divide to become a health service rather than a sickness service. But which, out of the welter of transformational measures expected in the white paper, will focus on improving public health delivery?

The answer is very likely to lie in the areas around choice and contestability. West Yorkshire strategic health authority and Poole primary care trust are among those that appreciate that the recently announced sweeping reconfiguration of PCTs (news, page 5, 4 August) could give them a crucial opportunity to create separate, independently managed public health or health improvement trusts.

These would unleash dedicated, accountable, non-clinical senior health improvement managers for the first time, according to West Yorkshire SHA chief executive Mike Farrar. Acting as commissioners, they would open up health improvement services such as sexual health and smoking cessation to contestable providers.

'[Looking at public health trusts] is about reviewing the capability and capacity to deliver public health targets and feeding that into the mix of the [PCT] fitness for purpose review, ' he says. 'The key thing is to have management dedicated to health improvement, with a possibility of joint governance between the PCT and local government, but with dedicated senior management and an accountable chief executive.' The question of whether they should commission or provide raises, he says, an 'interesting debate' about introducing new ways of delivering health improvement services. 'We are asking, can we introduce contestability into the public health agenda by managing services in different ways? This is interesting because [public health] targets are very difficult. So We are asking if there are ways of strengthening how we deliver.' Sources close to policy-makers suggest that many of the ideas and intentions of the public health white paper, Choosing Health, are likely to be reviewed by a new ministerial team mindful of Treasury public service agreements.

They suggest that it is not the ideas and outcomes that will be revised, but the delivery mechanisms.

One well-informed source says: 'Public health people have had 18 months to come up with solutions for delivering Choosing Health, but the cupboard remains bare. It remains a waffly, ideological debate.

No-one has come up with crunchy, hard ways of doing these things.' Some of the more radical ideas said to be floating in the ether among policy circles are ways of creating incentives - or penalties - to encourage citizens to improve their own health, such as reducing council tax bills for those taking steps to reduce their need for expensive 'illness services'.

Ms Hewitt's special adviser, Liz Kendall, hinted at these ideas in her previous guise as senior research fellow at the Institute for Public Policy Research. In an article for New Statesman magazine, she argued that the government should reject the pure 'consumerist model of health services' as it would ultimately be unsustainable, and adopt 'the citizenship model, where patients have rights but also responsibilities.' Since Choosing Health, the message has been clear that PCTs should work closely with their local authorities to push forward health improvement.

The Department of Health's recent directive for PCTs to become co-terminous with social services boundaries wherever possible is designed to speed this up. And many expect it to be bolstered by further integration of PCTs and social services in the white paper.

Poole PCT public health director Adrian Dawson, who holds a joint position with the local council, believes the new emphasis on co-terminosity between PCTs and local authorities is a good idea.

'There is a strong case for linking public health to the local authority agenda. Transport and the environment, for example, are definitely health improvement strands which need to be integrated'.

In the autumn, the Healthcare Commission will embark on new 'local area reviews of public health' with the Audit Commission, and will focus on how healthcare organisations, local government, and other partners are working together in a geographical area to improve health.

Healthcare Commission head of public health Jude Williams says the reviews are aimed at 'learning about how a joint approach between inspectorates can provide a rounded view of the quality of public health work across organisations'.

It will also 'inform' how the commission assesses performance in public health in future.

But how will health improvement fare in a new world of voice, choice, contestability, and alternative provision?

Ms Hewitt is adamant that offering choice 'can itself be good for health'.

In a speech last month she said there was now 'ample evidence to demonstrate that people who have more choice and more control over their lives tend to be healthier and live longer'.

Her aim is to 'create a virtuous circle of healthier people in safer communities supported by responsive public services'. The challenge for the white paper will be to create a structure that supports and delivers this vision.

UK Public Health Association chair Professor David Hunter says that despite government statements and the 'helpful' white paper, he does not think many PCTs 'are charging into' the government's new health improvement agenda.

'Public health people are so browbeaten that they are waiting for the next set of government guidance before they start redesigning the function. Despite the government's aspirations, the entrepreneurial spirit is not there, ' he says.

He admits he is also concerned that with the reorganisation and planned reduction in PCT numbers, the local Choosing Health message 'might begin to fall down the agenda as reorganisation becomes a distraction'.

Professor Hunter warns that the fact that a lot of PCTs will not survive in their current form is likely to create a 'distracting effect' for public health, which he says has not yet 'become as embedded as other things like practice-based commissioning and payment by results'.

However, in Poole Mr Dawson is adamant that question marks over the future of PCT's should not distract the public health team from 'getting on with it' while they are waiting for a master plan.

Mr Dawson says his PCT's vision for a public health trust would operate along similar lines to the children's trust model. It would ensure that stakeholders from all local government departments would work alongside the police and the PCT to ensure that public health is a local priority.

Public health trusts would have a duty to protect and improve the health of their local population, not just through primary care but in their influence on wider planning; from new building developments to local environment and transport programmes, he says.

However, in general the public health community appears to be waiting to see what else the government proposes before it charges ahead with a radical redesign.

If this is the case, the new white paper needs to present health improvement aims for primary care in a starker light than anything that has come before.

Yorkshire and Humber regional public health director Paul Johnstone says PCTs must be given the clear message from government that they will still have a 'health improvement role - that it is not solely a commissioning one'.

But Central Cheshire PCT public health director Wendy Meredith says that as the role of PCTs changes, it is important for managers to consider not only the issue of service capacity.

but also how to manage demand for services through improving the determinants of ill health.

'Intelligent commissioning is needed to reduce health inequalities.

But in the long term, as choice becomes more embedded, commissioning itself could fade away, which ought to free up time for PCTs to manage demand, ' she speculates.

If public health teams are indeed waiting for more guidance and are not likely to kick-start themselves into delivering the kind of action that ministers want to see, the white paper will need to err on the side of clarity.

Ms Meredith points out that PCTs must be strongly reminded of their health improvement function - not least to avoid the scenario mapped out by Treasury adviser Sir Derek Wanless when he warned of an unsustainable NHS straining under the magnitude of the population's ill health.

As Sir Nigel writes in Creating a Patient-led NHS, all services should be 'provided within a health improvement environment'. .


Health minister Caroline Flint made an important announcement to the House of Commons at the tail-end of the summer session, signalling that the new ministerial team is committed to delivering on key aspects of Choosing Health.

She announced that 12 primary care trusts would receive an extra£200,000 of central funding to lead 'early adopter partnerships' with local government and the voluntary sector to unleash health trainers on the their communities.

A further 130 PCTs which 'expressed an interest' in introducing the trainers will receive£25,000 each.

She said health trainers will be tasked with 'motivating individuals to set personal goals for improving their health by developing personal health plans', in keeping with the government's desire to root out dependency on public services.

The early adopters are tasked with beginning to trial a government and Skills for Healthdeveloped 'draft set of core competencies and job descriptions' from September. They will also need to 'identify suitable local people' for the roles, provide training and then send them out to work with people in settings such as pharmacies and tenants' associations.

The trainers are expected to provide the links between 'fragmented' and 'patchy' support in areas with the highest health inequalities that have 'unequal' and 'erratic' access to services.