Published: 22/07/2004, Volume II4, No. 5915 Page 14 15

There is guarded optimism in the public health community about its high profile in the Treasury's public service agreements, but also concern over the choice of targets. In the first of a series examining the four PSA areas, Jennifer Trueland looks at improving the health of the population

The aim, the Treasury tells us, is to turn the NHS from 'an organisation primarily focused on treating to one emphasising precaution and health promotion - a true National Health Service'.

That is the government's explanation for the new public service agreements. Published along with the 2004 comprehensive spending review, these have an unprecedented public health element.

Of the four strategic objectives the health service will have to deliver to earn its share of the government's financial cake, improving the health of the population is the most detailed.

As well as the other three objectives of achieving improved care for people with chronic conditions, shortened waiting times and higher patient satisfaction, the NHS will have to deliver on helping people live longer, healthier lives. There are targets on smoking, teenage pregnancy, childhood obesity and reducing premature deaths from cancer and heart disease. Not to forget reducing health inequalities.

All laudable aims, but We have had warm words before about moving away from a National Sickness Service. There is also substantial concern over whether these are the right targets, if they are too hard or too soft and, above all, whether the resources will be available to make a difference.

But there is guarded optimism among some in the public health world, who are pleased that at least they are part of the mix.

'Of course we can pick holes about the specific targets, ' says Faculty of Public Health president Professor Rod Griffiths.

'We could say the smoking target could be more ambitious, for example, but I think we should be doing better than that.'

'Generally I am pleased. I think It is important to look at [the targets] in the round. There needs to be a balance between the different things and I think the move towards prevention-based targets is a step in the right direction.'

The specific targets do have a familiar ring - and not just because HSJ published a leaked copy of an earlier draft last month (news, page 3, 10 June), which was substantially the same as the final version.

On smoking, for example, while overall adult smoking level targets have been hardened (the new target is prevalence of 21 per cent or less by 2010, compared to the previous 24 per cent aim in the NHS cancer plan). However, the target on manual workers (26 per cent prevalence by 2010) remains the same as in the cancer plan.

Perhaps health secretary John Reid, who shies away from criticising working-class people's pleasure in a cigarette or two, had something to do with the split target.Or maybe it simply recognises the reality of different smoking rates between social classes.

The target on teenage pregnancy - to halve the rate by 2010 - remains the same as the previous PSA, although this time the Department for Education and Skills shares responsibility for hitting it. The previous PSA's targets on cutting premature deaths from heart disease and cancer have been repeated, although this time there is also a requirement to reduce inequalities by 40 per cent for the 20 per cent sickest and poorest sections of the community.

On the ground, directors of public health are already sharpening their mental business cases for receiving more of the extra resources promised for the health service. That is particularly the case in the more deprived areas of England, which will find it hardest to meet these new targets.

Southwark primary care trust director of public health Dr Alan Maryon-Davis sounds almost gleeful as he considers the leverage the PSA targets will give him and his colleagues.

'There is very little money to play with for new developments as most of the budgets that come into primary care trusts are already spoken for. But there are opportunities round the margins, and that margin is bigger because of the increased resource coming into the health service.You can be sure that public health will be pitching for that resource and our arm will be strengthened by these targets.'

The soon-to-be-published public health white paper should also provide a 'hefty shot in the arm', he believes. Of course, there are those who look at the smoking target in particular and despair that it is so much less challenging than the one advocated by Derek Wanless, author of two reports into health for the Treasury.

In his 'fully engaged' scenario, the target smoking rate would be 17 per cent. 'The 21 per cent target is not nearly ambitious enough, ' says director of anti-smoking organisation Ash Deborah Arnott.

'The rate is already decreasing by 0.4 per cent per annum and we haven't yet seen the effects of some policy measures which should make an impact - for example, the ban on tobacco advertising has just come into place.'

The ageing population, too, will inevitably mean a smaller proportion of people smoke - because older smokers tend to die younger.

Ambitious targets on smoking rates - and action to make them achievable - are vital, she believes, if the government is to meet its other aims around cancer and heart disease.

NHS Alliance public health lead Professor Chris Drinkwater feels the real targets should concern community engagement and social capital - that is, giving people, particularly those from deprived areas, a stake in improving their own health. He is also wary about how national targets are translated locally. 'They can lead to gamesmanship, with PCTs cherry picking to meet the target rather than helping the people who need it most.'

British Medical Association public health committee chair Dr Peter Tiplady acknowledges that middle-class areas will find it easier to meet national targets because richer people are quicker to adopt healthier behaviours, but says it is no excuse for not trying to improve the situation in poorer areas. 'We have to look at the underlying factors, and that includes poverty, which is a major determinant of ill-health, ' he says.

'Sometimes I think we should look at regional targets or give PCTs relative targets, which might be fairer than national ones.'

King's Fund director of health policy Anna Coote is unwilling to pass detailed judgement on the new PSA targets. 'It is terribly hard to judge at this stage, ' she says. 'But what matters is not so much the targets as what incentives are in the health system to motivate people to give them priority.'

Reluctantly, she says, she believes the targets are useful in the current context. 'If you live in a target culture, which we do, and There is nothing on public health, then it will be bypassed, ' she says.

'In setting targets you need a mixture of pragmatism about what can be measured and what can be achieved. I'll give them a chance to run and see what happens.'

We do not yet know how the targets will work locally or what the sanctions or carrots will be for trusts and PCTs which apparently let the side down. But public health doctors, at least, will welcome them, if Drs Maryon-Davis and Tiplady are to be believed.

As a former director of public health in North Cumbria, Dr Tiplady thinks that public health doctors will feel quite comfortable with them, although he acknowledges that they may upset some GPs.

Professor Griffiths also sounds optimistic, but he says a properly trained and resourced public health workforce is essential. 'We need to narrow the life expectancy gap and the new targets are a legitimate action to do that. What we need are community development officers to engage with communities and find out what works.'

He welcomes the target to halt the rise in obesity in the under-11s but says there is little evidence on what works.

'We need action to tackle this urgent problem but we need to build an evidence base, ' he says.

Likewise, he is pleased to see the target on teenage pregnancies.

'Why are we so bad at sex?' he asks. 'It has to be possible to make progress.'

The PSA in brief Improving the Health of the Population

By 2010, the target is to increase life expectancy at birth in England to 78.6 years for men and to 82.5 years for women'.This is supported by a number of targets.These include:

reducing mortality rates by 2010 from heart disease and stroke by 40 per cent (20 per cent for cancer) in the under-75s, with at least a 40 per cent (6 per cent for cancer) reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole; for suicide and undetermined injury the target for mortality rate reduction is 20 per cent.

reducing health inequalities by 10 per cent by 2010 as measured by infant mortality and life expectancy at birth;

tackling the underlying determinants of ill health and health inequalities by reducing adult smoking rates to 21 per cent or less by 2010 (to 26 per cent in routine and manual groups), halting the year-on-year rise in obesity among children under 11 and reducing the under-18 conception rate by 50 per cent.