Published: 17/03/2005, Volume II5, No. 5947 Page 14 15

The Department of Health wants primary care trusts to focus on five key areas to kick-start implementation of the public health white paper. Here, we detail the key areas that need to be included in PCTs' local delivery plans over the next three years. In addition, two action plans, released last week alongside the implementation paper, outline plans for getting the population more active and reducing soaring obesity levels (see boxes below).

Reducing the number of people who smoke

The government has set a public service agreement target to reduce adult smoking rates to 21 per cent or less by 2010, with a more challenging target of 26 per cent among blue-collar workers.

The DoH wants PCTs to make this a top priority. That means extensively rolling out smokingcessation services, identifying hardto-reach groups, and using every opportunity when the local population come into contact with a health professional to hammer the stop smoking message home.

The delivery plan uses hard economic facts in an attempt to get PCTs to prioritise this.

It flags up the fact that '70 per cent of smokers want to quit' and 'smoking costs the NHS between£1.4bn and£1.7bn per year'.

It also sets out a number of 'big wins' for the local NHS. PCTs should endeavour to make their smokingcessation services 'more accessible and responsive [with] wider availability of nicotine replacement, particularly to manual groups', and better use of technology such as electronic booking, together with targeted support for NHS employees.

Reducing alcohol dependency

There are more shock figures on alcohol. The financial burden on the NHS caused by alcohol misuse is£1.7bn annually, and there are 150,000 hospital admissions a year associated with alcohol misuse.

So what should PCTs be doing?

The paper says that planning local responses is key to reducing the burden. PCTs need to involve local authorities, the police, the licensing trade and other statutory partners.

The national audit of alcohol services and the models of care guidance, which the DoH is set to publish later this year, should also be used to develop local services.

'Training professionals to identify and target support at harmful and dependent drinkers' as well as 'establishing referral protocols between primary and secondary healthcare settings and specialist alcohol services' is highlighted as good practice.

Modernising sexual health services

For every£1 invested in contraceptive services, there is a saving of at least£11 on associated NHS costs, and a 25 per cent reduction in HIV incidence would save up to£500m a year.

The DoH has identified sexual health as another key priority on the public health radar and as such has allocated£300m in additional funding over the next three years for sexual health services.

PCTs need to develop a teenage pregnancy strategy that 'strengthens delivery to reach vulnerable groups and target areas with high rates of under-18 conception'.

The plan says that there should be further investment in all sexual health services to provide the local population with 'more accessible and effective contraceptive, abortion and sexually transmitted infection services'. PCTs will need to work with the Health Protection Agency and implement standards for HIV and sexually transmitted infection services.

City and Hackney Teaching PCT public health director Dr David Sloan says: 'The delivery paper will help to build innovation around sexual health.

'At the moment we have not got enough capacity for sexual health services and for young people they, are not always provided in settings that are appropriate or that they want to use. This may start to change.'

Health trainers and training for the workforce

The DoH is keen that the local NHS builds on the way that health professionals provide not only care but also help their population to improve their health and wellbeing.

PCTs need to think about establishing a group of health trainers to give help to people who want to develop their own health guides, provide advice and practical support to stop smoking, practise safer sex, deal with stress, and support people who lack basic health skills.

The delivery paper says that every spearhead PCT will have to run a 'skilled for health' programme in an attempt to educate local people who do not have 'health literacy aptitude'.

Marketing campaigns will also be launched from April to focus on deprived communities and young people to promote healthier lifestyles, including obesity, sexual health and smoking.

However, NHS Alliance public health lead Professor Chris Drinkwater raises concerns about the paper's suggested model for health trainers. 'They seem to be going lock, stock and barrel on supporting individuals in behaviour change.

'I would prefer to see a community development model where people in the community are given support to develop a knowledge and understanding of their community before they move onto individual behaviour change, ' he says.

Developing the workforce

DoH head of programme coordination for the delivery plan Nick Lawrence wants PCTs in tandem with the rest of the local NHS to expand and train their health improvement workforce.

The delivery paper puts the emphasis on 'engaging' the NHS workforce by 'using new contractual arrangements to engage primary care in improving health through everyday practice'.

PCT local delivery and workforce plans need to identify gaps in the health improvement workforce, improve specialist and practitioner capacity in public health and address specific skills deficits.

However, Chelmsford PCT public health director Dr Mark Shackell questions whether there is real potential to increase the overall workforce capacity for every PCT.

'Are over 300 PCTs going to try and recruit a health improvement workforce at the same time from a pool that may not be there?'

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NHS staff are to be offered free fitness, diet and lifestyle advice to help them act as role models for patients who want to lose weight and become more active.

Public health action plans published last week also require primary care trusts to work with schools and local authorities to encourage healthy eating and promote sports and activity.

Choosing Activity: a physical health action plan, launched last week alongside the public health implementation plan, describes a society in which activity and exercise are exceptions rather than the norm and obesity in children means that they have a greater chance of dying before their parents.

PCTs have been allocated an additional£55m for 2006-07 and 2007-08 to provide initiatives on diet, activity and obesity.

Sport England has been given responsibility by the Department of Health to work with strategic health authorities and PCTs to help them develop the public health aspects of their local delivery plans.

Sport England chief executive Roger Draper says his organisation 'will develop a free consultancy service to the DoH and NHS staff to help them lead more active, healthy lives'.

'The plans are a great opportunity to boost participation in sport and leisure activities and create a healthier nation.' Just 37 per cent of men and 24 per cent of women currently meet the chief medical officer's recommendations for activity in adults and are sufficiently active to benefit their health.

The plan says PCTs will be required to increase the opportunity for patients and the public to participate in sports and physical activity and encourage walking or cycling to work or school.

It sets targets for increased activity and puts a strong emphasis on building good habits in school.

Health secretary John Reid, launched the action plan last week at Charlton Athletic Football Club (see picture above); it has the backing of England football coach Sven-Göran Ericksson.

Mr Reid said the DoH would work closely with professional sports, including football and rugby, to 'use their brands to promote physical activity and sport'.

The DoH will develop Health Direct, a TV, internet and digital TV 'virtual health trainer' offering the public (especially children and older people) health professionals and employers education about improving lifestyles and changing unhealthy behaviour.

PCTs and sports clubs will be receiving a DoH guide to encourage good practice and foster links on health improvement work. Pilot schemes allowing GPs to offer referrals to diet regimes such as Weight Watchers will also be extended.

Easington PCT chief executive Roger Bolas says the aim and targets in the plan are 'challenging but welcome'. 'It certainly takes our thinking out of the operating theatre and waiting room and into schools, businesses and leisure services.' 'I speak as someone with a 36-inch waist who used to be 32. We have to lead by example and we are talking with a local fitness club about offering exercise classes.

'We already make membership of a leisure centre available to all staff at a cost of£5 per month as part of Improving Working Lives. You will see that fruit is more common than biscuits at meetings.'


Primary care trusts say they are concerned they will not be able to deliver on anti-obesity initiatives outlined in the food and health action plan published last week.

The plan requires PCTs to take the lead on halting the 'year-on-year rise in obesity among children under 11 in the context of a broader strategy to tackle obesity in the population as a whole'.

But PCTs are worried there is a dearth of data on the extent of the problem or how it can be tackled. City and Hackney PCT public health director Dr David Sloan says 'obesity is going to be a really challenging one'.

'The evidence for effective obesity interventions is not as robust as for stopsmoking services, the local area agreements are an attempt to get away from the different funding streams we have for obesity. The delivery plan does help but it is going to take time, ' he adds.

Chelmsford PCT public health director Mark Shackell says 'accessing the right data and information is going to have to be part of how we go about doing things differently'.

'We do not have easy access to data on obesity, he says. 'We can't say where the baseline is; some of it is going to be about having to go back to ground zero.' Greater Manchester strategic health authority assistant director for health improvement Alayne Robin says that while the plans provide a useful direction for changing lifestyles and wider factors that influence obesity levels, 'there are no actions in the plans to demonstrate how the year-on-year rise in obesity rates will be halted, without more focus on how primary care contributes to these targets'.

But Tower Hamlets PCT public health director George Leahy - whose east London trust has obesity rates for under-16s of 18.9 per cent - is more optimistic and welcomed the initiative.

'Large public health gains will be made from reducing average weights and body mass index rather than just focusing on those labelled obese, ' he says.

The plan also calls for each PCT to have 'at least one full-time year-round, qualified school nurse working with a cluster group of primary schools and related secondary schools.

'School nurses will help develop health guides for each pupil, using them to discuss health, nutrition and physical activity.' Pat Jackson, professional officer for school nursing at the Community Practitioners' and Health Visitors' Association, says some areas have so few school nurses that they are 'struggling with even the basics and with no capacity to send school nurses on the specialist practice training


British Heart Foundation chief executive Paul Lincoln and Diabetes UK campaigns director Benet Middleton both agree that the most effective way to reduce obesity is to ban junk food advertising.

Mr Lincoln also wants tougher controls on food in schools. 'Lottery money should be spent on allowing schools to re-equip kitchens that no longer contain cooking equipment.

'As we have see from the TV series Jamie's School Dinners,