We must enhance the focus on STPs and accountable care approaches in championing public health, says Saffron Cordery

Ambulance

To quote Professor Sir Michael Marmot, “Public health is everyone’s business”. Rightly so.

 A focus on public health has never been important nor more challenging

By its nature it matters to us all, whether we believe this to be the case or not. It is this characteristic that can make it one of the most difficult aspects of our health and care system to define and delineate. Yet it also makes it one of the most democratic in its potential to use our social and political structures to deliver huge benefit in terms of individual and collective health and wellbeing.

At NHS Providers we have recently asked trust leaders, academics, system leaders and local government representatives what they think the role of providers is in shaping and delivering public health and care. What emerged was a shared understanding that a focus on public health has never been important nor more challenging.

The views expressed were unsurprisingly diverse, but they did coalesce around the importance of the following issues:

  • The iNHS mpact of sustainability and transformation partnerships and accountable care approaches in championing public health
  • The substantial challenges of constrained funding in both local government and the NHS
  • The imperative to innovate and to embrace digital technology to improve efficiency and individual’s experiences
  • The primacy of population health and the role of the public health clinician
  • The enduring importance of a condition-specific approach, be it smoking, obesity, mental health or frailty

Health inequalities

The thread that runs through any consideration of public health is health inequalities, and more specifically the wider determinants of health and wellbeing. A precondition to good public health is socio-economic prosperity, and equity: individuals and communities being enabled to access the support they need to thrive.

It is appropriate that public health’s national leader, Duncan Selbie, chief executive of Public Health England, talks so passionately about this: “…A job, a safe and warm home and someone to care for and about are the foundation of what works for improving health and closing the gap between those who are affluent and those who are not…”

Sir Michael goes to the heart of what we need to deliver equity: “Really, it’s a question of social action. Individual behaviours matter enormously, but they are influenced by and conditioned by environments and social determinants.”

No institution or individual can deliver “public health” alone. That is its strength. However, therein lies an inherent weakness. Who leads? Who is accountable and responsible for such a wide ranging set of roles, functions and initiatives?

The individuals that constitute the public of “public health” must be afforded proper agency

With the UK in the midst of Brexit negotiations it might seem strange to turn to an EU concept for the answer to these questions. However, one of the underlying themes to emerge is that public health is everybody’s business in different ways. A form of subsidiarity – operating at the appropriate level, closest to the people – holds water here.

National bodies, councils, trusts, the third sector all have a different relationship to the individual. They operate at different levels and in different ways. It’s about identifying the most appropriate. Alongside this, without genuine integration of services and functions, effective, value-for-money public health will be impossible to deliver.

It is critical that we remain true to the core intention to improve public health. One way of doing this is to think about how the structure of health and care delivery relates to the individual and communities. At a system level it is funding, strategic direction and national level actions that predominate.

A sense of place is also critical and is likely to be the way forward. It is broadly the unit of planning and the unit of community/communities. Here we see the potential of approaches such as STPs and accountable care.

The institution or organisation’s role is as the engine of delivery – whether it’s an NHS trust, a council or a voluntary sector organisation.

Each type of organisation has different accountabilities but they share the following: a need to marry institutional and strategic imperatives both to those of other local organisations and to nationally defined priorities; and a specific relationship with individuals through service delivery.

In all of this, however, the individuals that constitute the public of “public health” must be afforded proper agency. Any approaches where people are “done to”, sanctioned or punished will not deliver a return on investment.

Where next?

Public health operates at every level and should matter to national government as much as individuals. So where should we be headed next?

  • Structurally – maintain and enhance the focus on the public health role of STPs and accountable care
  • Financially – reverse the cuts to local government public health budgets and shift payment systems so that the incentive is to prevent rather than cure.
  • Clinically – reinstate a strong and strategic role for public and population health clinicians in provider organisations which will benefit all other parts of the public health system
  • Culturally – bring about a change in mindset across the NHS that is focused on public health and its role in empowering individuals to look after their health
  • As the public sector – continue on the journey of influencing fundamental determinants of health and health inequalities

I’ll give Dame Gill Morgan the final words here: “Let’s get back to a proper debate. Health services are not bad; primary prevention is not a panacea for the challenges of the NHS. A proper population and value-driven approach is needed now more than ever.”

Public health: everyone’s business? published by NHS Providers, is part of the Provider Voices series in which health leaders explore how the NHS can respond to the major challenges ahead. 

 

 

 

David Sloman: STPs are refocusing attention on population health