It is often said, probably correctly, that the biggest health gains have come through public health not through medicine. Things like immunization, clean water, adequate sewerage, decent housing and even decent education all contribute to improving health and increasing life expectancy. Increasingly we learn from political geographers like Danny Dowling that life expectancy and poor health can be predicted from post code at birth just as educational attainment, crime rates, and teenage pregnancy rates. We all have the equal opportunity to climb as high as our “parent’s” income permits.
Fixing the positioning and role of public health as a public sector function has been complicated by the establishment of the NHS as the only major personal public service completely outside any democratic control and thus as an island with its own culture, run in the interests of a loose coalition of vested interests. Responsibility for public health has moved around between health bodies and local government.
It appears everyone agrees we have to move more around education and prevention and to tackle the causes of ill health, not just treat the poor health when it happens. Making people healthier has to be achieved by an integrated approach guided by clear policy and driven by inspirational public leadership; the kind of leadership which cleared the slums. Instead, we have fragmentation, an unstable policy base and In the NHS public leadership is vested in the PCTs which are led by people who are unelected and unaccountable and if the ConDems are to be believed – incompetent.
To many this appears that Local Government must have a much greater role, even though they don’t want it, they have the power to do pretty much anything so long as they can argue that it improves the “well being” of the community they served.
The link between well being to public health is obvious and powerful and the White Paper, in one of its better portions, makes the links and states how local authorities will have explicit functions around public health (with funds attached) as well as having some vague and ill defined role of “promoting” integrated commissioning of care. Health and Wellbeing Boards are to be set up, but not as a formal Council Committees and without a Portfolio Holder/Cabinet Member responsible.
Local authorities will have greater responsibility in four areas:
· leading joint strategic needs assessments to ensure coherent and co-coordinated commissioning strategies;
· supporting local voice, and the exercise of patient choice;
· promoting joined up commissioning of local NHS services, social care and health improvement;
· leading on local health improvement and prevention activity.
The recent letter to Directors of Public Health from Professor Dame Sally Davies – Chief Medical Officer (Interim – does this make her a Management Consultant?) tells of the development of a National Public Health Service (PHS) within the DH – good centralising move, but sheds little real light on what is expected locally. The claim is of an exciting vision for an integrated service but with both the DH and the local authorities still in the mix this is a false hope. More is promised later in the year.
You are left with the feeling that the proposals don’t actually join up. Local authorities have a role but not the responsibility or even the authority to make things happen. The GP Consortia Commissioners have the authority to commission the health services and are accountable to the DH (sorry Commissioning Board), but they have some sort of responsibility to take part in the Health and Wellbeing Board – Councillors meet GPs!
The only sensible path to integration is to give all the responsibility and authority to the local authorities for all aspects of care as well as public health. For many aspects of commissioning, especially of health services, the responsibility might be delegated to other bodies (such as with Practice Based Commissioning) and it would have to be informed by working with health professionals, and patient groups. The Strategic Needs Assessments which local authorities have to carry out could be the driving force for integrated commissioning in a way that just has not happened so far.
That gives a real platform to drive integration but also saves a great deal of bureaucracy and management cost as local authorities already have in place much of what will have to be duplicated to create the governance and performance management infrastructure for the GP Consortia. And, the health of the public will benefit.
Irwin Brown
Socialist Health Association