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Analysis - fit for purpose?

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  • Some areas of health getting worse

  • Experts argue responsibility should be handed back to councils

  • But others say it should stay with NHS

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For too long debates around postcode lotteries have centred on cancer drugs, not life expectancy.

In the popular mind, the dramatic health improvements of the last 150 years are the work of heroes in white coats. But students of medical history know that those in the town hall often also had a big hand in its delivery.

Councils were responsible for many key interventions like functioning sewage systems, which created the conditions for reduced infant mortality and increased life expectancy.

Recent Scottish statistics provide a more up-to-date illustration of how non-medical policy interventions can lead to dramatic changes in health. They show that the number of heart attacks has fallen by 17% since smoking was banned in public places just over a year ago.

But a report, published by the King's Fund last week, shows that in many other areas efforts to improve health are sliding into reverse.

It leads some to wonder whether responsibility for public health should be handed back to councils. Professor David Hunter, chair of the UK Public Health Association, argues this case (see box). Is he right and is the current public health regime fit for purpose?

If anybody wants to know why many are questioning whether public health is safe in the NHS's hands, they only have to look at the King's Fund conclusions.

It shows that the proportion of English men classified as clinically obese is set to rise to 33% by 2010, while the figure for women will be 28%. Just two years ago, the figure for all adults was 25%. It also shows that the proportion of children rated as clinically overweight has grown by more than a half over the past decade. Given the strong correlation between obesity and diseases like diabetes and heart disease, the report warns that current trends threaten to capsize existing NHS funding arrangements by 2020.

And while the government has made public health a priority, the number of consultants and registrars involved in illness prevention work has "gone down overall". Contrast that with the nearly 60% increase in the number of non-public health clinical staff and it is easy to see why some are questioning if the NHS is the right place to house preventative work. The report concludes that raiding public health budgets to relieve NHS financial deficits "has not been in the long-term interests of the public health of the nation".

Karen Jochelson, a fellow in health policy at the King's Fund, offers an insight into why public health has been sidelined. She says: "If you are a council or a primary care trust [PCT], you have to be accountable for expenditure. The problem public health has is that it's hard to see where you are making an impact, whereas clinical medicine delivers instant results."

A senior social care source puts it more bluntly: "Nobody got hung for not doing public health. But they will if thereÕs a crisis on the acute side of their services."

But Prof Hunter's shake-up would be a radical change - not since the 1960s have councils been responsible for public health. And few in the healthcare and local authority worlds are willing to embark on such a major reform.

John Beer, executive director of health and social care at Southampton City Council, believes transferring public health out of the NHS could be Òeven more damagingÓ than leaving it where it is.

David Hawker, director of children, families and schools at Brighton & Hove City Council, agrees. "There's an argument for that, but I would not want to have public health without the direct involvement of health care providers. The most important thing is to have a strong partnership between the NHS and the local authority.

"In an ideal world, we would have a single set of arrangements covering the NHS and local authorities, rather than a partnership with shared responsibility. But we don't want the NHS to just become the sickness service, we want it to be a health service."

Liam Hughes, the Improvement & Development Agency's national adviser for healthy communities, believes the recent NHS trust deficit crisis is abating, allowing the focus to shift back onto less immediately pressing issues, such as public health. The former PCT chief executive adds that councilsÕ recent record on tackling public health is a "mixed" one.

Former Kirklees Metropolitan Council chief executive Tony Elson insists local government is taking the topic more seriously. Mr Elson, who has been advising the Department of Health since retiring from local government three years ago, says: "There was a time when councils didn't see it as their business. Fewer of them take that view now."

The main recent change has been the appointment of joint directors of public health by councils and PCTs. While the Public Health Association's Prof Hunter worries that joint arrangements will lead to fragmented responsibility, most welcome the move, now adopted in most councils.

Brighton & Hove's Mr Hawker says that having a joint director of public health has been a "very important step forward" in driving forward preventative health work in Brighton.

In Southampton, which has had a joint director for several years, Mr Beer says the arrangement has been "invaluable" in making the partnerships between councils and the local PCT work more effectively.

However, the lives of the new joint directors have been complicated by the recent shake-up of PCTs. "In some areas, the recent reorganisation of PCTs has simplified working arrangements with councils, but in others it has not," says the IDeAs Mr Hughes.

While in most areas PCTs and councils now share boundaries, in others the former is much bigger than the latter.

These relationships have been reinforced by the inclusion of healthier communities as one of the four key themes for local area agreements (LAAs). Meanwhile, moves to create a more outcome-based approach in the local government performance framework are likely to give public health issues a higher profile within councils. Mr Hughes says LAAs help focus the attention of chiefs and the
elected on the whole population, not just their services.

Social services directors are now charged with an additional duty to promote wellbeing. They should be particularly tuned in to the financial benefits of a healthy, active population. "If they are engaged in the community and are able to get about, people will stay fitter for longer," says Mr Beer.

And the message on healthy living needs to be heard a lot further than in those departments that have traditionally engaged with health care issues, like social services. Planners, together with education and transport officers, also need to sign up, given the crucial role they play in shaping people's
environment. Here, the consensus is that some progress is being made. In London, for example, it is increasingly common for planning applications to be accompanied by a health impact assessment.

But while promoting public health may deliver long-term health benefits, cash-strapped services are likely to be vulnerable to the short-term cost pressures faced by PCTs.

It is clear that in a country where how long people live still depends to a large extent on where they were born, public health is an issue councils must embrace with a new sense of moral purpose.

Local government is the natural leader in promoting public health, says David Hunter

Public health continues to dominate the political agenda. Obesity, smoking, alcohol misuse, work and health and other so-called "diseases of comfort" jostle for attention. Yet too little is being done to tackle them effectively. Leadership is lacking and public health remains the Cinderella of the NHS.

In his 2004 review, former government adviser Derek Wanless claimed the NHS is not a health service but a sickness service. Three years on in a hard-hitting critique of government progress to shift the balance towards health and away from treating ill-health, he finds public health practitioners are "undervalued", with "significant opportunities" lost. Constant restructuring and raids on budgets have not helped.

Despite talk of the major public health role that local government has, for the most part it remains in the shadow of the NHS. Yet the natural public health leaders are local authorities. Their "place-shaping" role and ability to take a wider view of the determinants of health are critical to the success of Wanless's "fully engaged scenario" and sustainable communities.

Our lifestyles are shaped by our environment and the way we lead our lives at work, school or in the home. Local government can influence all these since virtually all the functions over which it presides impact on health. Yet there is far too little recognition of its importance, even among its members and officers.

Local government is the natural leader for public health and it should have the courage, confidence and conviction to demonstrate it.

David Hunter Professor of health policy and management, Durham University, and chair, UK Public Health Association

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