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The public health white paper poses joint challenges for councils and the NHS. But there are concerns about where t...
The public health white paper poses joint challenges for councils and the NHS. But there are concerns about where the power and funding lies, says Mark Gould

When health secretary John Reid launched the public health white paper, he took journalists on an Underground ride from west to east London. He told them that for every stop on the journey, life expectancy dropped by almost a year.

Mr Reid was outraged that in 2005 the richest people - those in the St James ward of Westminster - should live around eight years longer than the poor of Canning Town South, where male life expectancy is just

69 years.

The Choosing Health white paper was launched in November 2004. Last month local government and its NHS, voluntary and community partners were issued a 132-page delivery plan which sets out a series of strict health improvement goals to be met within five years.

Local government and the NHS, via primary care trusts, must hammer out local area agreements working to deliver top-line national public health improvement targets. At the same time, these must have the flexibility to address specific local problems.

But while the democracy and local accountability is with local government, the cash is going to the NHS.

PCTs will receive an extra£342m for 2006-07 and 2007-08 to implement the public health drive. They will be encouraged to align and pool funding streams with local government, but many see this as a lost opportunity.

'We have the democratic mandate locally, which is where things should start,' says David Rogers (Lib Dem), chair of the Local Government Association community wellbeing board. 'I like the commitment to work together with other agencies but I would have liked to see the government go further and faster on smoking. There is still a lot of complexity and confusion around the smoking ban and premises serving food.'

He is unhappy that additional resources have gone into health improvement through PCTs, while at the same time councils are told by the Office of the Deputy Prime Minister to keep council tax low.

What about the idea floated by some commentators that PCTs should be seen as banks where local government can draw on resources? Mr Rogers says it is not as simple as that. 'It is clear where the money has gone and we want to make sure anything specifically for local government [to do] should be resourced,' he says.

Shouldn't councils have the freedom to be more inventive, for instance offering council tax discounts for people who do not own cars? 'That is where we are pleased the government has got national targets but with local flexibilities,' Mr Rogers says.

David Woods is director of housing and health at Barking & Dagenham LBC, a couple of tube stops further east from Canning Town but with the same health inequalities.

From his point of view, tackling these problems is already an equal partnership, but he feels government needs to be more specific that this is a joint approach and not one led by one sector.

'We havea joint director of public health [with the PCT] and more development going into health policy,' he says. 'We have a range of posts that could be joint appointments. Look at community trusts and children's trusts - that is about a local authority response to improving health.'

Mr Woods says the crucial elements are stability and finance. 'It is terrific that there has been a 30% increase in NHS funding over the last six or seven years but we haven't seen the balance of health change that much - all the inequalities are still there,' he says.

Mr Woods says the Spearhead initiative - a collaboration of councils and PCTs in areas with the worst health inequalities - has been very welcome but that money is due to run out in 2007-08. 'On top of that, we have a PCT that is 10% underfunded,' he says. 'It is getting a 3% increase but we are still talking about substantial deficits, not marginal sums.'

Mr Woods calls for structural stability in the NHS. 'The NHS has had more structural changes in the last 15 years than we in local government have had in 100,' he says. 'We need stability in terms of organisations and guaranteed levels of funding.'

What about past legislative moves such as seat belts and breathalysers, which although initially detested have brought about real health gains? 'If I were minister for a day, I'd ban smoking,' Mr Woods says. 'If it were a new product, it would never get a licence.'

Find out more

>> Choosing Health white paper and the delivery plan,

>> Information on local health inequalities work by the public health observatories,

>> Evidence on the effectiveness of public health work is published by the Health Development Agency, now part of the National Institute of Health and Clinical Excellence,

On yer bike

Due to a relatively low population spread over a large area, the car is king in rural Suffolk.

But when Suffolk CC relocated its headquarters to Ipswich, it became a catalyst to cut car use and promote healthier forms of transport.

As a result of travel plans implemented last April, car use among the 1,200 employees based at headquarters has fallen from 52% to 38%. Meanwhile cycling more than doubled to 9%, as has train use to 7%. In total more than 300 of the workforce changed from cars to modes of transport that cause less pollution and congestion, in

a year.

Employees pay to use the staff car park, dependent on seniority and length of time they are parked, and profits are used to subsidise sustainable transport.

The council also negotiated ride-to-work discounts with the local bus and train companies, but it also used the opportunity to ask staff to think about new styles of working, which include flexible working patterns and mobile working.

Notts action plan

As one of the 12 health inequalities shared priorities pathfinder authorities, Nottingham City Council wanted to find out the extent of partner organisations' knowledge of health inequalities.

Through a strategy group, the city put together an action plan to support a range of activities at the council, primary care trust and within the voluntary sector.

The action plan focused on physical activity and smoking cessation. One of the targets was to improve the health of the over 50s. Figures collected in 2003 revealed 21% of this group take some form of physical activity every day. The target is to increase this to 27.7% by 2006.

Need to know - the public health white paper

The key priorities are to:

>> Reduce the percentage of people who smoke to 21% or less by 2010, with a target of 26% among blue-collar workers

>> Reduce alcohol dependency through partnership working between the NHS, councils, the police, the licensing trade and others

>> Modernise sexual health services with£300m extra funding over the next three years, with investment in teenage pregnancy and sexually transmitted diseases

>> Set up a team of health trainers to help people live healthy lives. From this month, the government will begin marketing campaigns in deprived communities

>> Halt the rise in obesity among children under 11 by 2010 as part of a public service agreement target. Each PCT must have at least one full-time qualified school nurse working with a cluster group of schools

>> The white paper is accompanied by separate delivery papers, Choosing Activity and Choosing a Better Diet, which are focused on improving nutrition and activity among children, young people and the elderly

>> These papers are underpinned by a set of shared priorities between central and local government, where local government can have a positive effect on inequalities

>> The priorities focus on creating safer and stronger communities; improving the quality of life for older people, children, young people and families at risk; promoting healthier communities; getting people back to work; and improving the local environment

>> Councils will have responsibility for ensuring effective local planning mechanisms are set up to drive improvements in health and wellbeing

>> Local needs will be identified by public health observatories, which will deliver local information reports, annual reports to councillors and health and wellbeing equity audits.

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