Healthy Lives, Healthy People: Our strategy for public health in England

This White Paper on Public Health starts by painting a picture of failure in the arena of public health. As the Secretary of State’s Foreword points out, Britain boasts the most obese population in Europe, among the worst rates of sexually transmitted infections recorded, a relatively large population of problem drug users and rising levels of liver disease attributable to alcohol abuse. We also have problems with health inequalities where the wealthy can expect to live longer than the poor.

In response to these challenges, the Department of Health proposes to step back but will be establishing a new professional public health service; Public Health England. This will be responsible for spend totalling around £4bn and will support local innovation, help provide disease control and protection and spread good practice. It will fund preventative health services including health protection, emergency preparedness, recovery from drug dependency, sexual health, immunisation programmes, alcohol dependency prevention, obesity, smoking cessation, health checks and nutrition. Functions carried out by the Health Protection Agency and the National Treatment Agency for Substance Misuse will be transferred to Public Health England pending regulation.

This White Paper confirms more structural reform in the health service with local authorities to have greater and protected responsibility for public health. Public health budgets will be ring-fenced and an Outcomes Framework (to be consulted on later this year / early next year) will provide the strategic focus for local authorities’ work. The system will be based on evidence. These ring-fenced funds will not be allocated to local authorities until April 2013.

As previously announced a ‘health premium’ will incentivise local government and communities to improve health and reduce inequalities, although further detail on this is lacking – there is to be a further consultation on funding and commissioning of public health. Local statutory Health and Wellbeing Boards will support joint commissioning of NHS, social care and public health services.

Responsibility is a watch-word and is mentioned, in various forms, more than 70 times throughout the 100-page document. It is expected that individuals, local authorities, the NHS, businesses and commissioners will all take responsibility for improving health. Only where other approaches fail will central government need to intervene. The Nuffield Council on Bioethics’ ‘intervention ladder’ (below) is referenced as a guide to the range of potential interventions.

The emphasis will be on enabling and guiding personal choices or ‘nudging’ people into behaviour change rather than dictating what people have to do. The focus is on empowering individuals to make healthy choices and lifestyle changes.

Nuffield Council on Bioethics’ Intervention Ladder

The Department will launch the Public Health Responsibility Deal in early 2011 which promises advances in its work with business and the voluntary sector. This includes five networks on food, alcohol, physical activity, health at work and behaviour change. The White Paper suggests imminent announcements on agreements on issues from reduction of salt in food to promotion of responsible consumption of alcohol. It also contains the warning for business that where such voluntary agreements do not work, the Government will move up the intervention ladder.

There is also a commitment to use the best evidence to support these approaches to stimulate behaviour change and the National Institute for Health Research will house a School for Public Health Research and a Policy Research Unit on Behaviour and Health to encourage a new level of interest and engagement in public health and availability of data.

The Chief Medical Officer’s role is to be strengthened to provide advice and coordination across Government. The role of Directors of Public Health will be critical to the success of the White Paper reforms and an Annex to the report spells out a vision of that role. Clinicians - GPs and Directors of Public Health –will be central to the Government’s NHS reform programme, including playing an active role in public health.

However, as with the White Paper on NHS reform, key questions on accountability mechanisms are left unanswered. Indeed, at times the White Paper is short on detail, but further information will emerge in the near future with the publication of a detailed ‘roadmap’ of the new public health environment, responses to consultative questions on the White Paper content and key documents that build upon the Government’s new approach, including mental health, tobacco control, obesity, and sexual health.

Points for pharmacy

  • Community pharmacies are described as a “valuable and trusted public health resource”
  • The potential for pharmacy to tackle health inequalities and improve public health is emphasised
  • NHS Health Checks will continue to be provided and pharmacies remain an important delivery vehicle
  • Health and Wellbeing Boards will be responsible for producing Pharmaceutical Needs Assessments
  • Healthy Living Pharmacies in Portsmouth are highlighted as examples of innovative good practice
  • The DH will improve work with the community pharmacy sector on stop-smoking initiatives
  • Public Health England will work with the NHS Commissioning Board on a new pharmacy contract
  • Falls prevention is mentioned throughout the consultation and pharmacists should play a major part in this

Points of issue

  • The Pharmaceutical Needs Assessment that are being developed now need to include the benefits of delivering services via Community Pharmacies as these will set the blueprint for pharmacy services in the future
  • It is not clear where the ‘control of entry’ for pharmacy contracts sits –it appears likely it will sit with the Health and Wellbeing Boards
  • Pharmacy profession needs to engage with LAs at a local level and LGA (and PHS in the future) at a national level
  • Pharmacists should be members of the Health and Wellbeing Boards, especially as PNAs will  be carried out at this level
  • Some essential public health roles will be undertaken by those working in the NHS such as pharmacists working in areas of antibiotic stewardship and co-ordination of vaccination
  • Pharmacists need to demonstrate delivery of a quality based service with good outcomes for patients


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