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Editor's blog Tuesday November 30 2010: Public health White Paper out ahead of schedule; not worth the abbreviated wait

Healthy Lives, Healthy People, the new public health White Paper, is out a few hours ahead of the scheduled embargo, and was not worth even this slightly-shorter-than-anticipated wait.

Sure, it's a bad title, but then Shark Sandwich is already taken.

Its lo-fi cover is visually reminiscent of 1980's infamously-buried Black Report.

This public health White Paper takes the piss more thoroughly than a phalanx of urinals.

Is there a contest in the DH for silliest policy of the year?

Its foreword states, "Britain is now the most obese nation in Europe. We have among the worst rates of sexually transmitted infections recorded, a relatively large population of problem drug users and rising levels of harm from alcohol. Smoking alone claims over 80,000 lives every year. Experts estimate that tackling poor mental health could reduce our overall disease burden by nearly a quarter. Health inequalities between rich and poor have been getting progressively worse. We still live in a country where the wealthy can expect to live longer than the poor.

"The dilemma for government is this: it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live. Recent years have proved that one size-fits-all solutions are no good when public health challenges vary from one neighbourhood to the next. But we cannot sit back while, in spite of all this, so many people are suffering such severe lifestyle-driven ill health and such acute health inequalities.

"We need a new approach that empowers individuals to make healthy choices and gives communities the tools to address their own, particular needs. The plans set out in this White Paper put local communities at the heart of public health. We will end central control and give local government the freedom, responsibility and funding to innovate and develop their own ways of improving public health in their area. There will be real financial incentives to reward their progress on improving health and reducing health inequalities, and greater transparency so people can see the results they achieve."

Umm. There is a problem with this, which is that other than the stats on 'Our Unhealthier Nation' (to coin a phrase), it's talking, in civil-service-speak, round objects.

A few examples of the more egregious bits of crap: "we still live in a country where the wealthy can expect to live longer than the poor". WTF? 1. That is every country in the world, bar perhaps North Korea. 2. Coalition Government wants earlier deaths for higher-rate taxpayers?

Or again, "it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live". Blatant horseshit. Public health measures that made undeniable and significant impacts include: seatbelt laws, drink-driving laws, the smoking ban. Public health is not solely about using the tax system and legislation to ban things, but both are vital tools in the arsenal.

McDonalds, KFC and Pepsi (or whoever) are not going to do things that meaningfully threaten their core business: the vending of youth-branded convenience, high-energy or high-fat products. It is Pollyanna-ish optimism to think otherwise.

Fundamentally confused
So on the one hand, "one-size-fits-all solutions are no good when public health challenges vary from one neighbourhood to the next.". And on the other, "we are simplifying the way we organise things nationally, too, with a dedicated new public health service – Public Health England – taking the place of the complex structures that exist today.".

Ooo-kay. "Public Health England will fund those services that contribute to health and wellbeing primarily by prevention rather than treatment aimed at cure ... Public Health England should be responsible for funding and ensuring the provision of services such as health protection, emergency preparedness, recovery from drug dependency, sexual health, immunisation programmes, alcohol prevention, obesity, smoking cessation, nutrition, health checks, screening, child health promotion including those led by health visiting and school nursing, and some elements of the GP contract (including the Quality and Outcomes Framework (QOF)) such as those relating to immunisation, contraception, and dental public health".

Moreover, "Public Health England will have three principal routes for funding services:
• granting the public health ring-fenced budget to local government;
• asking the NHSCB to commission services, such as screening services, and the relevant elements of the GP contract; and
• commissioning or providing services directly, for example national purchasing of vaccines, national communication campaigns, or health protection functions currently conducted by the Health Protection Agency (HPA).

"These are not exclusive; for example, if appropriate, there may be an option for GP consortia to commission on behalf of Public Health England".

So: it's all about localism, except when it's about Public Health England ... or the National Commissioning Board ... or the GP commissioning consortia. Clear now?

Local authorities: accountable to national bureaucracy
I wonder if local authorities have spotted that according to the schematic diagram (Figure 41) on page 60, they're accountable to the Department of Health?

Power and money
So - the power and money is all going to local government by April 2013. Jolly good idea in principle. It may of course be worth thinking about who runs the local government where all the poor people live. Just a thing to keep our eye on, I suspect.

I'm getting the impression that they don't even read their own policy documents: "Public health will be part of the NHS Commissioning Board’s (NHSCB) mandate, with public health support for NHS commissioning nationally and locally. There will be stronger incentives for GPs so that they play an active role in public health".

How will it be part of the commissioning board's role if it's in the hands of local government?

How will "stronger incentives for GPs" be funded? BMA contract negotiations are going to be a proper chortle.

Some good bits
There are some good bits, once you get a dozen pages in: "The contrast between what we know about the causes of premature death and illness in our society and the domination of our attention and spending on secondary care represents a profound challenge to our policy and our society as a whole. At a population level, it is not better treatment, but prevention – both primary and secondary, including tackling the wider social factors that influence health – which is likely to deliver greater overall increases in healthy life expectancy".

Page 16 also has a nice summary: "Healthcare services have been estimated to contribute only a third of the improvements we could make in life expectancy – changing people’s lifestyles and removing health inequalities contribute the remaining two thirds. Many of the biggest future threats to health, such as diabetes and obesity, are related to public health".

The ongoing commitment to ring-fence the money is important.

Page 20's mental health stats are suitably depressing to re-focus attention on thsi crucial area.

And the idea of a cross-Cabinet committee considering the public health aspects of government policy is a very good one indeed. So one non-Bronx cheer for that.

Talking out of your Rs
So,. the new approach is going to have us talking out of our Rs:
• responsive – owned by communities and shaped by their needs;
• resourced – with ring-fenced funding and incentives to improve;
• rigorous – professionally-led and focused on evidence; efficient and effective; and
• resilient – strengthening protection against current and future threats to health

It sounds good. It's also a pretty perfect definition of what Spearhead PCTs used to do. And what happened to them? Oh, yeah ...

The politics of the public health White Paper are neatly encapsulated in its statement that "top-down initiatives and lectures from central government about the ‘risks’ are not the answer". Laissez-faire's great until you get a pandemic. Or have to deal with an issue like the triple MMR vaccine which was a major fail for the last government.

It also says, "Centralisation has failed". Has anyone told NHS CE Sir David Nicholson?

The proposed model for intervention is  the Nuffield Council of Bioethics Ladder of Interventions. Its aim is that instead of reaching for choice-limiting regulations at every opportunity, the Government will employ a range of evidence-based approaches to improve health.

The ladder increases in intrusiveness as follows:
1. Do nothing or simply monitor the situation. Some behaviour trends are minor and fizzle out, so intervention isn’t needed.
2. Provide information. Giving people the information and education to make a choice for themselves based on evidence.
3. Enable choice. Give people a ‘nudge’ in the right direction so they can change their behaviour. For example, through access to public exercise facilities, cycle paths, or safe playgrounds.
4. Change the default to help guide choice. Using positive ‘social norms’ is a way of encouraging this.
5. Guide choice through incentives. A ‘points mean prizes’ approach, for example the more a child walks to school, they earn points for healthy prizes like an activity day.
6. Disincentives, such as taxation or other price related action, to discourage people from smoking or drinking.
7. Restrict choice, probably through regulation, such as raising the legal age for smoking or banning trans fats.
8. Eliminate choice altogether. Rarely used, but most common examples include making seatbelts compulsory and making dangerous drugs illegal.

Arguably, 1 and 2 have already been tested to destruction. 3 is confused: 'nudging' isn't enabling choice: it's simply a less-blatant paternalism. 4 has splendid potential, but could easily just be fantasy without real thought and engagement. 5 and 6 are two sides of the same economic behaviouralist coin. 7 and 8 definitely work.

Not targets: outcome domains!
Targets are so 2000s, darlings! The latest thing is outcomes, and even better when they're in domains. "We propose that the public health outcomes framework should cover five broad ‘domains’ of public health:
• Domain 1 – Health protection and resilience: protecting people from major health emergencies and serious harm to health;
• Domain 2 – Tackling the wider determinants of ill health: addressing factors that affect health and wellbeing;
• Domain 3 – Health improvement: positively promoting the adoption of ‘healthy’ lifestyles;
• Domain 4 – Prevention of ill health: reducing the number of people living with preventable ill health; and
• Domain 5 – Healthy life expectancy and preventable mortality: preventing people from dying prematurely".

Of course outcomes are important. They're also hard to measure, and certainly hard to move in a short timescale. So sometimes, in public health as in other areas, process measures are useful, if you don't get too caught up in the how and remember the why.

There is a confusing suggestion that "The arguments about when it is appropriate for government to intervene in people’s health and to what extent have become oversimplified. They are often presented as a straightforward choice between two extremes – intrusive intervention into people’s lives or completely hands-off. These fail to capture the wide range of interventions that are available and the need to make decisions on a case-by-case basis about which to use".

Nobody with any real sense makes those assumptions. The meaningful question is simple: what will work here?

For nearly fifteen years (and with the honorable exception of the smoking ban), Government has shat its collective pants over the thought of banning, regulating or taxing most things known to cause harm (and indeed even over enforcing extant laws, such as serving alcohol to the evidently inebriated) because it has been scared of what the Daily Mail might say.

Which is richly ironic, because the Dacre world view would happily ban everything it doesn't like.

Deal or no deal
A "Public Health Responsibility Deal ... will aim to base these approaches on voluntary agreements with business and other partners, rather than resorting to regulation or top-down lectures".

Spare me. Deal - the timber, cut from Scots Pine - is a soft wood. But not as soft as this deal.

The localism strategy involves:
a. empowering local government and communities, who will have new resources, rights and powers to shape their environments and tackle local problems;
b. taking a coherent approach to different stages of life and key transitions, instead of tackling individual risk factors in isolation. Mental health will be a key element;
c. giving every child in every community the best start in life;
d. making it pay to work, through comprehensive welfare reforms, creating new jobs through local growth and working with employers to unleash their potential as champions of public health;
e. designing communities for active ageing and sustainability. spaces and improve access to land so that people can grow their own food; and
f. working collaboratively with business and the voluntary sector through the Public Health Responsibility Deal

And health visitors are going to build the Big Society - that is, if the FT which employs them allows them to: "The Department of Health will increase investment in health visitors, through a four-year transformational programme, and will publish a plan shortly. Health visitors will have a new role in building a stronger local community, in partnership
with local voluntary and community groups, peer support and befriending networks".

There is some pretty fair stuff on education ands school years, including, "we need to develop approaches that tackle the root causes of failure, rather than reacting to behavioural problems with programmes designed to tackle their symptoms. School-based mental health promotion can improve self-esteem and reduce risky behaviour, particularly for those at higher risk".

Putting fags into plain packets? As someone who, way back in the Bad Old Days Of Smoking used to greatly enjoy Death cigarettes, I can vouch for the fact that this is going to have diddly-squat impact (please excuse me if this health policy jargon goes a bit over your head).

Fridges and fruit silliness. What did you think my TLA was short for, people?

The Change4Life Convenience Store Programme means that lard-seeking fools will be 'nudged ' onto buying healthy kumquats, by dint of an accord to hide the crisps and chocolate next to the A4 manila brown envelopes in convenience stores. Genius.

More policy escaoplogy ensures: "There will need to be close partnership working between Public Health England and the NHS at a national level, and between local government, DsPH and GP consortia at the local level".

Fine. Where are the incentives to achieve this? Closer partenership working cannot be wished into existence by the policy fairy.

"We will keep to a minimum the constraints as to how local government decides to fulfil its public health role and spend its new budget. There will be payment for progress made against elements of the public health outcomes framework".

The wait
Oh, we're rocking here: "The Department of Health recently consulted on proposals for local statutory health and wellbeing boards, which will bring together the key NHS, public health and social care leaders in each local authority area to work in partnership ... able establish a shared local view about the needs of the community and support joint commissioning of NHS, social care and public health services in order to meet the needs of the whole local population effectively. Responses to the consultation have been generally very supportive of local statutory health and wellbeing boards, with a desire to see clarity of accountability in the system between local authorities, GP consortia and the NHSCB. Local government and the NHS have also wanted to see close partnership working and joined-up commissioning strategies between the NHS and local authorities".

And this will work how? Oh, wait! And wait! For the response to be published. Just like you're waiting for the "consultation on the details of the proposed funding and commissioning routes for public health. This consultation includes the funding and commissioning remit that the Department proposes for Public Health England in the future".

And the promised 'health premium to reward progress in improving public health outcomes, it would be good to know about that? "We intend the support for progress in reducing health inequalities to be clear and significant ... The forthcoming consultation document will discuss further some of the issues we will need to consider when developing the health premium, to allow more detailed discussions with local authorities and public health professionals. We will only set out a detailed model when we have established the baseline and potential scale of the premium clearly, and have agreement about the outcomes we will use.".

Directors of public health "will be employed by local government and jointly appointed by the relevant local authority and Public Health England".

And jointly disciplined? Or jointly sacked?

Money for GPs
"The Department of Health will work to strengthen the public health role of GPs in the following ways:
• Public Health England and the NHS Commissioning Board will work together to support and encourage GP consortia to maximise their impact on improving population health and reducing health inequalities. This will include looking specifically at equitable access to services and outcomes.
• Information on achievement by practices will be available publicly, supporting people to choose their GP practice based on performance. By increasing transparency about how effective different GP practices are in giving public health advice, Public Health England will enable local communities to challenge GPs to enhance their performance.
• Incentives and drivers for GP-led activity will be designed with public health concerns in mind, for example, in terms of prevention-related measures in the QOF. To increase the incentives for GP practices to improve the health of their patients, the Department proposes that a sum at least equivalent to 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. The funding for this element of QOF will be within the Public Health England budget.
• Public Health England will strengthen the focus on public health issues in the education and training of GPs, as part of the Department of Health’s development of a workforce strategy".

So, some more questions:
1. Public health performance 'league tables' for GPs are on their way. Who will do them, and how much do those people like pain?
2. Where do DH negotiators think they are going to take 15% out of the existing QOF to fund a public health QOF?
3. How will a new GP workforce strategy be enforceable in an NHS of all providers being foundation trusts?

Changing roles - chunks of quotes
As the Department of Health is freed from the operational management of the NHS, it will refocus efforts on protecting and improving the health and wellbeing of England as a whole.

The CMO will have a central role in providing independent advice to the Secretary of State for Health and the Government on the population’s health. He or she will be the leading advocate for public health within, across and beyond government, challenging industry, employers, and civil society to take a bigger role in and responsibility for the public’s health.

Public Health England will be part of the Department of Health, accountable to the Secretary of State for Health. It will not be a separate legal entity ... Public Health England will also include elements of public health activity currently held within the Department of Health and within strategic health authorities (SHAs) along with functions of the Public Health Observatories and cancer registries ... Public Health England will be subject to the planned reduction of one-third of nonfrontline administration costs across the whole system, while protecting frontline services. This will be managed within the overall human resources and financial framework of the Department of Health as part of its transition programme ... managing health protection, especially emergency preparedness, will require strong links between Public Health England and the NHS, local government and others throughout the country. For example, infectious disease outbreaks often spread beyond the boundaries of a
single local area, requiring co-ordinated management. Public Health England will therefore have an important local presence in the form of Health Protection Units (HPUs), working closely as now with the NHS and local government colleagues.

Oops! The Secretary Of State has forgotten that in an all-FT system, there will no longer be NHS providers
"At a national level, the Secretary of State of Health will have powers of direction in the event of what he considers to be an emergency, including powers to direct NHS providers as to how they should respond".

Once foundation trusts start being owned by hedge funds (or as they will no doubt be termed, 'workers' co-operatives') and venture capital firms, that will lead to some fairly crunchy conversations should the SoS be sufficiently unwise to try it.

"In the coming year, the Department will focus on drawing together existing public health information and intelligence functions (for example, the Public Health Observatories, cancer registries, and relevant parts of the HPA), working to eliminate gaps and overlaps and to develop the specialist workforce required".

And then cut them all by one-third.

Oh, but hang on! "The Government wants to build on the achievements and skills of the current public health workforce. Maintaining a well-trained, highly motivated public health workforce will be critical to the success of the public health system".

Motivate me, DH! Cut everything by 1/3 and then if I am not part of that 1/3, transfer my employment to a sector that has just lost 27% of its central funding - which is almost all of its funding! I can feel the joie de vivre and esprit de corps welling up.

You probably didn't think it could get any better, but trust me: it does: "It is critical that scarce public health skills within the system are retained, including capacity to support senior leadership of the public health service. The Department of Health will therefore encourage PCTs and local government to discuss the future shape of public health locally. It is important to ensure that specialist staff, including medical and clinical staff, are rewarded fairly wherever they work; that their pay is properly governed locally; and that reasonable arrangements are in place to promote the flexibility and mobility of the workforce in the longer term. The Department of Health will work with the Local Government Association to consider what advice, support and guidance may be needed to support this".

Here is the future shape of public health locally: now we are consulting you on it! Dumping 1/3 of you; feel loved and valued! Shifting you to employment in a sector losing 25% of its funding: have a nice day!