Public health prose

Happy New Year for 2014. This edition's public health prose is a personal view from a public health professional in a London local authority. We will bring future messages from different public health perspectives, organisations and functions. January is the month where people are even more sheepish than usual when they bump into me as they wait on the ground floor for the lift, or as they break into a bag of crisps in the kitchen. In February we can plan to take action as part of National Heart Month¹ and walk up the stairs or eat our “five a day”. In January, however, we review the past year and look forward to the next.

Looking back on 2013

Last year was an eventful one for public health and primary care. For one thing, 1 April 2013 (April Fools' Day) saw the implementation of the Health and Social Care Act, breaking the electoral promise of “No top down reorganisation” of the NHS.²

These reforms transfer the local public health function from the NHS to local government, where it last sat in 1974. Local authorities are given a new responsibility to protect and improve the health and wellbeing of their residents.^3,4 Public health provides an important way to do this. Statutory multi-agency health and wellbeing boards bring together key players from the health and care systems in order to agree upon an integrated way of improving the health and wellbeing of the local population and to reduce health inequalities.⁵ GPs continue as providers of primary care while assuming commissioning duties as Clinical Commissioning Groups.

From April onwards the transition unfolded. From my perspective I saw the continuation of “core public health business” alongside major shifts in processes, structures and cultures. For some boroughs, public health resources have increased through the ring fenced public health grant allocations.

The three core functions of public health:⁶ health improvement (health promotion and prevention programmes), health protection (legal and enforcement aspects of public health) and healthcare public health (technical public health skills to support quality improvement) have remained. However the emphasis, structures and key players have shifted. Take health improvement for example: NHS Health Check programmes (cardiovascular disease prevention for 40–74 year olds) have been developed, promoted and commissioned by public health in the NHS. It is now a mandatory function⁶ for local authorities, most likely to be led by public health. A health protection function, such as the management of outbreaks of diseases like food poisoning and ‘flu, will mainly sit with Public Health England. However at a local level there are opportunities for public health to lead stronger work across the council to impact upon health. For example tackling tobacco control in partnership with local authority trading standards and enforcement officers. In the case of healthcare public health, Directors of Public Health and their teams will continue to be required to provide an intelligence and advice service to NHS commissioners.⁶ This would include technical public health skills, such as service evaluation or population needs assessments, to inform commissioning. This expertise could also enhance social care policy. We will elaborate more on these core functions in future editions.

Moving the public health function from NHS to local government has involved transition between two complex systems. Practical examples include the meticulous transfer of most public health contracts, unpicking budget lines for sexual health services, transfer of undertakings (protection of employment) of staff and adjusting to new systems for finance, contracting and human resources. These adjustments were inevitable and predicted, and have been managed well in many cases. However, time and resources expended have diverted some resources away from other activities; for example, developing cross cutting programmes with our new colleagues in the council, or strengthening the quality and uptake of existing programmes.

Arguably the part of the transition that is most significant is the shift in accountabilities, responsibilities and organisational culture. Prior to April 2013 public health accountabilities were to the NHS. Post April 2013 our masters are the local authorities. Local authorities and our democratically elected local politicians are accountable to our local residents, the focus of all public health work. These fundamental changes in accountability and associated culture afford the greatest potential challenges and opportunities moving forward. They link with the theme of this edition: community-orientated integrated care.

Looking forward in 2014

Facing ahead in January, after the customary excesses of the festive season, we move into a sobering situation. However, there is room for optimism. Articles and editorials in the London Journal of Primary Caer can provide food for thought.

Mostly we will continue to manage the bread and butter of the transition, adopting new processes for everything we do. Nationally the wider concerns of the Health and Social Care Reforms that were warned of by many professional groups unfold to greater and lesser degrees, including: fragmentation of the NHS, loss of management and commissioning expertise, overload of GPs and the advance of the private sector. The welfare reforms and the economic downturn present challenges. They are likely to have far reaching impacts on mental and physical health and social circumstances of local people.⁷

My optimism comes from the opportunities provided by the parts of the reforms that I have always seen as most positive and visionary. First, local government has responsibilities for education, housing and the environment. The move of the public health function to local government should therefore give opportunities to tackle the social determinants of health. This is critical to a long-term reduction in health inequalities. Second, the statutory health and wellbeing boards and strategy provide an opportunity to bring together priorities and to integrate health and social care. As David Morris points out, there are opportunities to use the integration agenda to shift the nature of the system much more profoundly than simply improving cost-efficiency. Third, local government bodies are democratically accountable to their residents, the focus of public health work and “population medicine”. Locating the responsibility for public health and the leadership of the health and wellbeing boards within local authorities gives a focus for partners to strengthen engagement with local communities. Can we move towards “connected communities”? Can we develop local interventions for inclusion of wellbeing as David Morris suggests?⁸ David Morris also states that there is a compelling argument that engaging communities will help us to make more effective use of limited resources. These are complex problems requiring complex solutions. The articles and editorials in this journal over the coming months should provide a feast of information to embellish the conversation and take this forward. We would love to hear from you with your comments, queries and thoughts.

This prose is written in a personal capacity by Dr Fiona Wright. It does not express the views of any organisation to which I belong or by which I am employed. We would love to hear from you with comments, queries and thoughts. Address for correspondence: phprose@gmail.com