In November, the coalition government launched its public health White Paper, ‘Healthy Lives, Healthy People’. The DoH claimed the proposals would ‘radically’ change how England tackled public health problems, with an emphasis on combating worsening health inequalities.
The proposals will take responsibility for population health away from the NHS and hand it to local authorities for the first time since the 1970s. The NHS will not wipe its hands of public health, though, and GPs – as commissioners and practitioners – will still have a role in the government’s vision.
Progress on the reforms was largely eclipsed in the first half of 2011 by the clashes over the Health and Social Care Bill, and the creation of the NHS Future Forum and the ‘listening exercise’ stalled progress further.
But following a consultation on the plans, significant concerns have surfaced among health organisations including the BMA and the Faculty of Public Health – primarily over the finer details of the changes.
What progress has been made on the public health reforms?
The White Paper was met with optimism – experts largely welcomed the move to put local authorities in charge of public health.
From December 2010 to March this year, two public consultations on the proposed changes ran in parallel, on funding and commissioning routes and on the public health outcomes framework.
While the government was preparing its response, the House of Commons health select committee launched an inquiry into the proposals in May.
Throughout the inquiry there was general agreement that integrating thinking about health matters into wider local authority responsibilities – such as housing, schools and environment – would allow a more dynamic response to public health.
However, the committee heard evidence from the authors of last year’s Marmot review into health inequalities who claimed the plans were disjointed. They said the proposals were ‘confused and inadequate’ and failed to follow the advice of their report.
The government’s controversial ‘nudge’ policy for public health interventions had ‘no evidence base’, MPs were told, with NICE cautioning over the ‘unintended consequences’ of the policy.
The committee also heard concerns that proposed local health and wellbeing boards would become ‘glorified talking shops’.
In the latest and last inquiry session in July, England's public health minister Anne Milton rejected concerns that the reforms would jeopardise the independence of scientific advice.
By the time the government published its response in July, along with a timetable for the reforms, health organisations had become increasingly sceptical of the plans.
In particular, the BMA said there were worrying gaps in the plans. It raised concerns that cuts to public health staff could leave the NHS lacking specialists able to deal with emergencies, such as a future flu pandemic.
The DoH’s response to the consultation said that much detail is yet to be explained. There are plans to roll out a series of reform ‘updates’ over the autumn to keep stakeholders in the loop over further details.
In particular, these will focus on public health finance, including how local authority budgets will be ring fenced, details of the health premium to reward good commissioning, and how the new commissioning outcomes framework will operate.
It is now nine months since the white paper launched and the DoH has yet to explain many of the key working details of its idea.
What role will GPs play in the public health reforms?
The most significant impact on GPs’ clinical role in relation to public health will be via the QOF. Ministers want 15% of the framework – one in seven pounds – to be ‘devoted to evidence-based public health and primary prevention indicators’ from 2013.
The latest proposed ‘menu’ of indicators from NICE, which put forward five new indicators for smoking and obesity, is a step in this direction.
In future, process measures with high levels of achievement will be phased out in favour of tougher, preventive measures.
How will GP commissioners link with local authorities?
GPs involved with clinical commissioning groups will have direct input into the design of some public health services in the community.
These include immunisation programmes, contraception in the GP contract, screening programmes, public health care for those in prison or custody and children’s public health services from pregnancy to age 5, including health visiting.
The July update to the reforms also speaks of increasing brief interventions in primary care, funded by the NHS.
On top of this, GP commissioners will join public health experts, local councillors and others on local health and wellbeing boards, which will advise on priorities for local government investment.
GPs’ input into this process will be vital. Last month, Dr John Middleton, vice president of the UK Faculty of Public Health, urged GPs to block any local government attempt to spend health budgets on services such as housing or schools.
GPs will, in effect, represent the interests of their population’s health when local authorities plan how to improve the health of the population. Whether strategies work will directly affect the patients, and the illnesses, GPs see each day.
Why is the new national public health body part of the DoH and not fully independent?
Public Health England (PHE) will replace the HPA and several other health protection groups as the new centralised body for the population’s health in England.
The government proposed that, instead of establishing the body as a fully independent special health authority as the HPA is now, PHE would be an agency of the DoH.
The Faculty of Public Health reacted strongly to this proposal. Giving evidence to the select committee inquiry, faculty president Professor Lindsey Davies said it was vital that Public Health England retained an independent voice.
‘If Public Health England is set up as it is planned at the moment, as just one more directorate of the DoH, it will lose an opportunity to really speak influentially and authoritatively to the public about important public health matters. I think that would be a huge loss,’ Professor Davies said.
But Ms Milton rejected this concern insisting that public health doctors in PHE could criticise government plans if they disagreed: ‘I don't have any doubt that they will be free to express their view.’
Her comments are unlikely to reassure many, including the HPA itself, which claimed its successor ‘may not be, or may not be perceived by the public, by professional groups or by key stakeholders to be, completely independent and might be thought to be subject to political pressures’.
The concern is that, with PHE as part of a government department, scientists will feel pressured not to oppose government policy. MPs on the committee cited to the case of Professor David Nutt, who was sacked as chairman of the independent Advisory Council on the Misuse of Drugs (ACMD) in 2009 after he claimed alcohol was more dangerous than illegal drugs such as cannabis.
Ms Milton said the Professor Nutt case was ‘completely separate’ from the debate over the independence of PHE.
These issues, like many others around the public health reforms, are unresolved.
What is the timeline for the reforms?
The transfer of power to local authorities will take effect from April 2013, when authorities will also take responsibility for directors of public health, who will oversee public health commissioning.
Public Health England will also begin operating in April 2013, not in April 2012 as first anticipated.
By the end of this year, local authorities will receive shadow allocations for public health grants for 2012/13. Full grants will be made in 2013/14, when local authorities will assume full control over public health.
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