taking the long view of public health: a new dawn or poisoned chalice?

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School of Medicine Pharmacy & Health


Taking the Long View of Public Health: a new dawn or poisoned chalice?

Presented by David HunterProfessor of Health Policy and Management31st October 2013

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What is Public Health?

Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.

Sir Donald Acheson, former Chief Medical Officer for England (1988)

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Domains of Public Health

Health protection Health promotion Health service performance

UK Faculty of Public Health

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School of Medicine, Pharmacy & Health

A Tale in Two Parts

Looking backA not too Horrible History of

Public Health

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A Tale in Two Parts

Looking forwardNew dawn or poisoned

chalice?

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Looking Back (1)History tells us that local government played thegreatest historical role in the sanitary revolutionduring Britain’s rapid industrialisation in 1800s Improved housing Cleared nuisances Introduced gas lighting Provided public bathing and washing facilities Implemented infectious disease control

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Looking Back (2)

Rediscovery of public health in more recent times Rise of non communicable diseases: cause of

86% of deaths in the WHO European Region – 53 countries, 900 million people

Smoking Obesity Alcohol misuse

Communicable disease control: flu pandemics, sexually transmitted infections

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Looking Back (3) From 1974 - 2013 the National Health Service

(NHS) had responsibility for public health Clinical dominance of public health workforce Multidisciplinary public health workforce becomes

a reality (2003): Introduction of UK voluntary register for public health

specialists Faculty of Public Health Medicine becomes Faculty of

Public Health Joint Directors of Public Health appointments between

NHS and local government

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Public Health and the NHS: a difficult relationship

While the NHS claimed from the outset to give high priority to the promotion of health…in reality this aspect of the service was never more than weakly developed, notwithstanding claims to the contrary, habitually made in ministerial speeches.

Charles Webster (1996)(Official NHS Historian)

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Looking Back (4) Brief renaissance of public health under New Labour: first

Minister for Public Health (1997) Wanless I (2002) and II (2004): 'fully engaged scenario' Joint Directors of Public Health posts: recognition of local

government's role in public health – 'multidisciplinary public health will become a reality' (Blears, 2002)

NICE assumes responsibility for public health evidence (2005)

World class commissioning: focus on population health (2007)

The Marmot Review: focus on SDH (2010)

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Wanless’s CritiqueNumerous policy statements and initiatives in the field of public health have not resulted in a rebalancing of policy away from health care (a ‘national sickness service’) to health (a ‘national health service’). This will not happen until there is a realignment of incentives in the system to focus on…tackling the key lifestyle and environmental risks.

Derek Wanless (2004), Government Adviser

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Looking Back (5) Persistent tension between focus on individual

lifestyle change (nudge) and government action to improve health (shove): ‘lifestyle drift’ prevails over ‘nanny state’

Responsibility deals Behaviour Insights Team (Nudge Unit) No action on plain packaging for cigarettes or

alcohol minimum pricing

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Where are we Now?The coalition programme…involves a restructuring of…public services that takes the country in a new direction, rolling back the state to a level of intervention below that in the United States – something which is unprecedented. Britain will abandon the goal of attaining a European level of public provision. The policies include substantial privatisation and a shift of responsibility from state to individual.

Taylor-Gooby and Stoker, The Political Quarterly (2011)

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Reflections: the Negatives

Public health caught up in neoliberal agenda: from the welfare state to the market state

Continuing tension between the nanny state and the enabling state

‘Lifestyle drift’ policy bias, especially evident in England

Medical resistance to non-medical specialists

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Source: The Economist, 12 November 2003.

Evolutionary Trends: How far have we really come?

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Reflections: the Positives

Acknowledgement of wider public health and its multidisciplinary workforce

Smoking ban – example of government action with public support

Example of evidence informed policy Recognition of local government’s

key role in public health

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Looking Forward

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Key Challenges

Return of public health to local government (April 2013): realising the potential

New organisation at centre to lead on public health: Public Health England

Making the public health workforce fit for purpose with new skills

Changing leadership styles Applying evidence and strengthening

knowledge to action

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Local Government: public health’s natural home

Many people in local government believe it is their organisations, rather than health authorities, that are public health authorities.

Tony Elson (1999)(former local authority chief executive

and adviser to Department of Health)

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The Main Determinants of Health

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Meeting the Public Health Challenge Investment in public health

Health spend per capita: £2000 per year Preventive spend: £80 per year (4%)

Using ring-fenced public health budget to unlock resources elsewhere in local government

New partnerships: are Health and Wellbeing Boards the answer?

New skills and competencies required Relationship building Political astuteness

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Concluding Reflections (1)Is the glass half-empty? Demise of the public health profession as we

know it: future of specialist-practitioner-wider workforce paradigm at risk

End of DsPH as we know them Emergence of a divided and fragmented

workforce split between different cultures Failure to recognise and invest in public

health skills training Devaluing the evidence base in political

world of local government Time of austerity: public spending cuts

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Concluding Reflections (2)Is the glass half-full? Transform the way public health is conceived and

delivered Break away from the shackles of a biomedical

model and embrace a social model: from a deficit to an assets-based approach

Develop new skills and competencies – not a case of preserving the old and familiar

Embed new leadership style focused on influencing others engaged in health improvement and wellbeing

Use of ring-fenced public health budget to lever in resources from elsewhere

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The Journey Continues– Thank you!

taking the long view of public health: a new dawn or poisoned chalice?

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