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

2. Taking the Long View of Public Health: a new dawn or poisoned chalice? Presented by David Hunter Professor of Health Policy and Management 31st October 2013

3. 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)

4. Domains of Public Health • Health protection • Health promotion • Health service performance • UK Faculty of Public Health

5. A Tale in Two Parts • Looking back • A not too Horrible History of Public Health

6. A Tale in Two Parts • Looking forward • New dawn or poisoned chalice?

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

8. 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

9. 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

10. 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)

11. 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)

12. Wanless’s Critique Numerous 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

13. 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

14. 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-Goobyand Stoker, The Political Quarterly (2011)

15. 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

16. Evolutionary Trends: How far have we really come? Source: The Economist, 12 November 2003.

17. 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

18. Looking Forward

19. 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

20. 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)

21. The Main Determinants of Health

22. 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

23. 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

24. 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

25. The Journey Continues– Thank you!