To quote Professor Sir Michael Marmot “Public health is everyone’s business”. Rightly so.
By its nature it matters to us all, whether we believe this to be the case or not. It is this characteristic that can make it one of the most difficult aspects of our health and care system to define and delineate. Yet it also makes it one of the most democratic in its potential to use our social and political structures to deliver huge benefit in terms of individual and collective health and wellbeing.
What emerged was a shared understanding that a focus on public health has never been important nor more challenging.Director of Policy and Strategy
At NHS Providers we have recently asked NHS trust leaders, academics, system leaders and local government representatives what they think the role of providers is in shaping and delivering public health and care. What emerged was a shared understanding that a focus on public health has never been important nor more challenging. The views expressed were unsurprisingly diverse, but they did coalesce around the importance of the following issues:
- Impact of sustainability and transformation partnerships and accountable care approaches in championing public health;
- The substantial challenges of constrained funding in both local government and the NHS;
- The imperative to innovate and to embrace digital technology to improve efficiency and individual’s experiences;
- The primacy of population health and the role of the public health clinician; and
- Enduring importance of a condition specific approach be it smoking, obesity, mental health or frailty
The thread that runs through any consideration of public health is health inequalities, and more specifically the wider determinants of health and wellbeing. A precondition to good public health is socio-economic prosperity, and equity: individuals and communities being enabled to access the support they need to thrive. It is appropriate that public health’s national leader, Duncan Selbie, chief executive of Public Health England, talks so passionately about this: “…A job, a safe and warm home and someone to care for and about are the foundation of what works for improving health and closing the gap between those who are affluent and those who are not…”
A precondition to good public health is socio-economic prosperity, and equity: individuals and communities being enabled to access the support they need to thriveDirector of Policy and Strategy
Professor Sir Michael Marmot goes to the heart of what we need to deliver equity: “Really, it’s a question of social action. Individual behaviours matter enormously, but they are influenced by and conditioned by environments and social determinants.”
Navigating the system
No institution or individual can deliver “public health” alone. That is its strength. However therein lies an inherent weakness. Who leads? Who is accountable and responsible for such a wide ranging set of roles, functions and initiatives?
With the UK in the midst of Brexit negotiations it might seem strange to turn to an EU concept for the answer to these questions. However one of the underlying themes to emerge is that public health is everybody’s business in different ways. A form of subsidiarity – operating at the appropriate level, closest to the people – holds water here. National bodies, councils, trusts, the third sector all have a different relationship to the individual. They operate at different levels and in different ways. It’s about identifying the most appropriate. Alongside this, without genuine integration of services and functions, effective, value for money public health will be impossible to deliver.
Without genuine integration of services and functions, effective, value for money public health will be impossible to deliver.Director of Policy and Strategy
It is critical that we remain true to the core intention to improve public health. One way of doing this is to think about how the structure of health and care delivery relates to the individual and communities. At a system level it is funding, strategic direction and national level actions that predominate.
A sense of place is also critical and is likely to be the way forward. It is broadly the unit of planning and the unit of community/communities. Here we see the potential of approaches such as sustainability and transformation plans and accountable care.
The institution or organisation’s role is as the engine of delivery – whether it’s an NHS trust, a council or a voluntary sector organisation. Each type of organisation has different accountabilities but they share the following: a need to marry institutional and strategic imperatives both to those of other local organisations and to nationally defined priorities; and a specific relationship with individuals through service delivery.
In all of this however the individuals that constitute the public of ‘public health’ must be afforded proper agency. Any approaches where people are ‘done to’, sanctioned or punished will not deliver a return on investment.
Public health is everybody’s business, it operates at every level and should matter to national government as much as individuals. So where should we be headed next?
- Structurally – maintain and enhance the focus on the public health role of STPs and accountable care
- Financially – reverse the cuts to local government public health budgets and shift payment systems so that the incentive is to prevent rather than cure.
- Clinically - reinstate a strong and strategic role for public and population health clinicians in provider organisations which will benefit all other parts of the public health system
- Culturally – bring about a change in mindset across the NHS that is focused on public health and its role in empowering individuals to look after their health
- As the public sector - continue on the journey of influencing fundamental determinants of health and health inequalities
Public health is everybody’s business, it operates at every level and should matter to national government as much as individuals.Director of Policy and Strategy
I’ll give Dame Gill Morgan the final words here: “Let’s get back to a proper debate. Health services are not bad; primary prevention is not a panacea for the challenges of the NHS. A proper population and value- driven approach is needed now more than ever.”
This article was first published by the HSJ on 26 October 2017
Read our second Provider Voices report - Public Health: Everyone's business