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Nudge or fudge?
Despite covering everything from planting trees to cycle lanes,
the White Paper on Public Health is much stronger on rhetoric than
it is on detail, especially embracing the idea that people will
make healthy decisions for themselves, given encouragement. What
these policies will mean in reality will not be clear until a
series of further documents are published in 2011.
The Government published a White Paper on Public Health
yesterday, titled “Healthy Lives, Healthy People”, openly aimed at
addressing the “lifestyle driven health problems” – citing obesity,
alcohol and smoking - which are behind so much of the demand on the
NHS.
As with the rest of the NHS reforms agenda, the emphasis is on
the choices made by empowered and informed consumers. The approach
advocated is to “nudge” them into making the healthy choice, rather
than simply telling them what to do, decried as the “Whitehall
diktat” or “nanny” state approach of the previous Government.
Key proposals
- empowerment of local leadership and greater responsibility for
improving health and well being across society
- greater focus on key outcomes with an emphasis on transparency
and accountability through a proposed new public health outcomes
framework
- feedom for local authorities to innovate to tailor solutions to
their communities
- ring fenced public health funding from within the NHS budget,
with a new health premium rewarding local authorities for progress
against proposed public health outcomes
- emphasis on partnership working, with local authorities given
responsibility for promoting the development of new commissioning
strategies
Some of the key principles – such as moving responsibility for
public health to local authorities - were heavily trailed in the
preceding White Paper “Liberating the NHS”, which set out plans for
the abolition of PCTs and SHAs, with their responsibilities to be
redistributed between local authorities, consortia of GPs, and a
new National Commissioning Board.
Hopefully 2011 will see a clear delineation of respective roles,
where currently there is uncertainty. For example, we do not know
yet who will deal with Continuing Healthcare, Offender Healthcare
or Individual Funding requests. Public health may prove to be only
a small part of the wider healthcare responsibilities that local
authorities eventually assume.
“Healthy Lives” confirms that there is to be a new “integrated
public health service” – Public Health England – from 2012, as part
of the Department of Health. A crucial co-ordinating role will also
be played by local Health and Well-being Boards, which will be a
statutory requirement in each local authority.
“Localism will be at the heart of the system”, and this approach
(which will also drive GP consortia commissioning) will place key
responsibility on Directors of Public Health, based in local
authorities but working across health and social care. However,
local decision making inherently tends to create or exacerbate
variation (ie a “Postcode Lottery”). In February 2010, the Marmot
Review highlighted profound inequalities in health outcomes across
society and across regions, and the need to address this is said to
underpin the White Paper. After the promised removal of the “layers
of bureaucracy” between the Secretary of State and the front line,
the key challenge will be to reconcile this localism with the need
to ensure consistency of provision, and as well as planning on a
more strategic level when required, for example to respond to
pandemic flu or terrorism.
The public health budget will be ring-fenced, with funding
transferred to local authorities by way of a section 31 grant,
which will enable the DH to place conditions on how the money will
be used, though there will be some flexibility. In reality, the
dividing line between health and social care provision is very
blurred, and it seems inevitable that some will complain that
public health funds are actually being used to compensate for cuts
in social care budget. The forthcoming comprehensive review of the
funding of adult social care may change everything again.
One strong and possibly controversial theme is the “Public
Health Responsibility Deal”. Rather than regulation, this promotes
voluntary agreements with businesses (such as food and drink
companies) and other partners (such as schools). The details on
this, as with many of the proposals, are to follow in Spring 2011.
The White Paper also promises many more documents during 2011,
dealing with smoking, obesity, mental health and emergency
planning, among other things.
The timetable for these proposed changes is designed to follow
the changes set out in the NHS White Paper. ‘Shadow allocations’
will be made to local authorities in 2012/2013, with real
allocations introduced in 2013/14, in line with the abolition of
PCTs. Further details are expected in the NHS Operating Framework,
which should be out within the next two weeks.
The DH has launched a consultation on the Public Health White
Paper, open until 8 March 2011. It asks five very broad
questions, reflecting the lack of detail at this stage. We are
considering our response to this consultation, and if you have any
comments or would like to contribute to our response we would be
delighted to hear from you.
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