Moving public health into local government is a very positive development. The timing however was difficult, with the sector severely hit by the austerity programme.
However, the cash crunch enabled local government to really look at ways to transform what it does: in that sense, it created opportunities to look to innovate and do things differently, and gave a chance to step back and explore how to improve population health through all elements of councils’ work.
The opportunity factor
In certain councils, those opportunities have been really well used, and a lot has moved forward. But we mustn't underestimate the enormity of the funding cuts, and the pace has meant that some councils have perhaps had less ability or time to explore how to develop new models of improving population health while using all the active tools councils have.
So the scale and pace of cuts has been a considerable challenge for local government and public health. The available advantages are opportunities for public health to work differently, and the countervailing risk is that cuts are of a scale and pace that is not necessarily beneficial to population health.
What’s very positive in the move to local government is the huge advantage in local government’s ability to influence real determinants of health, and we’re only just getting started on that journey.
Short term and longer term
It’s hard to give a score out of 10 on how the public sector, including the NHS, is delivering on the Five-year forward view’s stated expectation of a big shift to prevention. The financial challenges have too often led to a focus on short-term finances, and prevention efforts don't always fit into short-term timescales.
When you need cashable savings, it is that much more difficult to prioritise prevention efforts. It isn't easy, but taking a medium to long-term approach is really critical if we agree to tackle the major health issues our nation is facing at the moment.
The provider as preventer
In order to meet the scale of the health challenge, prevention has to be everyone’s business, it can’t just be about the public health grant. What’s disappointing is the gap between the expectation – set up initially though the sustainability and transformation partnership (STP) process – of a major focus on prevention, and then the reality of what is in final plans. Unfortunately, while there is some positive increased focus on prevention, it’s simply not being translated into the scale of prevention we need.
An STP change
The STP process acknowledges that much more prevention is needed through the NHS itself, and that the public is generally not sufficiently involved. Public health does get involved in the STP processes, but I’m disappointed that the funding is not there to implement
what is needed. So much more could be done to improve efforts around prevention, be it primary, secondary or tertiary.
For example with alcohol-related harm, we have strong evidence on the benefits of alcohol liaison teams and targeted, focused efforts in acute and community settings, but unfortunately rather than scaling these up, they’re being cut back. That’s short-sighted.
As for smoking, I think every patient with a smoking-related illness should have access to a brief intervention and support to stop smoking: that should be standard across the NHS, as should encouraging healthier habits in physical activity and diet.
And we have to work with patients and communities to improve people’s understanding of their risk factors and what they can do to improve their own health and wellbeing. We need to empower them.
For NHS providers, having public health sitting in local authorities can enable us to work together on exploring innovative ways to influence health determinants across all sectors of people’s lives, and to enable healthier choices to be easier. It means an opportunity to influence the high street, housing and schools.
A lot of NHS trusts are doing great work around areas such as healthy catering and reducing their carbon footprints, looking at how to create environments to enable healthier lives and make a healthy choice the easy choice for patients and staff. This is the NHS ‘doing’ prevention; and, with local authorities, we need to scale up our efforts across our places and our communities.
Hospitals are huge sites, and NHS England’s chief executive Simon Stevens has a good focus on trying to get healthier food and drinks on offer. Some trusts have policies on smoking, but we need to ensure every NHS site has a no-smoking policy, which is enforced, and provides proper support for staff, and patients, who want to stop smoking.
The NHS should support its own large workforce to live healthier lives. Making every contact count has to involve us all.
Really understanding prevention
I understand how important politically it is to prioritise efforts where there’s a strong evidence base. We should expect nothing less, but with public health having done this in our contributions to the STP process, I am unclear that funding has been shifted at all from treatment into prevention. We know that we need that shift from a strongly treatment-focused service to a health service so things are more financially sustainable in the medium and longer term.
Also, the very word ‘prevention’ can mislead – we do try to prevent illness, but why don't we take an asset-based approach and say that we’re trying to enable longer, healthier and more fulfilling lives.
The best focus for a big public health effort? I think it would be smoking. The dramatic reduction in the prevalence of smoking is fantastic, and shows what a public health approach can achieve. However increasingly, smoking is concentrated in populations on low incomes, in those with mental health issues, and in certain communities. So that’s set to drive inequality in the life expectancy gap. Our variable approach to dealing with smoking is really not acceptable.
We need to ratchet up our efforts to reduce smoking: we can't sit back and think we’ve achieved enough and ticked that box. We have to maintain really strong efforts to continue to push down smoking prevalence, especially in those groups where it’s high. It’s ludicrous that in the 21st century, so much harm is still evidenced by people with smoking-related diseases.
Jeanelle de Gruchy is director of public health for Haringey Council and vice-president of the Association of Directors of Public Health, where she leads its programme of policy work. She is currently director of public health lead on health inequalities and public mental health for London, becoming director of public health for Haringey CCG in 2010.