Sunday, December 5, 2010

National Health Service Reforming public health in England

National Health Service Reforming public health in England .........
Health improvement to be driven locally

Healthy Lives, Healthy People: Our strategy for public health in England’ sets out the Government's long-term vision for the future of public health in England.
The plans outlined will transform public health and for the first time create a ‘wellness’ service: 'Public Health England', to meet today’s health challenges.

In a move to strengthen both national and local leadership, directors of public health, employed by local authorities and jointly appointed with Public Health England, will lead on driving health improvement locally. Local authorities will deploy resources to improve health and well-being in their communities using ring-fenced health improvement budgets allocated by the Department of Health.

THE temptation for politicians to move the pieces around in the National Health Service is usually overwhelming. Precisely because it is a state-run organisation ministers can reshuffle and reshape as much as they like (in England at any rate, since devolution). Already, the coalition government has announced controversial plans to hand over most of the NHS budget to consortia of family doctors that will purchase hospital care. Now Andrew Lansley, the Conservative health secretary, is announcing a big shake-up of public health, the various ways that governments try to prevent illness in the first place.

The title of today’s white paper, "Healthy Lives, Healthy People" may sound banal, but it will result in two important reforms. First, the state will "nudge" rather than exhort people to adopt healthier behaviour. And second, local councils are to be given a new role in promoting better health and will receive money from the NHS to finance this. Both sound promising, but may deliver less than Mr Lansley hopes.

The goal of improving public health is common ground. A longstanding critique of the NHS is that it is a national illness rather than health service. And yet it has long been clear that the path to better population health in advanced economies passes through the kitchen and the gym rather than the doctor’s surgery. As Victor Fuchs, an eminent American health economist, pointed out in his classic text "Who Shall Live?" in 1974, "differences in diet, smoking, exercise, automobile driving and other manifestations of "lifestyle" have emerged as the major determinants of health".

That poses a difficulty all the same. Should ministers try to change damaging behaviours such as alcohol abuse or seek to combat obesity, and if so, how? Can they really be nannies to the people who elect them?

Politicians tend to give muddled answers to these conundrums probably because people are muddled. On the one hand, they deplore the fact that there are deep health inequalities in Britain, many of which arise from differences in lifestyles such as whether or not people smoke or keep their weight under control. On the other hand, they dislike being told what to do.

Under Tony Blair, Labour was initially leery of seeming to support a nanny state. But towards the end of his time at Number 10, his government had introduced a smoking ban in public places. The longer Labour was in office, the more weight it attached to public health. Mr Blair himself highlighted the importance of tackling harmful behaviour in 2006 when he said: "Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle."

By contrast, Mr Lansley is stressing the importance of public health from the outset. However, like the early Mr Blair he too is reluctant to play the role of nanny. Indeed he argues that exhortation can prove counter-productive. Rather, he wants to use the lessons from behavioural economics, in particular those set out in "Nudge" by Richard Thaler of Chicago University and Cass Sunstein who now works for President Obama. The central idea is that people can be coaxed rather than forced into better decisions by often quite subtle changes in the way that they are framed; for example, repositioning food options in a canteen or a shop so that healthier ones take pride of place.

That sounds clever, but could it be too clever? An early critique of American advertising was called "The Hidden Persuaders". Whether people will take any more kindly to well-intentioned stealth tactics is unclear. It may turn out that this attempt to occupy a middle ground, by pursuing "libertarian paternalism", will quite simply prove to be a contradiction in terms. What will happen, for example, if food manufacturers and retailers fail to co-operate meaningfully in moves to promote better diets?

Probably the more important change is to give councils a greater say in public health. This makes a lot of sense because they are best-placed to bring together diverse ways of improving health at a local level, such as promoting exercise both through recreational services and by making it safer for people to cycle. Paradoxically, the reform may give public health greater prominence because the longer-term agenda of tackling the causes of ill-health will no longer be crowded out by the more pressing demands within the NHS of dealing with actual sickness.

Public health responsibility deal
The Government’s view is that society, government and individuals share collective responsibility for public health and the new public health system will encourage all to play their part in improving and protecting the nation’s health and well-being.

With the aim of making it easier for people to make healthy choices and live healthier lives, the public health Responsibility Deal is being driven forward by the Secretary of State.

Working with industry, the voluntary sector, non-governmental organisations, and leading experts from the field, it should lead to, for example, better food labelling, more information about the harmful effects of alcohol, and a much greater contribution from industry into campaigns such as Change4Life.

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