What is the public health white paper?
Last week, the coalition government published its promised public health white paper, Healthy Lives, Healthy People. It is a policy document outlining what it calls “radical” changes to the way public health is managed in England.
It builds on the NHS white paper published in July and fulfils several policy pledges Andrew Lansley made in opposition, including ring-fenced funding and a dedicated government department for public health.
Why is it needed?
Healthy Lives, Healthy People is the coalition government’s response to Sir Michael Marmot’s 2009 review of health inequalities, Fair Society, Healthy Lives.
The government says its “bold” approach to managing public health is necessary because of the “alarming levels” of lifestyle-driven health problems in England. Alongside the public health white paper, it has published a review of evidence on health and wellbeing in the country, Our Health and Wellbeing Today.
Its findings include:
- Maternal depression and anxiety affects between 10 and 15 per cent of pregnant women; rates are nearly twice as high among mothers living in poverty and three times as high for teenage mothers.
- There is a 70 per cent gap in infant mortality between the richest and poorest groups and rates for some ethnic groups are almost twice the national average.
- One in five mothers is obese, one in six smokes during pregnancy and breastfeeding prevalence at six to eight weeks is just 46 per cent.
- One in five three-year-olds and two-thirds of adults are overweight or obese.
- Obesity-related conditions cost the NHS an estimated £4.2 billion a year.
- One in five adults smoke – the single biggest preventable cause of early death and illness.
- The NHS spends more than £2.7 billion a year treating smoking-related illness, but less than £150 million on smoking cessation.
- Circulatory diseases, cancers and respiratory diseases together account for three-quarters of deaths across all ages.
- Over 30 per cent of deaths from circulatory disease could be avoided mainly through lifestyle changes.
- By 2024, half of the population will be more than 50 years old.
- Dementia costs the UK £17bn a year, with 750,000 people in the UK affected and numbers set to rise; half of dementias have a vascular component.
- 15.4m people in England have a longstanding illness; musculoskeletal conditions, circulatory diseases and mental health diseases account for over 70 per cent of the burden of longstanding ill health.
- The UK could save up to £100bn a year by reducing working-age ill health.
- One in 10 people who get an STI will become reinfected within a year.
- People living in the poorest areas will, on average, die seven years earlier than those living in richer areas, and will spend up to 17 more years living with ill health.
The government says England’s current approach to public health is “not up to the task of seizing these huge opportunities for better health and reduced inequalities in health”.
How will it work?
The coalition says “localism” will be at the heart of its proposed public health system. The core proposals of the public health white paper are:
- The transfer of the role of directors of public health (see White paper lingo decoded, left), currently within PCTs to local authorities, where they will be “strategic leaders” for public health in local communities.
- Ring-fenced public health funding, allocated to local authorities.
- A dedicated public health service, Public Health England, within the Department of Health.
- An evidence-based approach to public health initiatives, with the set up of a National Institute for Health Research (NIHR), School for Public Health Research and a Policy Research Unit on Behaviour and Health, and the regular publication of health outcomes.
- A central role for the chief medical officer and the planned NHS Commissioning Board (NHSCB) in public health.
- “Stronger” incentives for GPs to play a role in public health.
How will it be funded?
The public health budget, ring-fenced within the overall NHS budget, will be allocated to local authorities, weighted for inequalities. To encourage health inequalities reduction, authorities will receive “health premium” incentive payments for progress based on a public health outcomes framework.
The government’s “early” estimates suggest that the current spend on areas that will become Public Health England’s responsibility could be over £4bn. (The actual value will be influenced
by the government’s overall plans for cost reductions and efficiency gains.)
The government has promised to publish a consultation on the proposed funding and commissioning of public health “shortly”.
How will commissioning work?
The public health budget will fund services primarily aimed at prevention rather than treatment, including smoking cessation, screening and sexual health services.
Public Health England will have three main routes for funding such services:
- Local authority allocations
- NHSCB commissioning of services
- Direct commissioning, such as national communications campaigns.
However, the government says there may be other options, such as GP consortia commissioning on behalf of Public Health England, if appropriate.
Where does pharmacy fit in?
While it is not yet clear exactly how the commissioning of local enhanced pharmacy services will be affected by the public health white paper proposals, other than the above, community pharmacy does get some significant mentions in the document. These suggest that
the coalition government does see a crucial role for the sector in tackling the public health challenges outlined.
The public health white paper says: “Community pharmacies are a valuable and trusted public health resource. There is a real potential to use community pharmacy teams more effectively to improve health and wellbeing and reduce health inequalities.”
The sector also gets the following specific pledges and mentions in the white paper:
- Community pharmacies are potential locations for NHS Health Checks.
- The DH will strengthen its working relationship with community pharmacies, as well as the pharmaceutical industry, on smoking cessation.
- GP consortia will be encouraged to work with “a diverse range of clinicians”, including pharmacists.
- Public Health England will influence the development of the community pharmacy contract alongside the NHSCB.
- Local authorities will produce pharmaceutical needs assessments (PNAs) that will inform the commissioning of pharmacy services by the NHSCB and local public health commissioning decisions.
- The chief pharmaceutical officer will work closely with public health leaders, including on the role of community pharmacies as businesses and employers.
- The Health Living Pharmacy initiative in Portsmouth is making “a real difference” (see What about Healthy Living Pharmacies?, below).
When will this happen?
The core elements of the proposed system will be set out in the upcoming Health and Social Care Bill, which will have to go through parliamentary approval. Subject to this, the government has pledged to have the proposed system in place by April 2013 (see Timetable for change, below).
The details of the arrangements needed to make this happen will be set out in “a series of planning letters throughout 2011”, according to the government.
In the immediate term, there is a public consultation on some of the white paper proposals, which is open until March 2011.
White paper lingo decoded
Public health: Defined by the Faculty of Public Health as “the science and art of promoting and protecting health and wellbeing, preventing ill health and prolonging life through the organised efforts of society”.
Directors of public health (DsPH): Currently a role within PCTs, moving to local authorities under the public health white paper proposals; defined by the government as “the lead public health professionals who focus on protecting and improving the health of the local population”.
Public Health England: The dedicated public health service to be established within the Department of Health during 2011 and take on full responsibilities – including functions of the Health Protection Authority and National Treatment Agency for Substance Misuse – for the national approach to public health by April 2012.
Health premium: Part of the coalition government’s proposed new funding mechanism for public health, which it says “will reflect deprivation and reward progress against health improvement outcomes in local areas”.
The 4 Rs
The government says its “radical” approach to public health will be:
- Responsive – owned by communities and shaped by their needs
- Resourced – with ring-fenced funding and incentives to improve
- Rigorous – professionally-led, focused on evidence, efficient and effective
- Resilient – strengthening protection against current and future threats to health
The 5 domains of public health
The public health outcomes framework will cover the following:
- Health protection and resilience – Protecting people from major health emergencies and serious harm to health.
- Tackling the wider determinants of ill health – Addressing factors that affect health and wellbeing.
- Health improvement – Positively promoting the adoption of healthy lifestyles.
- Prevention of ill health – Reducing the number of people living with ill health.
- Healthy life expectancy and preventable mortality – Preventing people from dying prematurely.
What about Healthy Living Pharmacies?
“Healthy Living Pharmacies (HLPs) are making a real difference to the health of people in Portsmouth, with 10 pharmacies awarded HLP status by NHS Portsmouth. HLPs have to demonstrate consistent, high-quality delivery of a range of services such as stopping smoking, weight management, emergency hormonal contraception, chlamydia screening, advice on alcohol and reviews of the use of medicines. They proactively promote a healthy living ethos and work closely with local GPs and other health and social care professionals.
“Early indications show that HLPs have greater productivity and offer higher-quality services. Early evaluation results include a 140 per cent increase in smoking quits from pharmacies compared with the previous year; and 75 per cent of the 200 smokers with asthma or chronic obstructive pulmonary disease who had a medicines use review accepted help to stop smoking.” Source: Healthy Lives, Healthy People
Timetable for public health change
December 2010 – March 2011
- Consultation on the public health white paper, public health outcomes framework and funding and commissioning of public health.
- Shadow Public Health England set up in DH.
- Working arrangements with local authorities begin to be set up, including matching PCT directors of public health to them.
- Public health professional workforce strategy developed.
- Public Health England takes on full responsibilities, including functions of Health Protection Authority and National Treatment Agency for Substance Misuse.
- Shadow ring-fenced public health allocations to local authorities published.
- Ring-fenced funding for local authorities.