Taking the Long View of Public Health

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School of Medicine Pharmacy & Health
Taking the Long View of Public
Health: a new dawn or poisoned
chalice?
Presented by David Hunter
Professor of Health Policy and Management
31st October 2013
School of Medicine Pharmacy & Health
What is Public Health?
Public health is the science and art of preventing
disease, prolonging life and promoting health
through the organised efforts
of society.
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Sir Donald Acheson, former Chief
Medical Officer for England (1988)
School of Medicine Pharmacy & Health
Domains of Public Health
 Health protection
 Health promotion
 Health service performance
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UK Faculty of Public Health
School of Medicine Pharmacy & Health
A Tale in Two Parts
 Looking back
A not too Horrible History of
Public Health
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School of Medicine, Pharmacy & Health
A Tale in Two Parts
 Looking forward
New dawn or poisoned
chalice?
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School of Medicine, Pharmacy & Health
Looking Back (1)
History tells us that local government played the
greatest historical role in the sanitary revolution
during Britain’s rapid industrialisation in 1800s
 Improved housing
∂
 Cleared nuisances
 Introduced gas lighting
 Provided public bathing and washing facilities
 Implemented infectious disease control
School of Medicine, Pharmacy & Health
Looking Back (2)
Rediscovery of public health in more recent times
 Rise of non communicable diseases: cause of
86% of deaths in the WHO European Region – 53
countries, 900 million people
 Smoking
 Obesity
 Alcohol misuse
∂
 Communicable disease control: flu pandemics,
sexually transmitted infections
School of Medicine, Pharmacy & Health
Looking Back (3)
 From 1974 - 2013 the National Health Service
(NHS) had responsibility for public health
 Clinical dominance of public health workforce
 Multidisciplinary public health workforce becomes
a reality (2003):
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 Introduction of UK voluntary register for public health
specialists
 Faculty of Public Health Medicine becomes Faculty of
Public Health
 Joint Directors of Public Health appointments between
NHS and local government
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Public Health and the NHS: a
difficult relationship
While the NHS claimed from the outset to give
high priority to the promotion of health…in reality
this aspect of the service was never more than
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weakly developed, notwithstanding claims to the
contrary, habitually made in ministerial speeches.
Charles Webster (1996)
(Official NHS Historian)
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Looking Back (4)
 Brief renaissance of public health under New Labour: first
Minister for Public Health (1997)
 Wanless I (2002) and II (2004): 'fully engaged scenario'
 Joint Directors of Public Health posts: recognition of local
government's role in public health – 'multidisciplinary public
health will become a reality' ∂(Blears, 2002)
 NICE assumes responsibility for public health evidence
(2005)
 World class commissioning: focus on population health
(2007)
 The Marmot Review: focus on SDH (2010)
School of Medicine, Pharmacy & Health
Wanless’s Critique
Numerous policy statements and initiatives in the
field of public health have not resulted in a
rebalancing of policy away from health care (a
‘national sickness service’) to health (a ‘national
∂ happen until there is a
health service’). This will not
realignment of incentives in the system to focus
on…tackling the key lifestyle and environmental
risks.
Derek Wanless (2004), Government Adviser
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Looking Back (5)
 Persistent tension between focus on individual
lifestyle change (nudge) and government action to
improve health (shove): ‘lifestyle drift’ prevails over
‘nanny state’
∂
 Responsibility deals
 Behaviour Insights Team (Nudge Unit)
 No action on plain packaging for cigarettes or
alcohol minimum pricing
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Where are we Now?
The coalition programme…involves a restructuring
of…public services that takes the country in a new
direction, rolling back the state to a level of intervention
below that in the United States – something which is
unprecedented. Britain will abandon the goal of attaining
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a European level of public provision. The policies include
substantial privatisation and a shift of responsibility from
state to individual.
Taylor-Gooby and Stoker, The Political Quarterly (2011)
School of Medicine, Pharmacy & Health
Reflections: the Negatives
 Public health caught up in neoliberal agenda:
from the welfare state to the market state
 Continuing tension between the nanny state
and the enabling state
∂ especially evident in
 ‘Lifestyle drift’ policy bias,
England
 Medical resistance to non-medical specialists
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Evolutionary Trends: How far
have we really come?
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Source: The Economist, 12 November 2003.
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Reflections: the Positives
 Acknowledgement of wider public health
and its multidisciplinary workforce
 Smoking ban – example of government
action with public support
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 Example of evidence informed
policy
 Recognition of local government’s
key role in public health
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Looking Forward
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School of Medicine, Pharmacy & Health
Key Challenges
 Return of public health to local government
(April 2013): realising the potential
 New organisation at centre to lead on public
health: Public Health England
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 Making the public health workforce fit for
purpose with new skills
 Changing leadership styles
 Applying evidence and strengthening
knowledge to action
School of Medicine, Pharmacy & Health
Local Government: public health’s
natural home
Many people in local government believe it
is their organisations, rather than health
∂
authorities, that are public
health authorities.
Tony Elson (1999)
(former local authority chief executive
and adviser to Department of Health)
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The Main Determinants of Health
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Meeting the Public Health Challenge
 Investment in public health
 Health spend per capita: £2000 per year
 Preventive spend: £80 per year (4%)
 Using ring-fenced public health budget to unlock
resources elsewhere in∂ local government
 New partnerships: are Health and Wellbeing
Boards the answer?
 New skills and competencies required
 Relationship building
 Political astuteness
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Concluding Reflections (1)
Is the glass half-empty?
 Demise of the public health profession as we
know it: future of specialist-practitioner-wider
workforce paradigm at risk
 End of DsPH as we know them
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 Emergence of a divided and fragmented
workforce split between different cultures
 Failure to recognise and invest in public
health skills training
 Devaluing the evidence base in political
world of local government
 Time of austerity: public spending cuts
School of Medicine, Pharmacy & Health
Concluding Reflections (2)
Is the glass half-full?
 Transform the way public health is conceived and
delivered
 Break away from the shackles of a biomedical
model and embrace a social model: from a deficit to
an assets-based approach
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 Develop new skills and competencies
– not a case
of preserving the old and familiar
 Embed new leadership style focused on influencing
others engaged in health improvement and
wellbeing
 Use of ring-fenced public health budget to lever in
resources from elsewhere
School of Medicine, Pharmacy & Health
The Journey Continues–
Thank you!
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School of Medicine, Pharmacy & Health
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