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The Changing National Context Presented by David Hunter Professor of Health Policy and Management 13 th November 2012

∂ School of Medicine & Health A Little History History tells us that local government played the greatest historical role in the sanitary revolution during Britain’s rapid industrialisation  Improved housing  Cleared nuisances  Introduced gas lighting  Provided public bathing and washing facilities  Infectious disease control through MOH

∂ School of Medicine & Health 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 weakly developed, notwithstanding claims to the contrary, habitually made in ministerial speeches. Charles Webster (1996)

∂ School of Medicine & 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)

∂ School of Medicine & Health The Main Determinants of Health

∂ School of Medicine & Health New Public Health System (1) A tale of two parts  Return of public health locally to local government  Creation of Public Health England at centre

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∂ New Public Health System (2) Key drivers  ‘Centralisation has failed’  Localism at heart of new system: principle of subsidiarity  Professional ownership and leadership  Central government focus on emergency preparedness and health protection (HPA)  More nudge, less shove  ‘Responsibility deals’: working with business

∂ School of Medicine & Health Making it Happen (1)  Transfer of DsPH to local government (2013)  Health and Wellbeing Boards  Health and wellbeing strategy, including JSNA  Ring-fenced budgets (2013)

∂ School of Medicine & Health Making it Happen (2)  ‘Health premium’  Clinical Commissioning Groups  Creation of Public Health England  NHS Commissioning Board  Public health outcomes framework

∂ School of Medicine & Health Public Health Outcomes Framework 4 domains  Improving wider determinants of health  Health improvement  Health protection  Health care public health and preventing premature mortality

∂ School of Medicine & Health Public Health Workforce Issues  Risk of fragmentation of public health workforce with transfer to local government and PHE  LAs lack expertise to plan and support public health specialists  Concerns about fate of multidisciplinary public health  Strategic vision for public health workforce not in place

∂ School of Medicine & Health Progress with Health & Wellbeing Boards (1)  Face considerable challenge to do things differently and overcome tribalism  Clarity needed about what HWBs want to achieve: risk of distraction, focus on NHS acute hospitals reconfiguration issues  Central-local tension with HWBs caught in the middle  Risk of re-badging previous partnership arrangements

∂ School of Medicine & Health Progress with Health & Wellbeing Boards (2)  Diversity to be expected – need to capture the learning  Risk of another layer adding to an already complex architecture and increasing transaction costs  Tough leadership challenge – do they come more complex or wicked?

∂ School of Medicine & Health Strengthening the Evidence Base  NICE public health guidance being given a makeover to be more local government facing  Relationship between NICE and PHE  NIHR School for Public Health Research (SPHR)

∂ School of Medicine & Health NICE’s Public Health ‘Offer’  Evidence reviews, briefings, guidance, quality standards, other evidence based outputs  Accreditation of other public health guidance producers  Methodological leadership and support on optimal ways of reviewing and appraising evidence  QOF for public health

∂ School of Medicine & Health Known Unknowns  Changing nature of DPH role  Impact of ring-fenced public health budget  How effective HWBs will be  Nature of links to CCGs  Future of public health workforce in NHS

∂ School of Medicine & Health More Known Unknowns  What is the nature of the ‘support’ to be provided by Public Health England through its 4 Regions and 15 Centres?  A more evidence-informed culture in local government – role of NICE, PHE and others  Balance between tackling SDH and addressing the ‘nudge’ agenda: where does Marmot figure?

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