Abstract
After a number of false starts, the 10-year plan for the National Health Service finally saw the light of day in January. In this long-awaited document, NHS Chief Executive, Simon Stevens has laid out his plans for the 20 billion extra pounds the government pledged last summer to deal with the ongoing crisis in the nation’s best loved institution. At its heart is a stated commitment to prevention and to population health management. So what are the implications for public health in England six years after Secretary of State Andrew Lansley’s threw the deck of cards up in the air leaving everybody to scramble for the pieces?
Setting aside the reservations that have been expressed about the real worth of the new settlement, following 10 years of austerity, frozen budgets and a rising tide of need resulting from an ageing population, the plan is ambitious, makes a great deal of sense and is to be welcomed. Probably for the first time, a leadership role for the NHS in prevention has been made explicit. The emphasis on the main causes of preventable ill health and premature death is spot on and the agenda of a Primary Care-led, closer to home and integrated set of arrangements has been a long time coming. However, from a public health point of view, this new role is very much tied to one of secondary prevention, of trying to restrain the horses when they are half way out of the door; the responsibility for primary prevention in the aftermath of the Lansley structures remains elusive.
The nearest the country ever came to a seamless connection between public health and medical care was actually to be found between World War I and World War II when local Medical Officers of Health sat on top of veritably integrated empires. The London School of Hygiene and Tropical Medicine’s Sidney Chave tells us that The MOH was responsible for the traditional environmental services of water supply, sewage disposal, food control and hygiene, the public health aspects of housing, for the control of infectious disease, for the maternity and child welfare clinics, health visitors and midwives, the TB dispensary and the VD clinic not to mention school health and the local municipal hospital …
So what is to be done if the NHS 10-year plan is to fulfil its ambitious promise? A fit for purpose system, grounded in a public health philosophy, would start with a commitment to producing a population fully health-literate as has happened in parts of Scandinavia; all health workers would be exposed to a comprehensive grounding in prevention and public health as happens in Cuba; and the formal public health system would be based in Multi-disciplinary Primary Care Networks, supported by properly resourced centres of expertise located in the emerging, devolved, county-level bodies with their responsibility for specialist strategic planning. Nationally, a Secretary of State for Public Health in the Cabinet Office would seek to influence ‘Health in All Policies’ with an appropriate team of experts, while a fully independent Board of Public Health, similar to the Office of National Statistics, would provide real independence of thought and feedback based on real evidence.
Could this stand any chance of happening? We are living in a time of crisis and instability unknown in recent years; such times present opportunities for seismic and transformational change. The key is the emergence of leadership and a vision that can command widespread support. Simon Stevens has opened the door with the publication of the NHS Long-Term Plan. It is time to develop a new consensus in which public health and prevention resume their place as equal partners with health and social care.