You’ll have heard the one about the doctor who told her patient that she had good news and bad news, but not to worry because she would tell the bad news to his widow.
I have heard some make bleak existential comments about the future of public health in England in the aftermath of the Health and Social Care Act 2012, and others saying that we are entering a golden era of health improvement.
Sorting out the subjectivity from the science is important and the QualityWatch programme makes a timely and evidence-based contribution to the debate. So is it good news or bad?
Societal trends key to public health
Many of the trends in public health indicators have more or less maintained their trajectory. This should not surprise us. Public health challenges are often deep rooted and reflect societal trends. Public health programmes will make a difference, but most local authorities ‘lifted and shifted’ NHS contracts and have taken time to carefully review them before recommissioning. Many of these new services are now up and running, but to expect an impact on national outcomes so soon would be optimistic.
Equally, blaming local commissioning decisions for trends which were evident before 2013 seems unreasonable. Most public health challenges, such as smoking, require a comprehensive response. Local stop smoking services are an important part of a strategy to help smokers quit, but national media (which has been significantly scaled back) plays a greater role in reducing prevalence.
Trends in sexual health are a cause of concern. Whilst there are broadly positive trends in genital warts, HIV late diagnosis and teenage conceptions, the trends in other sexually transmitted infections (which pre-date 2013) and the emergence of antibiotic resistance should sound the alarm bells. Local authorities have generally recommissioned sexual health services in a way which is integrated with family planning and has a greater emphasis on prevention. But as with stopping smoking, services are necessary but not sufficient. We need national as well as local action to reverse the increase.
The insights gained through interviews with public health leaders are helpful and are broadly consistent with what I hear from Directors of Public Health across England. There are many benefits to public health operating within local government. These are not only in terms of commissioning arrangements but also the chance to influence the factors which really affect our health and wellbeing such as jobs, housing and the environment. This is a long game. There is no question in my mind, as the QualityWatch respondents noted, that we would see quicker progress were it not for the cuts to local government funding and to public health budgets specifically, as well as the pressure on public sector finances more generally.
In the context of reduced resources it is inevitable that local areas will prioritise. Arguably this should be done even when the money is plentiful, if ever such a time were to exist. But it is important that public health interventions are prioritised on the same basis as any other health or social care intervention. Return on investment is the icing on the cake but it is not the cake. The health needs of the local population and the relative cost effectiveness of the interventions should be the driving factors behind where the budget is spent. To assess public health interventions solely on their return on investment is unfair and short sighted.
Poor access to data is another bug bear for Directors of Public Health. We need much better access to data if we are to assess the effectiveness of programmes and ensure resources are properly directed towards need.
Another barrier to improvement highlighted by the QualityWatch report is the fragmentation of commissioning arrangements for certain issues, notably sexual health. Whilst in some areas local agreements have been reached to overcome these problems, they are not universal and still represent a major challenge.
A mixed picture
So overall what is the QualityWatch diagnosis of public health in England since 2013?
Probably both good news and bad. There is nothing to suggest terminal decline but neither has there been a dramatic improvement in the health of the public. This is to be expected. Whilst it is important to monitor short to medium term indicators, and we need to get better at doing this, it is only through the lens of history that the true value of the move to local government and the creation of a national public health agency can be judged.
My view? With adequate resources (in particular adequate specialist public health capacity) I am convinced that the prognosis for public health is, well, healthy.