Changes to national policy and local service delivery in public health have been fast-moving in recent years, and this is compounded by financial pressures. So it is timely to take a step back and assess whether the quality of services has changed, which is the focus of the latest QualityWatch report from Nuffield Trust and The Health Foundation.
Given the transfer of public health back to local government only took place in 2013, the report itself recognises that it is too soon to form a judgement on progress using public health indicators for which most of data available only runs to 2014. Yet providing an overview of direction of travel over the five years since 2009 will help future benchmarking for key services newly commissioned by local government in the transfer: sexual and reproductive health and HIV; substance misuse; smoking, childhood obesity; and immunisation.
Beyond the discrete service areas for which commissioning was transferred, the wider value of public health returning to local government for prevention purposes is the opportunity to integrate with the range of local services that can be better aligned to contribute to health outcomes, such as housing, planning, environment, licensing and leisure. So looking towards the medium term, measuring population level changes in lifestyle-related diseases such as heart attacks and diabetes will also be important. It is here that the real opportunity lies for provision to be effectively aligned locally to maximise support and accessibility for people to make healthy decisions that lead to better health outcomes.
People as the starting point
The insights from the report’s qualitative evidence from public health professionals revealed tensions at the heart of the present system, which echo some of the challenges identified by the recent Place-based Health Commission report. This made a strong case for “health” to be addressed not in simply a narrow clinical sense, but taking a broader approach which activates the non-clinical, existing resources of places.
Only by shifting from an institutional framework that is set up to treat ill health, to a focus on supporting good health and wellbeing, can a genuine shift in the balance of energy in the system towards prevention take place. The Commission advocated taking the starting point of people themselves rather than existing services to inform how best to support people to live healthy lives.
Fragmentation and territorialism in current system
As the evidence from the QualityWatch Report confirms, the current health system is held back by fragmentation and organisational territorialism which undermines this starting point. While the transfer of public health to local government has created new opportunities for commissioning and integration, removing the function from the NHS has to an extent closed down public health input into local NHS commissioning.
This finding is concerning, and reflects the need for stronger shared visions in places to be built, based on an understanding of population-level health needs. This must reach across the institutions that work within the system, all too often to their own priorities, including but not only the NHS. While integration gathers pace through the Sustainability and Transformation Planning process there will be an inevitable focus on structures, but the relationships and cultures within and between organisations will be as important if reform is to unleash a sustained system-wide focus on better outcomes.
Short-term vs long-term budget decisions
In relation to finance, it is no surprise that funding pressures were cited by the professionals as having a detrimental effect on quality and an uncertain future for public health. Funding cuts have been made in the context of short-term national funding cycles which separate out costs and consequences of budget decisions.
When investments made today have potential payoffs over the longer term, these don’t easily hold up against the demands of day-to-day operational pressures. As further integration of health and social care budgets takes place, new pooled budgets from which services are jointly commissioned, with payment mechanisms that better align risk and reward, must begin to shift the balance of funding in the health and care system away from crisis management and towards investment in public health and prevention.
The future quality and viability of services that are geared towards prevention will depend on this. Continued close monitoring of progress in the coming years will be essential.
Jessica Studdert is the co-author of Get Well Soon, the report of the Place-based Health Commission.