Just the beginning

I do not envy the task of the white paper team at the Department of
Health. They are supposed to produce a policy document on public
health in July. A massive public consultation closed at the end of
May. Individuals and interest groups around the country have poured
precious time and energy into it, producing mountains of
information, advice and exhortation. Expectations are running

We have the chancellor of the exchequer to thank for that. Alarmed
at the prospect of escalating health care costs, he commissioned
Derek Wanless, former head of NatWest Bank, to report on how to
achieve a public health culture, or what Wanless described as a
“full engaged scenario”, in which individuals were far more highly
motivated to stay healthy than at present and enjoyed optimal
conditions for choosing healthy lifestyles. Wanless argued that
putting prevention before cure was the only sensible way to go – it
was good for health and good for the public purse.

Not to be caught on the back foot, health secretary John Reid
announced in early February, a few days before the launch of the
Wanless report, a dramatic shift in health policy. His aim, he
said, was to build a “health service rather than an illness
service”, with a major consultation leading to a white paper – all
within six months. There has never before been a time when
government has given such high priority to keeping people well, as
distinct from looking after them when they are sick.

So the white paper team is having to deal with this outpouring of
hope and ambition, conjuring out of it a credible policy on public
health. I am tempted to bet that its parameters were determined
long before the consultation ended. The white paper will set out
strategies for reducing smoking and obesity, and perhaps alcohol
abuse too. It will focus chiefly on how the NHS can address these
specific heath risks.

If that is all it does it will be a bitter disappointment, not
least for those involved in social care. I hope the white paper
will make it clear that this is the beginning, not the end, of a
policy-making process and that more will follow in the year ahead.
I also hope it will be strongly endorsed by other government
ministers to signal clearly that health (rather than health care)
is a matter not just for the NHS, but needs strong commitment from
departments in charge of local government, education, employment,
pensions and income support, environment and community

Above all, local government has a crucial role to play in
preventing illness and reducing health inequalities. This is partly
because it delivers social services, but also because it deals with
urban planning, housing and regeneration, street lighting and
cleaning, parks and leisure facilities, environmental health and a
range of services that influence the quality of daily life.

Local government wants to play a bigger role in health promotion.
It has a duty to promote “well being” and many local authorities
work closely with primary health care trusts. But, in general,
there is not a strong enough framework, nor are there clear enough
incentives, to ensure that this happens with the same driving
commitment in every borough in England. Scotland and Wales are
ahead of the game, having already created structures that encourage
joined-up health and local government services.

Perhaps the next step should be a white paper on public health from
the Office of the Deputy Prime Minister (which oversees local
government), endorsed by the Department of Health.

First, it could establish beyond doubt that promoting population
health is part of the core business of local government, and one of
the key issues on which performance is judged.

Second, it could make sure that each local authority had a senior
officer responsible for health – with a team capable of delivering
significant change. Where possible, the senior officer would be a
director of public health appointed jointly by the council and the
local primary care trust.

Third, it could set out a strategy for introducing into social care
policy and practice a public health culture – one that favours
early preventive measures to safeguard mental and physical well
being. The logic of Wanless applies with equal force in social
care: effective prevention wins a double prize – improving the
quality of people’s lives and saving vast sums of taxpayers’ money.

Anna Coote is director of public health, The King’s

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