Memorandum by Kings' Fund (WP 106)
SUMMARY
In March 2005, the Government released its implementation
plan for Choosing Health, its public health White Paper
(November 2004). The sixth major public health policy document
to be produced since New Labour came to power in 1997, the paper
reflects a significant shift in government health policy.
It shows a new sense of urgency about the need
to prevent illness, a reluctance to take action that might incur
charges of "nanny statism", a diminished enthusiasm
for targets and a new focus on personal choice and changing individual
lifestyles and behaviour.
This briefing analyses the White Paper and the
challenges that will need to be tackled in implementing it.
What is in the White Paper?
Selected highlights include:
— The Choosing Health philosophy.
Health problems result from individual choices. The right approach
is to empower people, give support where it is wanted and foster
environments that make healthy choices easier. Delivery is underpinned
by three principles: supporting informed choice for all, personalisation
of support to make healthy choices, and partnership working to
make health everybody's business.
— Communications. A new strategy
to promote health information and health literacy. As part of
this, a new service—Health Direct—is to run alongside
NHS Direct and NHS Online, and efforts to improve information
to the public on food, drink and tobacco. Ofcom is to consult
on proposals for tightening rules for broadcast advertising of
food and drink to children. The Government is to enforce change
if voluntary action fails to produce satisfactory changes by 2007.
— Child health. A Child Health
Promotion Programme is to be led by health visitors. New Children's
Health Guides are to be drawn up for individual visitors. Investment
in more school nurses is planned. Ofsted inspections are to include
an assessment of schools' contribution to children's health and
well-being.
— Community health. New regulations
to ban smoking from all enclosed public places and workplaces
including restaurants, and pubs and bars that serve food. Public
Health Observatories are to produce customised reports designed
for Primary Care Trusts and local authorities. Primary Care Trusts
are to develop local health targets. A Communities for Health
scheme is to be launched in Spring 2005. A network of local health
champions is to be developed. Use of pedometers by Primary Care
Trusts and in schools is to be encouraged. The UK Sustainable
Development Commission, with funding from the Department of Health,
will develop the capacity of NHS organisations to act as good
corporate citizens.
— Supporting individual choice.
Health trainers are to be made available ultimately to any individual
who wants one, starting with those in disadvantaged neighbourhoods.
Personal health guides will be developed by individuals who want
to be healthier, setting out their current state of health, what
changes they want to make and where they can get help. A stock-take
of health will be offered to individuals at key life stages.
— Turning the NHS into a health-improving
service. Key points include general measures to improve NHS
capacity to focus on prevention, managing chronic conditions and
addressing major health risks. A National Health Competency Framework
to improve skills and capacity of NHS staff is to promote health
and prevent illness, including obesity prevention and treatment.
Community matrons are to provide personalised care and health
advice for those with chronic conditions. Definitive guidance
from the National Institute for Clinical Excellence (NICE) on
prevention, identification, management and treatment of obesity
is to be available in 2007.
— Promoting healthier working conditions.
Evidence-based guidelines on occupational health. Investors in
People (IiP), a framework for delivering business improvement,
is to develop a new healthy business assessment. All government
and NHS buildings are to be smoke free, with a new campaign to
help nurses to stop smoking. The NHS is to lead by example.
— Implementation. Health is
to be a component of regulatory impact assessment of all future
legislation. The Department of Health will publish six-monthly
reports on progress towards health improvement targets. A Health
Information and Intelligence Task Force will be set up to oversee
information gathering and knowledge management. A Health Improvement
Workforce Steering Group is to be established to develop strategy
and to co-ordinate action needed to deliver the White Paper's
objectives. The Modernisation Agency and its successor organisation
will prioritise the implementation of the White Paper.
What is to be welcomed in the White Paper?
— Scale and scope. It includes
many changes and contains many more practical initiatives than
earlier public health policy documents.
— Embedding change. There are
clear attempts to embed change in the operational processes of
the NHS, as well as in other relevant organisations and relationships.
— A strong local dimension.
The White Paper recognises that locally focused activities by
local organisations are essential to improving health and tackling
health inequalities.
— Focus on partnership working.
The value of joint working between the NHS and local government,
businesses and voluntary organisations is firmly acknowledged.
— Support for disadvantaged groups
and neighbourhoods. Many initiatives are to be targeted, with
the initial focus on disadvantaged communities.
— Engaging with the media. Support
for a more proactive dialogue with regional and national media,
and possibly also a national centre for media and health, along
the lines of the Science Media Centre.
— Healthier schools. Helpful
moves include increasing numbers of school nurses, improving nutritional
standards of school meals, encouraging healthy eating and physical
activity and extending the scope of Ofsted inspections to schools'
overall contribution to health and well-being. This will have
a specific focus on healthy eating.
— Curtailing food and drink promotion
for children. The carrot-and-stick approach to broadcast advertising
of food and drink for children is to be welcomed.
— An obesity strategy. This
outlines a strategy for preventing, identifying, managing and
treating obesity, informed by guidance from the National Institute
for Health and Clinical Excellence.
— The NHS to lead by example.
The NHS is to promote health through its corporate activities,
such as food purchasing, capital development, providing a smoke-free
environment, and healthy working conditions. The Sustainable Development
Commission is to help develop good corporate citizenship.
— Changing the relationship between
the individual and primary health services. Proposals to introduce
children's health guides, personal health guides and periodic
health checks or stock-takes merit further testing.
— Community-based health advocates
or "trainers". These can help disadvantaged individuals
and groups gain access to the knowledge and services they need
to maintain and improve their health.
— Employment as a determinant of
health. Occupational health to be promoted in the NHS and
other organisations, with help for people returning to work after
illness or injury.
— Action on smoking. The ban
on smoking in enclosed public spaces including restaurants and
bars that serve food is a step in the right direction.
Shortcomings and weaknesses
— Lack of connectedness. The
White Paper shows little sense of its own history. Showing how
it connects with earlier health policy documents, such as the
Acheson Report (1998) and Our Healthier Nation (1998)
could help to give greater coherence to the vast array of initiatives
in Choosing Health.
— Reconciling choice and inequality.
The ideology of choice is firmly imprinted on the White Paper.
However, the task of reconciling individual choice with a commitment
(also clearly stated) to reducing health inequalities will be
a real challenge. The initiatives targeted on disadvantaged individuals
and neighbourhoods are welcome, but it is still unclear whether
the Government has committed itself to the radical agenda that
will be required to ensure that everyone has a genuinely equal
chance to enjoy a long and healthy life. If it does not do this,
it will have been a missed opportunity.
— Failure of nerve on smoking.
The White Paper fails to follow Ireland, New York and others in
banning smoking in all enclosed public spaces. There is evidence
that a total ban would be popular with the public and this has
worked well in other countries.
— Too much dependence on voluntarism.
It is doubtful whether discussions with the food industry will
lead to prompt and effective action on food content and labelling,
unless there is a promise of enforcement if voluntarism fails.
— Shortage of detail on critical
points. How will the Child Health Promotion Programme, the
Communities for Health scheme and health champions operate, and
how will the latter relate to the proposed health trainers? How,
if at all, will health trainers relate to the large numbers of
health advocates already operating at community level? Mental
health and alcohol are dealt with at some length, but little is
said about upstream prevention.
— Too little attention to black
and minority ethnic health. There are few substantive references
to black and minority ethnic communities, in spite of significant
inequalities and specific health needs relating to minority ethnic
groups.
Questions and challenges
— Can choice and equal opportunity
be reconciled? The White Paper attempts to accommodate these
two objectives. It will be a real challenge to make them work
together, and this is not recognised in the document.
— Is there enough money? The
Department of Health plans to invest at least £1 billion
in public health over the next three years to help implement the
White Paper, but it is not clear whether this is all new money,
where it comes from and what it is expected to cover.
— How much of it will be implemented
and by when? The Department of Health released its implementation
plan in March 2005. Everything depends on the quality of implementation,
and on how well the many component parts of the White Paper fit
together and work in practice.
— Will there be strong and sustained
leadership for change? Will public health policy continue
to have a high profile and be given priority at senior level across
the Department of Health and the NHS? Strong and sustained national
and local leadership will be essential, to continue well beyond
the next election.
— Is there a clear story that everyone
can understand and support? Will all those required to act
be able to share a view about what the objectives are and what
can be achieved? Much will depend on how it is interpreted by
those responsible for disseminating its messages and drawing up
the implementation plan.
— What are the incentives for the
NHS to push the improvement of public health up the agenda?
At present, the NHS is receiving unprecedented financial investment.
Even so, many NHS organisations, in particular Primary Care Trusts,
are hard pressed financially. Given the lack of strong evidence
of the cost-saving effect of measures to improve public health,
it is not clear what the incentives are for Primary Care Trusts
in particular to focus seriously on some of the measures proposed
in the White Paper. Unless this issue is addressed, there is a
risk that the excellent measures proposed will not be implemented
in a sustained way, especially in the future when resources for
the NHS may be tighter.
— What can be done to evaluate the
cost effectiveness of a range of health-promoting interventions?
There is an urgent need for a programme of research to assess
the impact of both the more specific (yet complex) interventions
to improve the health of people with chronic conditions and those
designed to improve health more widely. Evaluation of such complex,
and often multifaceted, interventions is difficult, but in the
short term it will be critical to examine their impact specifically
on the use of health care, to test the assumption that better
health reduces use as asserted in the first Wanless Inquiry. There
may be a role for the National Institute for Health and Clinical
Excellence in this respect.
The Government issued Choosing Health, its
new White Paper on public health, on 16 November 2004. It has
now released its implementation plan to clarify how the initiatives
will be carried out. The plan makes the new expectations and responsibilities
clearer to public health professionals, but the impact of the
initiatives on improving public health and reducing health inequalities
will take longer to assess. The strengths and weaknesses of the
White Paper will also influence the potential success of the new
strategy.
BACKGROUND AND
CONTEXT
Choosing Health is the sixth major public health
policy document to be produced since New Labour entered government
in 1997. The first five were:
— Independent inquiry into inequalities
in health: The Acheson Report (1998). [194]This
reviewed the causes of health inequalities and set out 39 recommendations
for tackling them, with four overriding priorities. All policies
likely to have a direct or indirect effect on health should, it
said, be evaluated for their impact on health inequalities and
should be formulated to favour less well-off people. Priority
should be given to the health of women of child-bearing age, expectant
mothers and young children. And further steps should be taken
to reduce income inequalities and improve the living standards
of poor households.
— Our Healthier Nation: A contract
for health (1998). [195]A
Green Paper pledging to increase "the length of people's
lives and the number of years people spend free from illness"
and to "improve the health of the worst off in society and
to narrow the health gap". Targets to reduce premature deaths
from cancer, coronary heart disease and stroke, accidents and
mental health would be met though a "contract" between
individuals, local communities and national government, working
in three settings—healthy workplaces, healthy schools and
healthy neighbourhoods.
— Saving Lives: Our Healthier Nation
(1999). [196]A
White Paper presenting a narrowly focused strategy of NHS-related
measures intended to meet the four targets set out in the earlier
Green Paper, with numbers of deaths to be avoided and dates specified.
— Tackling Health Inequalities:
A Programme of Action (2003). [197]This
set out plans to achieve targets to reduce inequalities in health
outcomes by 10% by 2010, measured by infant mortality and life
expectancy at birth. It claimed to be "the most comprehensive
programme of work to tackle health inequalities ever undertaken
in this country", with a range of initiatives on education,
welfare-to-work, housing, neighbourhoods, transport and the environment
that will help improve health. In effect, it was a summary of
most aspects of the social and economic policies being pursued
across government.
— Securing Good Health for the Whole
Population (2004). [198]The
second of two reviews commissioned by the Treasury from former
banker Derek Wanless, this explored evidence-based ways of realising
a "fully engaged scenario" in which priority is given
to preventing illness and individuals are committed to safeguarding
their own health. In his first review, Wanless had calculated
that failure to shift towards this scenario would cost some £20
billion extra in annual healthcare costs by 2020.
Early in 2004, just before the publication of
the second Wanless review, Health Secretary John Reid announced
a major consultation, entitled Choosing Health?, which
he promised would lead to a public health White Paper later in
the year.
When it arrived, the Choosing Health
White Paper reflected a significant shift in government health
policy. This can be characterised as follows:
— A new sense of urgency about the
need to prevent illness. This is distinct from improving health
care and was largely prompted by the Wanless reviews, which had
begun to estimate the price of failing to take prevention seriously.
— A new, official rationale for
the sequencing of government priorities. Public health, it
was said, had had to wait until the government had adequately
addressed the shortcomings of the NHS. Only when issues such as
waiting times had been tackled could the Department of Health
justify giving fuller attention to managing chronic disease and
preventing illness.
— A clear reluctance to take action
that might incur charges of "nanny statism". This
provoked a public debate about the limits of state intervention
and seemed to signal an attempt to shape public opinion in favour
of government taking less, rather than more direct action to promote
population health.
— A diminished enthusiasm for target
culture. This has loomed large in Saving Lives and most health
care policy since 1997.
— A new focus on personal choice
and changing individual lifestyles and behaviour. This reflected
a cross-government emphasis on "personalisation" of
public services and a strong commitment in health care policy
to "patient-centred care" and "patient choice".
Personalisation and choice were envisaged as dominant themes in
a general election campaign expected in 2005.
Tracing the journey taken by Labour's health
policy makers between 1997 and 2004, one can see that, with the
first flush of victory, came a passionate interest in tackling
health inequalities, echoing the Prime Minister's commitment to
ending social exclusion and child poverty.
Next came an attempt to carve out a "third
way" between traditional left and right approaches, with
a strategy born of careful policy analysis, comprising a "contract"
between individual, community and state, for action in specified
social settings. This was soon overshadowed by a desire to deliver
measurable results, coupled with a pragmatic reversion to clinically
defined objectives.
For several years thereafter, public health
policy languished in the shadows of health care policy, which
was almost entirely preoccupied with reorganising the NHS (yet
again) and meeting stringent service-related targets. Not until
the Treasury intervened with the Wanless reviews in 2002 and 2004,
did public health emerge as a high-profile policy arena.
At this point, the social analysis of Our Healthier
Nation and the disease-based targets of Saving Lives gave way
to the new choice agenda that was being primed for the forthcoming
election. This fitted quite comfortably with Wanless emphasis
on the need for individuals to change their behaviour in order
to restrain spiralling health care costs. It fitted less well
with the continuing commitment to reduce health inequalities and
(in the words of Health Secretary John Reid) "to refocus
the NHS as a service for health". The claim that more choice
would bring greater health equity had not been thoroughly thought
through.
What is in the White Paper?
Choosing Health is a substantial document,
207 pages in all. It covers a wide range of issues, and is not
easy to navigate. In many respects, it is an "open text"
that can be given different meanings by different readers.
The chapter-by-chapter commentary that follows
is offered as one of many possible interpretations. It is not
definitive, but represents our best efforts to pick out the salient
points. Some measures are fresh to the White Paper while others
have already been introduced, although the distinction is not
always clear. We have tried to focus on material that is new,
or that has been given new significance by the White Paper.
COMMENTARY
Chapter One: Time for action on health and health
inequalities
This presents the rationale for the White Paper,
as follows:
— There are serious and rising risks
to health, especially in relation to smoking, sexually transmitted
infections, mental health and alcohol.
— There is evidence of public enthusiasm
for healthier living and for government action to support healthy
choices.
— Some people find it harder than others
to live healthily, for reasons beyond their control, for example
disability, mental health problems, poverty, unemployment or living
in disadvantaged neighbourhoods or temporary accommodation. They
need more support than others to change their behaviour if inequalities
are to be reduced.
— There must be a "step change",
not "more of the same"; old solutions have not provided
the necessary impetus; too much time and energy has been given
to analysing the problems and not enough to practical solutions
that connect with real lives.
— Health problems—new and old—are
the "cumulative results of thousands of choices by millions
of people over decades"; the right approach is to empower
people, give support where it is wanted and foster environments
that make healthy choices easier.
— Delivery is underpinned by three
principles. The first is supporting informed choice for all; the
second is "personalisation" of support to make healthy
choices, to ensure equal access for all; and the third is working
in partnership, with government in the lead, to make health "everybody's
business".
Chapter Two: Health in the Consumer Society
This deals with how to get across messages that
will encourage individuals to make healthy choices. It raises
awareness about risks and provides information, in various ways,
about what they can do to improve their health. The main new initiatives
fall into two categories: general health education and promoting
"health literacy", and improving the quality of information
to the public on food, drink and tobacco.
General health information and promoting "health
literacy"
— A new communications strategy to
be implemented by an independent body, appointed by the Department
of Health.
— New health education campaigns on
sexual health, obesity, smoking and alcohol, using creative social
marketing techniques and new technology, and based on an understanding
of the different needs of different groups in society.
— A new service—Health Direct—to
provide information on health choices, alongside NHS Direct and
NHS Online.
— New funding for Primary Care Trusts
to run local Skilled for Health programmes, which combine the
national adult basic skills programme, Skills for Life, with promoting
"health literacy", helping people gain a better understanding
of their health needs. Each trust to run one such programme each
year.
— More expert briefings from the Chief
Medical Officer on a wider range of health-related topics.
— Possible development of a national
centre for media and health to provide an independent forum for
national and regional media to discuss major health issues.
Improving information to the public on food, drink
and tobacco
— Efforts to encourage the food industry,
working with the Food Standards Agency, to signpost the content
of packaged food in ways that are simple, accessible and consistent.
— Discussions to encourage the food
industry to make healthy food more accessible, reducing salt,
sugar and fat content and portion size.
— A Food and Health Action Plan to
be published early in 2005.
— Ofcom to consult on proposals for
tightening rules for broadcast advertising of food and drink to
children. If voluntary action fails to produce satisfactory changes
by 2007, the Government plans to enforce change through existing
powers or new legislation.
— New information campaigns on alcohol
to be developed with the Portman Group, the industry-funded body
that claims to promote responsible drinking.
— An end to tobacco internet advertising
and "brand sharing" (using a non-tobacco product as
part of promotional activities) in 2005.
Chapter Three: Children and young people—starting
out on the right path
This lists a great many initiatives introduced
prior to the White Paper. These include the Public Service Agreement
target to halt rising trends in child obesity, children's trusts,
children's centres and locally integrated children's services,
extended schools, Sure Start, parental support measures, the extension
of the school fruit and vegetable scheme for four to six year
olds, support for cycling and walking to school, more school sport
and measures to reduce teenage pregnancy and sexually transmitted
infections among young people. Other initiatives include:
— A new Child Health Promotion Programme,
led by health visitors, which will introduce Children's Health
Guides. These provide a record of the child's health status and
set out what is needed to maintain or improve their health. Developed
and held in the early years by the parent or carer, the guides
are intended to encourage children, as they grow older, to take
responsibility for their own health goals, with help from health
professionals and others. The guides can be reviewed at key life
stages, such as entering secondary school and starting work, and
may become the foundation for personal health guides that can
be developed throughout an individual's life.
— School nursing to be "modernised
and promoted", with new funding from 2006-07 to ensure that
all Primary Care Trusts, starting with those in the most disadvantaged
areas, can provide at least one full-time qualified school nurse
for each "cluster" of schools.
— The Healthy Schools Programme to
be extended to all schools by 2009.
— Ofsted to inspect for schools' contribution
to children's health and well-being, including healthy eating.
Nutrient-based standards for school meals to be "strongly
considered". New guidance to encourage healthy eating and
drinking throughout schools.
— A new "lad's magazine"
called FIT to promote health information for young men aged 16-30.
— Legislation to strengthen controls
on tobacco sales to under-age young people.
Chapter Four: Local communities leading for health
This deals with community-level action for health
and, like the previous chapter, draws together a number of existing
initiatives, including Local Area Agreements and measures to promote
access to healthy food, sustainable transport and physical activity.
It stresses the importance of partnership working between health
trusts, local authorities and other local organisations, and sets
out the following new or partly new initiatives. These fall into
three main categories: community health, corporate citizenship
and smoking bans.
Promoting community health
— Public Health Observatories are to
produce reports designed for local authorities, using a standard
set of local health information, linked to other data sets.
— Primary Care Trusts are to develop
local health targets, agreed with partner organisations, to meet
national targets and priorities set by the White Paper and the
NHS Improvement Plan.
— The Healthy Communities Collaborative
is to be extended to tackle obesity and other issues.
— A scheme called Communities for Health
is to be launched in spring 2005, to promote action across local
organisations on locally chosen priorities for health.
— A network of local "health champions"
is to be developed. These will include local authorities and other
organisations and individuals who want to lead local action to
improve health. They will be supported by "arrangements"
to share good practice and celebrate success through an annual
award scheme.
— Pedometers are to be encouraged by
Primary Care Trusts and in schools.
"Good corporate citizenship"
— The UK Sustainable Development Commission
is to be given funding by the Department of Health to develop
the capacity of NHS organisations to act as "good corporate
citizens", namely, to use their corporate resources as employers,
purchasers, landholders, managers of energy, waste and travel
and commissioners of new buildings and refurbishments to promote
health and sustainable development. This work will focus initially
on food procurement and capital development.
— The Government will sponsor a debate
on good corporate citizenship, leading to "firm recommendations"
for all public and independent bodies to organise their activities
in ways most likely to improve the health of their employees and
the wider community.
Smoking bans
— New regulations to ban smoking from
all enclosed public places and workplaces including restaurants,
pubs and bars that serve food. Clubs, pubs and bars that do not
serve food can continue to allow smoking, but not in the bar area.
All government departments and the NHS are to be smoke-free by
the end of 2006. All other enclosed public places and workplaces
are to be smoke-free by the end of 2007, except for licensed premises,
where arrangements must be in place by the end of 2008.
Chapter Five: Health as a way of life
This is about supporting individual choice.
It mainly consists of fresh material and makes three key proposals:
— "Health trainers" to be
available ultimately to any individual who wants one, starting
with those in disadvantaged neighbourhoods. These trainers are
themselves trained and accredited by the NHS and are expected
to come mainly from the communities where they work. Their function
is to help individuals be aware of health risks and how to change
their behaviour to lead healthier lives. They can be accessed
through health centres, NHS Direct and possibly through other
local organisations.
— "Personal health guides"
can be developed by individuals who want to do so, with help from
a health trainer. These are custom-made plans that set out, in
the individuals' own terms, their current state of health, what
changes they want to make and where they can get help to do so.
The guide may be electronically stored and linked to HealthSpace,
a secure personal health organiser on the internet, as an "online
personal health planning kit". It can build on the Children's
Health Guide.
— A "stock-take" of health
will be offered to individuals at key life stages such as new
employment, childbirth, entering a new relationship, and preparing
for retirement. This provides an opportunity to review the personal
health guide, with help and support from a "health trainer"
or other NHS personnel.
Chapter Six: A health-promoting NHS
This sets out plans for turning the NHS into
a health-improving service. Key points fall in three categories:
General measures to improve NHS capacity to focus
on prevention
— National Clinical Directors to work
with clinicians across the NHS to find opportunities to extend
primary and secondary prevention. They will work with the Chief
Medical Officer to recommend a "comprehensive and integrated
prevention framework, linking all areas covered by National Service
Frameworks".
— Primary Care Trusts will receive
funding to enable them to give higher priority to areas of greatest
health need, and become a "tool to assess local health and
well-being".
— A National Health Competency Framework
is to improve the skills and capacity of NHS staff to promote
health and prevent illness, including obesity prevention and treatment.
— A strategy for pharmaceutical public
health, to be published in 2005, is to show how pharmacists can
contribute to health improvement and reducing health inequalities.
— Dentists are to be given a new focus
on prevention in contractual arrangements coming into force in
October 2005.
Managing long-term conditions
— Community matrons to provide personalised
care and health advice for those with long-term conditions such
as diabetes, asthma and arthritis, and to be responsible for case-managing
patients with complex health problems. By 2008, there will be
3,000 community matrons and they will be supported by health trainers
(see above).
— The Department of Health will bring
in independent sector "partners" to develop new approaches
to managing chronic conditions, including personal health guides.
Addressing major health risks
— Mental health. New models
of physical health care for people with mental health problems
and new approaches to help people with mental illness to manage
their own care.
— Smoking. A national taskforce
to help improve NHS services to help stop smoking. The Healthcare
Commission is to assess progress. (See also Smoking Bans above).
— Obesity. Definitive guidance
from the National Institute for Clinical Excellence on prevention,
identification, management and treatment of obesity is to be available
in 2007. A "weight loss guide" is to be produced and
a "national partnership for obesity" is to be established.
A "patient activity questionnaire", available by the
end of 2005, is to help NHS staff improve patients' physical exercise.
— Sexual health. New capital
and revenue funding for tackling sexually transmitted illnesses.
Improved chlamydia screening, possibly using independent partners
such as retail pharmacists. Audit of contraceptive services and
a target wait of a minimum of 48 hours by 2008 for those referred
to a GUM (genito-urinary medicine) clinic.
— Alcohol. A programme to improve
alcohol-treatment services, based on demand audits and "Models
of Care" guidance from the National Treatment Agency, with
additional funding from Pooled Treatment Budget for Substance
Misuse.
Chapter Seven: Work and health
This acknowledges the strong links between employment
and both mental and physical health. It sets out proposals for
healthier working conditions, and for encouraging the NHS and
other public sectors to lead by example. These include:
— The production of evidence-based
guidelines on occupational health.
— Sport England is to provide free
consultancy to government departments on how they can encourage
staff to be more active.
— There will be pilots to develop the
evidence base for effective health promotion at work.
— Investors in People (IiP) are to
develop a new "healthy business assessment", to be incorporated
in the new IiP standard when reviewed in 2007.
— All government and NHS buildings
are to be smoke free and a campaign to help nurses to stop smoking
is planned.
— The NHS is to become an exemplar,
providing healthier workplaces and encouraging people back to
work after injury, illness or impairment. Its progress will be
assessed by the Healthcare Commission.
— Guidelines on managing mild to moderate
mental ill-health in the workplace are to be published in 2005.
Chapter Eight and Annex B: Making it happen
These attempt to show how the ambitions of the
White Paper can be realised. They describe at some length how
different organisations will contribute and work together, nationally
and locally. Key points not already mentioned include:
— Health will be a component of regulatory
impact assessment of all future legislation.
— There will be new funding for health
education campaigns, more school nurses, health trainers and obesity
and sexual health services.
— The Department of Health is to publish
six-monthly reports on progress towards health improvement targets.
— Extra government funding will be
available for councils that achieve more ambitious local targets,
for example, on tackling health inequalities.
— Funding for public health research
is to reach £10 million by 2007-08; a public health research
consortium and a National Prevention Research Initiative will
be set up.
— An Executive Director for Health
Improvement will be appointed within the National Institute for
Health and Clinical Excellence (a merger of NICE and the Health
Development Agency), to provide professional leadership.
— A Health Information and Intelligence
Task Force will be set up to oversee information gathering and
knowledge management. £10 million a year from 2006 will be
made available for Public Health Observatories.
— Training for "health trainers"
and other frontline staff will be developed with partner organisations,
possibly leading to a new national Health Trainer Certificate.
— The Department of Health and partners
are to identify core skills and competencies needed for public
health leadership.
— A Health Improvement Workforce Steering
Group is to be established to develop strategy and co-ordinate
action needed to deliver the White Paper's objectives.
— Implementing the White Paper will
be the priority of the Modernisation Agency and its successor
organisation (when it has taken in the NHS University). A new
Innovations Fund (£30 million in 2006-07 and £40 million
thereafter) will support and evaluate new ways of working.
What is to be welcomed in the White Paper?
— Scale and scope. This is a
wide-ranging, ambitious exercise that covers a great deal more
ground than was ever suggested by the media reports that accompanied
its launch. It claims to instigate a great many changes and contains
many more practical initiatives than earlier public health policy
documents.
— Embedding change. There are
clear attempts to embed change in the operational processes of
the NHS, as well as in other relevant organisations and relationships.
Implicitly, the White Paper acknowledges the need not just to
introduce new measures or pursue targets, but to change the culture
and practice of the systems that deliver them.
— A strong local dimension.
The White Paper recognises that locally focused activities by
local organisations are essential to tackling health inequalities.
Primary Care Trusts are to set local targets, informed by customised
intelligence from Public Health Observatories, and the NHS is
expected to work with local authorities and other organisations
at that level.
— Focus on partnership working.
The value of joint working between the NHS and local government,
businesses and voluntary organisations is firmly acknowledged
as essential to effective implementation of the White Paper's
proposals. It sends out an unequivocal message that NHS organisations
are expected to play a leading role in local partnerships for
health.
— Support for disadvantaged groups
and neighbourhoods. A clear theme throughout the White Paper
is that people who are poor, socially isolated or otherwise disadvantaged
can find it harder than others to make "healthy choices"
and therefore need additional support. Many initiatives are targeted
in the first instance on disadvantaged communities; these are
quite obviously essential if inequalities are ever to be reduced.
— Engaging with the media. Following
consultations with media organisations conducted for the Department
of Health by the King's Fund, it has been suggested that there
should be a more proactive dialogue with regional and national
media, and possibly also a "national centre for media and
health" along the lines of the National Centre for Media
and Science. We welcome the fact that these ideas are reflected
in the White Paper; it will be essential to guarantee genuine
independence for any such centre.
— Serious about schools. The
White Paper holds out a reasonable prospect of ensuring that schools
create a healthier environment for children and play a stronger
role in promoting child health. Helpful moves include increasing
numbers of school nurses, improving nutritional standards of school
meals, encouraging healthy eating and physical activity, and extending
the scope of Ofsted inspections to schools' overall contribution
to health and well-being, including—specifically—healthy
eating.
— Curtailing food and drink promotion
for children. The carrot-and-stick approach to broadcast advertising
of food and drink for children is to be welcomed. The White Paper
promises regulation backed up, if necessary, by legislation, if
voluntary action by industry and advertisers has failed to produce
satisfactory change in the nature and balance of food promotion
by 2007.
— An obesity strategy. The White
Paper outlines a strategy for preventing, identifying, managing
and treating obesity, informed by guidance from the National Institute
for Health and Clinical Excellence. This is long overdue. It is
well supported by strategies to encourage healthy eating and physical
exercise for children and adults, and by a proposal to extend
the healthy communities collaborative to address obesity at local
level.
— The NHS to lead by example.
It is clearly stated that the NHS must lead by example, promoting
health through its corporate activities such as food purchasing,
capital development, providing a smoke-free environment and healthy
working conditions. We welcome the decision to fund work with
the Sustainable Development Commission to develop "good corporate
citizenship" within the NHS and to promote this model in
other public sector bodies too. In 2002, the King's Fund report
Claiming the Health Dividend: Unlocking the benefits of NHS
Spending[199]
made the case for using the corporate resources of the NHS to
promote health and sustainable development.
— Changing the relationship between
the individual and primary health services. The proposal to
introduce children's health guides, personal health guides and
periodic health checks or "stock-takes" is welcome.
The King's Fund has argued for a change in the way individuals
relate to the health system—from a passive doctor/patient
relationship to one where individuals are seen as co-producers
of their own health. [200]We
have suggested that individuals might have "health and lifestyle
checks" at key life stages and produce a "personal health
plan" that sets out their current state of health and what
needs to be done to maintain and improve their health, with plans
stored electronically and updated by the individual over the life
course. Very similar ideas have been set out in the White Paper.
We should welcome further testing of this approach, as one means
of shifting the emphasis from treatment and cure towards health
maintenance and improvement. There is a particular need to test
whether this approach works for those at greatest risk of ill
health—those in the most socially deprived groups and from
minority ethnic groups.
— Community-based health advocates
or "trainers". The King's Fund has called for community-based
advocates for health—already a well-established model for
helping disadvantaged individuals and groups gain access to the
knowledge and services they need to maintain and improve their
health—to be further developed and brought into the mainstream
of the health system. [201]We
welcome the proposal to introduce "health trainers"
(a concept that closely mirrors this idea), and for the NHS to
invest in training and accrediting them. Given that people's mental
health is as important as their physical health, we believe mental
health should be a core competency for all health trainers.
— Employment as a determinant of
health. We welcome the White Paper's commitment to occupational
health in the NHS and other organisations, and to helping people
return to work after illness or injury. Addressing working conditions
and other socio-economic causes of illness and well-being must
be central to an effective strategy to improve population health
and reduce health inequalities.
— Action on smoking. The ban
on smoking in enclosed public spaces including restaurants and
bars that serve food is a step in the right direction. Yet the
King's Fund sees it as a missed opportunity.
Shortcomings and weaknesses
— Lack of connectedness. The
White Paper shows little sense of its own history, or how it connects
with earlier health policy documents such as the Independent Inquiry
into inequalities in health report chaired by Sir Donald Acheson
and Our Healthier Nation. This suggests a desire to repudiate
"old" public health policies and start again. Yet earlier
strategies have strengths that can be built upon. For example,
the Acheson Report recommended giving priority to women of child-bearing
age and children; Our Healthier Nation called for a three-way
collaboration between individuals, local organisations in communities
and national government, and for action in specific social settings—schools,
communities and workplaces.
Reference to this kind of inheritance could help
to give greater coherence and stronger meaning to the vast array
of initiatives in Choosing Health. It could also be helpful for
those who have to implement the White Paper if they could see
more clearly how new initiatives relate to earlier ones, and if
they were able to gain a stronger sense of a developing sequence
of policies, one leading to another, bringing incremental change.
There are real connections to be traced but Choosing Health
largely ignores them.
— Reconciling choice and inequality.
The ideology of "choice" is firmly imprinted on the
White Paper. However, the task of reconciling individual choice
with a commitment (also clearly stated) to reducing health inequalities
will be a real challenge. The initiatives targeted on disadvantaged
individuals and neighbourhoods are welcome, but it is still unclear
whether the government has committed itself to the radical agenda
that will be required to ensure that everyone has a genuinely
equal chance to enjoy a long and healthy life. If it does not
do this it will have been a missed opportunity.
— Failure of nerve on smoking.
The White Paper fails to follow the success of Ireland, New York
and other places in banning smoking in all enclosed public spaces.
Instead, it goes for a partial ban, excluding pubs and bars that
do not serve food, as well as clubs. This is bound to cause confusion
among customers, as well as unhealthy competition between licensees.
It is also likely to widen health inequalities, as pubs that don't
serve food are concentrated in poor neighbourhoods, where more
people smoke and find it harder to give up. There is evidence
that a total ban would be popular with the public and has worked
well in other countries. This was a golden opportunity—missed
more for ideological reasons (the "choice" agenda again)—than
for any points of health-related evidence.
— Too much dependence on voluntarism.
In a similar vein, it is a pity that the carrot-and-stick approach
to restricting food and drink promotion to children has not been
extended to efforts to improve food content and labelling. It
is doubtful whether "discussions with the food industry"
will lead to prompt and effective action, unless there is a promise
of enforcement if voluntarism fails to show results within a specified
time frame.
— Shortage of detail on critical
points. In spite of its prodigious length and breadth, and
its multitude of announcements, the White Paper has too little
detail on a number of critical points. Some proposals sound intriguing
but lack substance. For example, how will the Child Health Promotion
Programme, the Communities for Health scheme and "health
champions" operate, and how will the latter relate to the
proposed "health trainers"? How, if at all, will "health
trainers" relate to the large numbers of health advocates
already operating at community level? Part of the problem may
lie with an apparent reluctance to connect the White Paper with
its antecedents, or to develop ideas that have originated in local
government rather than in the NHS. Other themes, such as mental
health and alcohol, are dealt with at some length but there is
little said about upstream prevention.
— Too little attention to black
and minority ethnic health. There are few substantive references
to black and minority ethnic communities. Evidence of inequalities
suffered by these groups, in physical as well as mental health,
has been highlighted by the London Health Observatory. [202]It
is regrettable that the White Paper did not pay closer attention
to their specific needs.
Questions and challenges
— Can choice and equal opportunity
be reconciled? The White Paper attempts to accommodate two
objectives that do not fit together easily. The first is to transform
the culture and practice of the NHS to provide a stronger focus
on preventing illness and reducing health inequalities. The second
is to promote a health agenda that seeks to change personal behaviour
by supporting individual choice. The Government needs to articulate
more clearly how these two objectives can both be pursued successfully.
— Is there enough money? The
Department of Health plans to invest at least £1 billion
in public health over the next three years, but it is not clear
whether this is all new money, where it comes from and what it
is expected to cover. The White Paper makes explicit reference
to investment in health education campaigns, school nurses, health
trainers and obesity and sexual health services. Is there enough
to meet the demands of all these objectives and how will all the
other initiatives mentioned in the White Paper be financed?
— How much of it will be implemented
and by when? If all the initiatives set out in the White Paper
were implemented within the next Parliament, there would be every
reason to expect a "step change" leading to better health
for all and reduced health inequalities. However, everything depends
on the quality of implementation, and on how well the many component
parts of the White Paper fit together and work in practice.
— Will there be strong and sustained
leadership for change? A critical factor will be how strongly
implementation of the White Paper is led from the centre. Will
public health policy continue to have a high profile and be given
priority at senior level across the Department of Health and the
NHS? Or will it have to wait to be realised until health care
problems are solved? If there is a new ministerial team after
the next election, which is highly likely, will they champion
the cause of implementing the White Paper, or want to start something
new of their own? Strong and sustained national and local leadership,
enduring well beyond the next election, will be essential.
— Is there a clear story that everyone
can understand and support? As the dust settles, will all
stakeholders be able to share a view about what the objectives
are and what can be achieved? This may be difficult, given the
length of the White Paper, its many and varied announcements,
and the fact that it harbours ill-fitting ideologies. Much will
depend on how it is interpreted by those responsible for disseminating
its messages and drawing up the implementation plan.
— What are the incentives for the
NHS to push the improvement of public health up the agenda?
At present the NHS is receiving unprecedented financial investment.
Even so, many NHS organisations—in particular Primary Care
Trusts—are financially hard pressed. Given the lack of strong
evidence of the cost-saving effect of measures to improve public
health, it is not clear what are the incentives for Primary Care
Trusts in particular to turn their attention more seriously to
some of the measures proposed in the White Paper. Unless this
issue is addressed, there is a risk that the excellent measures
proposed will not be implemented in a sustained way, especially
in the future when resources for the NHS may be tighter.
— What can be done to evaluate the
cost effectiveness of a range of health promoting interventions?
There is an urgent need for a programme of research to assess
the impact of both the more specific (yet complex) interventions
to improve the health of people with long-term conditions and
those designed to improve health more widely. Evaluation of such
complex, and often multifaceted, interventions is difficult, [203]but
in the short term it will be critical to examine their impact
specifically on the use of health care to test the assumption
that better health means less use of health care, as asserted
in Derek Wanless' first Inquiry, Securing Good Health for the
Whole Population: Population Health Trends (December 2003). There
may be a role for the National Institute for Health and Clinical
Excellence in this respect.
February 2005
194 The Stationery Office (1998). Independent Inquiry
into Inequalities in Health: report chaired by Sir Donald
Acheson. London: The Stationery Office. Back
195
Department of Health (1998). Our Healthier Nation: A contract
for health. London: The Stationery Office. Back
196
Department of Health (1999). Saving Lives: Our healthier nation.
London: The Stationery Office. Back
197
Department of Health (2003). Tackling Health Inequalities:
A programme of action. London: The Stationery Office. Back
198
Please see the following website: www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm Back
199
A Coote (2002). Claiming the Health Dividend: Unlocking
the benefits of NHS spending. London: King's Fund. Back
200
A Coote (2004). Prevention rather than Cure. London: King's
Fund. Back
201
B Heer (2004). Building Bridges for Health: Exploring the
potential of advocacy in London. London: King's Fund. Back
202
P J Aspinall and B Jacobson (2004). Ethnic Disparities in
Health and Health Care: A focused review of the evidence and selected
examples of good practice. London: London Health Observatory. Back
203
A Coote, J Allen and D Woodhead (2004). Finding Out What Works:
understanding complex, community based initiatives. King's
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