“If you’re born poor you will die on average nine years earlier than others”
1.In her first speech as Prime Minister, Theresa May put health inequalities first on her list of ‘burning injustices’ that need to be tackled. We strongly endorse this focus on health inequalities, and our report on public health sets out clear actions for the new Prime Minister and her Government to translate this priority into a reality.
2.The difference in life expectancy between rich and poor is well known. Perhaps less well known but equally important—indicated by the lower line of this graph—is the inequality in the years lived in good health.
3.But tackling health inequalities and improving public health will not primarily happen in hospitals, even though hospitals receive the lion’s share of health funding. Rather, it requires a whole life course approach, tackling the wider determinants of health in local communities, and through joined-up policy making at a national level. Whilst it was beyond the remit of our inquiry to consider Government policy on issues such as employment, income inequality and housing, we recognise that responsibility for improving public health and tackling health inequality must cross many departments. These policies must also take a long view, as many of the modifiable factors which can reduce health inequality will take decades to have a measurable effect. The long-awaited Life Chances Strategy and Childhood Obesity Strategy need to be ambitious and will be a litmus test for the Government’s intent to take these issues seriously.
4.Professor Sir Michael Marmot, a leading expert on health inequality who has written extensively on the wider determinants of health, gave the example of fuel poverty to illustrate this point:
Children develop less well if they grow up in cold homes, there is more mental illness, and, at the other end, there are the excess winter deaths, where somewhere between 20% and 25% of excess winter deaths can be attributed to being in the quarter of homes that are coldest. That is pretty simple. There are three issues here. One is the price of fuel; the second is poverty; the third is quality of housing. If you said, “We are developing a set of policies on housing. What is the likely impact on health and health inequalities?”, we could say, “We have a good enough evidence base to tell you that, if this happens, then that will happen in terms of health inequalities.”
5.The crucial importance of these wider determinants of health is the reason we welcome the move in 2013 of public health to local authorities. They are well placed to embed the health and wellbeing agenda within their local communities across all the policies for which they are responsible. Whilst recognising the challenges that public health practitioners have faced as a result of the large scale system change resulting from the Health and Social Care Act 2012, we consider that public health should remain embedded in local communities. This report primarily addresses the areas of public health provision covered by the Health and Social Care Act 2012.
The wider determinants of health
Source - Whitehead and Dahlgren, 1991
6.Public health is often thought of as three distinct, but overlapping domains: health improvement, which means promoting healthy lifestyles and healthy environments, as well as tackling inequalities; health protection, which means prevention, preparedness for, screening and response to infectious diseases and other threats to health; and health service improvement, which involves providing public health expertise to inform the effective and efficient planning and delivery of healthcare.
Source - Griffiths, S; Jewell, T and Donnelley, P. (2005) ‘Public health in practice: the three domains of public health’, Public Health, 119(10):907–13
7.Health improvement includes services to encourage people to live more healthily—such as smoking cessation services—but also involves addressing the issues that underpin health, such as housing, work and education. Health protection public health will include the national and local response to a wide range of threats as well as our internationally coordinated response to diseases like Ebola. A public health practitioner involved in health service improvement might, for example, work with commissioners and NHS colleagues across a range of disciplines to help design the most effective diabetes service for their local population.
8.There are many challenges which, if tackled effectively, could improve public health and reduce health inequality. Obesity rates continue to rise across England and in particular are continuing to rise in the most disadvantaged children, widening health inequality. Although smoking prevalence has fallen dramatically, nearly one in five adults is still a smoker. In the lowest socio-economic groups, the rate rises to over one in four. If the Government is serious about reducing health inequality, it must be prepared to take action when modifiable risks, such as problem drinking, hit the most disadvantaged communities. It must be ambitious in championing policies to improve the nation’s diet and physical activity, again focusing on those with the greatest need.
9.Further action is also required in other areas of public health. The Prime Minister also referred in her first speech to the need to improve access to mental health services. Our predecessor committee’s inquiry into children’s and adolescents’ mental health services (CAMHS)—amongst others—made the case that to improve public mental health, prevention and early intervention are the most cost effective approaches. There can be no cause for complacency on infectious diseases, especially in light of the grave risks from antimicrobial resistance. Tuberculosis rates have risen over the past decade (although they have fallen over the past two years), and national averages mask high rates in some local areas; likewise the emerging risk from multiple drug resistant sexually transmitted infections.
10.Public health matters not only for its role in improving health and wellbeing and in reducing health inequalities but because it is absolutely essential to reducing future demand on an overstretched health service. A ‘radical upgrade’ in prevention and public health was central to NHS England’s 5 Year Forward View.
11.The Nuffield Trust provide the following helpful explanation of why public health matters in reducing demand:
The top three causes of premature death in the UK (heart disease, lung cancer and stroke) are placing a significant burden on the NHS, social care and wider society, but all are largely preventable. The Department of Health (DH) estimates that 70% of the total health and social care spend in England is for the treatment and care of people with long-term conditions such as diabetes and heart disease (Department of Health, 2010a). Yet, many of the behaviours which contribute towards the development of long term illnesses such as these are also preventable, including smoking, excessive alcohol consumption, lack of physical exercise and obesity.
12.Despite the clear economic case for focusing on prevention, spending on public health currently accounts for just over 4% of total health spending. The Health Foundation estimate that the public health budget will have fallen in real terms from £3.47bn in 2015–16 to just over £3bn in 2020–21.
13.In 2013, much of the responsibility for public health was transferred from the NHS to local authorities—a fundamental change. The public health landscape has also become more complex, with the addition of a new national and regional public health agency—Public Health England—whilst some public health responsibilities remained with the NHS, through NHS England. The Secretary of State retains ultimate responsibility for public health, and has powers to take steps to improve the health of the people of England, as well as responsibility for health protection. The following diagrams illustrate the changes:
14.In this new public health landscape the role of the Secretary of State remains crucial. The public health responsibilities which remain with NHS England are not set in legislation, but given to it directly by the Secretary of State through an agreement under section 7A of the National Health Service Act 2006 (inserted into that Act by section 22 of the Health and Social Care Act 2012). Public Health England, meanwhile, is an executive agency of the Department of Health, giving it a closer relationship with the Secretary of State than NHS England, which is a non-departmental public body. The Secretary of State therefore retains—in theory at least—a more direct responsibility for public health than he does for the other health functions which are the responsibility of NHS England.
15.Local authorities now have a statutory duty to improve the health of their populations, and from 1 April 2013 they assumed responsibility for a large range of public health services including, for example, services to tackle drug or alcohol misuse. These services may be provided by commissioning services, for example through contracts with NHS, voluntary sector, or private providers. The Department prescribed 6 services—sometimes referred to as mandated services—that all local authorities must provide. They are sexual health services (sexually transmitted infections testing and treatment and contraception); the NHS Health Check programme; health protection; public health advice; the national child measurement programme; and most recently services for 0–5 year olds.
16.Public health—although it may be less visible to members of the public than hospitals and GPs—is absolutely crucial to improving individual and population health, reducing health inequalities and the future sustainability of the NHS. While the aim is to extend healthy life expectancy for citizens, it is the period of ill health towards the end of life that increases demand on the NHS and social care. The transfer of public health responsibilities from the NHS to local government was widely supported, but, like all change, it has the potential to be destabilising. We therefore decided to hold this inquiry as an initial ‘stocktake’ of the successes and challenges arising from the evolving new system for public health.
17.The evidence we have received suggests that the relocation of public health to local authorities in England has been largely positive, allowing public health to become integrated into all policies and to take account of the wider determinants of health. We endorse and support the embedding of public health teams within local authorities and commend the many examples of excellent practice presented to this inquiry.
18.Nevertheless, since 2013, those charged with protecting and improving public health have faced significant challenges. These challenges include:
19.These challenges have been compounded by cuts to public health funding including in-year cuts.
20.There has also been a noticeable contrast in the views of those providing evidence to our inquiry, with some public health professionals being overwhelmingly positive about the changes, and others being much more negative. We recognise that the system is an evolving one, and this initial inquiry will inform an ongoing process of review and support, through which we will hold the relevant organisations to account for addressing the outstanding issues and unacceptable variation presented to us.
21.We held three ‘overview’ sessions examining new public health structures, and supplemented this overview with two case studies into specific areas of public health—health protection and the ‘health in all policies’ agenda. To build as rich a picture as possible for our inquiry, we supplemented our Westminster evidence sessions with a seminar with leading public health academics, an informal roundtable meeting with 25 public health professionals, and a visit to Coventry City Council. We are extremely grateful to all of those who contributed, as well as to our specialist advisers, Dr Janet Atherton and Professor David Hunter.
22.Our report is set out as follows:
1 , Prime Minister’s Office, 10 Downing Street, 13 July 2016
3 Health and Social Care Information Centre, , 2014
4 ASH, , 2015
6 PHE, , 2015
7 NHS England, , Executive Summary, para 3
8 Nuffield Trust, , April 2016,p9
9 Health Foundation p1
10 Dr Atherton declared the following interests: Director, Janet Atherton Ltd, public health and management consultancy; Adviser to Public Health England on local government public health; Associate, Local Government Association working on Sector Led Improvement Programme; Associate, iMPOWER Consulting Ltd; Associate Member of the Association of Directors of Public Health; Fellow of the Faculty of Public Health; Member of the Department of Health’s Advisory Committee for Resource Allocation (ACRA); Non-Executive Director of Tobacco Free Futures (now Healthier Futures). Professor Hunter declared the following interests: Non-Executive Director, NICE (2008–present); Senior Investigator on evaluating the leadership role of Health & Wellbeing Boards, Department of Health Policy Research Programme (2014–16); Senior Investigator on Shifting the Gravity of Spending? Exploring methods for supporting public health commissioning in priority-setting to improve population health and address health inequalities. A fellow on study, NIHR School for Public Health Research (2015–16); Co-Investigator on Commissioning for Public Health: the impact of the health reforms on access to services, health inequalities and innovation in service provision, Department of Health Policy Research Programme (2015–17); Special advisor to WHO Regional Government for Europe and Director of WHO Collaborating Centre on Complex Health Systems Research, Knowledge and Action at Durham University (engaged in a number of consultancies (2015–16): Interim review of the European Action Plan for Strengthening Public Health Capacities and Services; Survey of country capacity to generate, appraise, translate and apply research evidence for health decision-making for WHO EVIPnet; Designing and facilitating short courses in capacity-building in Health in All Policies (HiAP)); Honorary Member, Faculty of Public Health.
30 August 2016