What the white paper might mean for public health

This coming winter, in the wake of the newly laid out plans for the NHS, the UK government will publish a white paper on public health.1 2 We are promised a new Public Health Service for England, and there is a real sense of anticipation in the public health world—though tempered by anxiety about upcoming public sector changes, suggestions of an influential role for the private sector in shaping public health policy, and the current economic climate.3 4 So, what might the new service look like?

For some years local public health teams have been based in primary care trusts. It seems that these teams will move into local authorities, although at what tier remains to be decided. Director of public health posts have already been moving in this direction through joint appointments with local authorities, although their teams have not necessarily followed. Aligning the directors with their departments would therefore seem sensible. This also provides a chance to even out some of the inequities in public health skills and resources that have developed between localities.

A further advantage of placing public health directors and their teams in the council architecture is the closer relationship with those involved in the distal determinants of health—for example, environmental health, housing, and transport.5 These are traditional domains of public health, and notwithstanding academic debates about the notion of historical progress6 there is more than a scent here of “historical circularity.”

The first post of medical officer of health in England was created in 1848, and in the second half of the 19th century such appointments spread through the country. Based in municipalities—precursors of local authorities—medical officers of health built their teams and their influence.5 7 Through the 20th century their responsibilities changed, but the role was not abolished until the 1970s, with the creation of community medicine and the shift of public health into health authorities and health service work.8 The proposal to move things back again may seem regressive, but there is a sound underpinning logic, and the plans may prove positive in terms of the agendas of health improvement and health inequalities. It is essential, though, that the proposed move to local authorities is adequately resourced and supported—otherwise the potential will not be realised.

The planned transition leaves a gap in providing technical support to general practitioners with their new commissioning role; how this will be provided remains unclear.9 Closing the gap in commissioning expertise in the new primary care consortiums is essential if they are to have credibility in negotiating with a range of NHS trusts, which may have vested interests in resisting change. Public health needs to retain influence within the NHS, to complement the individual focus of clinical medicine with a population perspective.10

What about the health protection function? This was separated from mainstream public health with the establishment of the Health Protection Agency (HPA) in 2004, on the back of health security concerns after the 11 September 2001 attacks in the United States.11 The functions of the HPA (currently a non-departmental public body) will move into the new Public Health Service, with accountability to the secretary of state for health.2 Such a shift may have the advantage of strengthening its influence on national policies; but retention of scientific impartiality is important, and there would be value in maintaining independence and a separate identity. Whether to keep community level communicable disease control under specialist health protection or to move it back under local directors of public health will require careful consideration of the advantages and disadvantages. The determining factor, however, should be what is best in terms of protecting the safety and wellbeing of the public.

The organisation of public health functions in the United States is a possible model for England. The Centers for Disease Control and Prevention (CDC) is part of the US Department for Health and Human Services, so moving the HPA’s functions into government would mirror this. The institutions have similarities in terms of national health protection functions, such as responses to large scale outbreaks, public health emergencies, health security, and environmental hazards.

However, there are also considerable differences. CDC is responsible for communicable and non-communicable diseases and has a substantial health improvement commissioning role, whereas the HPA does not.12 There is also a marked discrepancy in the US between the seemingly well resourced technological and scientific high end of public health at CDC and the reality of public health teams at the ground level in states, localities, and cities; many of these teams have a much lower level of resources and expertise. Also, although CDC is strong in field epidemiology, there is no formal universal system of public health training in the US, unlike programmes that exist in the UK and other Western countries.5 And health service delivery in the US is, of course, entirely different—notably the pervasive weakness in primary care and persistent inadequacies in health insurance coverage and the resulting poor health outcomes—which also complicates direct comparison of public health functions.

A broader role such as CDC’s might be attractive, but such a body would need strong links with government departments whose policies influence the determinants of health (sectors such as transport, housing, nutrition, agriculture, environment, and education). Political commitment to put public health at the heart of government policy would also be needed.

We may not always realise it, but despite the regular changes we are relatively blessed in the UK. Public health has a well recognised professional role, and national health and social service systems facilitate the delivery of public health functions. Once again the opportunity exists to improve the system and the public’s health further. If the new Public Health Service is to fulfil its potential, a more cohesive set of arrangements must be complemented by adequate resources and a commitment to tackling public health challenges at individual, local, and national levels.