The NHS long term plan and public healthBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l218 (Published 16 January 2019) Cite this as: BMJ 2019;364:l218
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In recognising that the NHS 10 year plan seeks to ‘contribute to what is within its compass’ Chapman and Middleton highlight just why any plan constrained by organisational boundaries cannot be a comprehensive plan for ‘health, wellbeing, equality, and care’ (1).
Fiona Godlee stresses that the NHS is limited in the extent to which it can effectively deliver on primary prevention (2) and given the plethora of determinants on health this will always be the case. A plan of how the NHS will continue to support a prevention agenda, albeit largely downstream, is clearly a step in the right direction. Yet the degree to which it can be truly ‘ambitious’ about preventing ill health and reducing disparities in access and outcomes remains constrained by a culture of individual organisational planning.
Certainly much of the secondary prevention proposed, such as in-hospital support for smokers should be welcomed. However, this comes at a time when Local Authority budget cuts mean smoking cessation services are shrinking or disappearing altogether (3). Positive from the NHS yes but given the ongoing rhetoric about systems approaches it still feels like one step forward, two steps back.
To deliver the much quoted ‘radical upgrade in prevention’ (4) long term plans addressing ill health must surely be developed alongside plans addressing factors that lead to ill health; ‘causes of the causes’ (5). A failure to do so limits potentially transformational impact and reinforces the idea that health is the job of the NHS rather than truly being ‘everyone’s business’(6). Chapman and Middleton champion the need for health in all policies (7) which whilst far from new still seems radical.
More radical still is the suggestion that any such plans would have a focus on health inequalities. Enthusiasm for the first NHS plan to recognise a responsibility for reducing health inequalities (1) is tempered by the fact that the black report is almost 40 years old (8). What impact would a greater NHS focus on inequity have had after 4 decades? Emphasis on reducing inequalities and improving outcomes is clearly good news. Although by now shouldn’t it be inconceivable that reducing inequalities isn’t hardwired into any long term plan for the NHS and indeed those of all government agencies who impact on the social determinants of health?
Organisational planning may be necessary but unless plans and outcomes are aligned prospectively we’ll spend time retrofitting them together, making shared ownership more difficult. The NHS and Local Authorities are amongst the biggest agencies with responsibilities for health. Suggestions of further swapping sexual health and other services between the two risks reinforcing the notion that organisations, rather than whole systems, are what determines outcomes. Claiming that public health has been ‘lost since the move to Local Authority’ also risks placing too much importance on where people have their desk. Public Health hasn’t been lost. Whilst smaller than in 2013, it is still in the same communities and serving the same populations. Do the public care that it’s in a different organisation as much as professionals do?
We should expect the NHS to play a crucial role in promoting, protecting and improving health but we shouldn’t expect it to do this alone. It simply cannot produce a plan for ‘health, wellbeing, equality, and care’ (Chapman & Middleton). If the health of the people is truly the highest law, shouldn’t we finally see an NHS plan as one part of a coherent, cross departmental approach with a consistent narrative and shared objectives? Locally organisations are expected to collaborate across organisations that have a remit for the determinants of health and care. Might this be easier if we saw a little more of this collaboration centrally?
1. Chapman R and Middleton J, The NHS long term plan and public health, BMJ 2019;364:l218 https://www.bmj.com/content/364/bmj.l218
2. Godlee F, Prevention is the role of governments, not health systems, BMJ 2019;364:l228 https://www.bmj.com/content/364/bmj.l228
3. Lacobucci G, Stop smoking services: BMJ analysis shows how councils are stubbing them out, BMJ 2018;362:k3649 https://www.bmj.com/content/362/bmj.k3649
4. NHS, Five Year Forward View 2014, https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
5. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng...
6. NHS Providers (2017), Public Health: Everyone’s Business? https://nhsproviders.org/media/3791/public-health-everyones-business.pdf
8. DHSS (Black Report) (1980), Inequalities in Health: Report of a Research Working Group, London Department of Health and Social Security
Competing interests: No competing interests