Intended for healthcare professionals

Rapid response to:


The major conditions strategy—just another NHS plan?

BMJ 2023; 382 doi: (Published 14 August 2023) Cite this as: BMJ 2023;382:p1867

Rapid Response:

The major conditions strategy—crucial roles for Directors of Public Health.

Dear Editor
We welcome the interim report from the Government on the major conditions strategy: case for change and strategic framework.(1,2) It combines a number of health papers from the government that are well overdue and urgently needed. This includes crucial areas such as obesity, mental health and inequalities.(3-11) For some of these areas substantial research has been undertaken in the past and there are clear evidence-based interventions that have been waiting to be implemented.

The report quite rightly stresses the importance of primary prevention and empowerment.(2) It also recognises that the wider determinants of health such as income, education, work, housing, and physical environments can have enormous impacts on the health of individuals. In addition, it acknowledges that research suggests that the wider determinants are more important than healthcare in determining health outcomes.

An important driving force for this strategy is cited as sound leadership.(2) We believe that at a national level, the Government needs to create a Minister for Public Health to coordinate action across different government departments, link various national organisations, and work closely with Directors of Public Health.(12) At a local level Directors of Public Health should be leading, enabling and coordinating the strategy in their communities.(13-16)

Fundamental roles of Directors of Public Health and their multidisciplinary teams should be oversight and expertise across all determinants of health and driving forward strategies and actions in different settings including hospitals, workplaces and schools.(13-16) They have the potential to make significant impacts in diverse but vital public health priority areas including: mental health, healthy eating, domestic abuse, physical activity, and inequalities. However long-term, protected investment in public health will be needed if they are to be successful in these areas.(17-20)

A focus on schools as health-promoting settings should be an urgent priority, given the current crisis in youth mental health and the acknowledgment in the report that the majority of mental health problems are established early on in life.(2, 7,8,11)

The Institute of Health Promotion and Education strongly recommends the return of a school nurse for every school with a remit to:
• promote positive health behaviours;
• liaise with school staff and parents to implement positive health campaigns;
• connect with health professionals in the local area; and,
• refer onwards for specialist support as needed.
Public health specialists within each area could work with school nurses and other staff to help to create health promoting schools.(21,22) Together they would target key priorities such as mental health, healthy eating and physical activity.

Directors of Public Health will need direct funds so that they can support settings such as schools and workplaces.(17-20) However, further investment is also needed across a wide range of areas including housing, leisure, transport, and welfare to tackle the root causes of ill health. In relation to leisure for example, opening more swimming pools could be used to target a number of public health issues including physical activity, drowning prevention, mental health, and obesity.(23) In addition, swimming is good for primary and secondary prevention.

In the UK today overall population health and health inequity indices are worsening.(24,25) However, with political will there is an opportunity to create a healthier nation for us and our children, as well as a more equal society. To create vision and provide guidance the health strategy should be more positive with three important overarching aims: to lengthen lives, improve the quality of lives, and ensure that no one is left behind. In the long-term this would also alleviate pressure on our overburdened health service.

1) McCay L, Lowe R. The major conditions strategy—just another NHS plan? BMJ 2023; 382 :p1867 doi:10.1136/bmj.p1867

2) Department of Health and Social Care. Major conditions strategy: case for change and our strategic framework. London: Department of Health and Social Care, 2023. (Accessed 15/08/2023)

3) BMA Food for thought: promoting healthy diets among children and young people. London: BMA 2015.

4) Watson M C, Thompson S. Government must get serious about prevention BMJ 2018; 360 :k1279 doi:10.1136/bmj.k1279

5) Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Feb 2020.

6) Watson M C, Owen P. Inequalities in 2020: time for a health strategy that unites the country BMJ 2020; 368 :m544 doi:10.1136/bmj.m544

7) Children’s Commissioner. The state of children’s mental health services. 2020-21. Jan 2021.

8) Watson M C, Lloyd J. Children’s mental health: the UK government needs to be far more ambitious BMJ 2021; 372 :n573 doi:10.1136/bmj.n573

9) Royal College of Physicians. Powerful stories make the case for a cross-government strategy to reduce health inequalities. 2021.

10) Watson M C, Lloyd J. England’s food strategy: local directors of public health need to be given power and resources. BMJ 2022; 378 :o1837 doi:10.1136/bmj.o1837

11) Young Minds. Yearly referrals to young people’s mental health services have risen by 53% since 2019. (Accessed 15/08/2023)

12) Torjesen I. Health must be embedded across all government policy, MPs say BMJ 2016; 354 :i4715 doi:10.1136/bmj.i4715

13) Watson M C, Lloyd J. BMJ briefing: meet the new masters of public health. BMJ Rapid Response, 08 July 2013.

14) Watson M C, Tilford S. Directors of public health are pivotal in tackling health inequalities BMJ 2016; 354 :i5013 doi:10.1136/bmj.i5013

15) The Association of Directors of Public Health. ADPH Manifesto for a Healthier Nation. London: The Association of Directors of Public Health, 2023.

16) Department of Health and Social Care. Role of the director of public health in local authorities. Updated 29 June 2023. London: Department of Health and Social Care, 2023. (Accessed 15/08/2023)

17) Watson M C, Lloyd J. Need for increased investment in public health BMJ 2016; 352 :i761 doi:10.1136/bmj.i761

18) UK Parliament Health Committee. 2015. Public health post 2013—structures, organisation, funding and delivery enquiry.

19) Watson M C, Theaker T. Public health grants: increased and sustained funding is needed BMJ 2023; 381 :p868 doi:10.1136/bmj.p868

20) Health Foundation. Public health grant. What it is and why greater investment is needed. 17 Mar 2023. London: Health Foundation, 2023. (Accessed 15/08/2023)

21) Lloyd J. Improving health outcomes and health literacy for children and young people through Personal, Social and Health Education in schools. Paper presented at the 17th EUSUHM Congress. 27 June 2013. Royal College of General Practitioners. London.

22) Watson M C, Lloyd J. Creating health promoting schools will improve population health and help reduce inequalities BMJ 2021; 373 :n1290 doi:10.1136/bmj.n1290

23) Centers for Disease Control and Prevention. Health Benefits of Swimming. Atlanta: CDC. (Accessed 15/08/2023)

24) British Medical Association. Valuing Health. Why prioritising population health is essential to prosperity. London: British Medical Association, 2022.

25) Cribb J. Falling employment and worsening health in the UK: connected or distinct trends? BMJ 2023; 380 :p647 doi:10.1136/bmj.p647

Competing interests: No competing interests

19 August 2023
Michael Craig Watson
Trustee, Institute of Health Promotion and Education.
Dr Karen E. Neil, Trustee, Institute of Health Promotion and Education.
Institute of Health Promotion and Education, 2nd Floor, Fairbank House, 27 Ashley Road, Altrincham, Cheshire, WA14 2DP.