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School of Medicine Pharmacy & Health
School of Medicine Pharmacy & Health
Taking the Long View of Public Health: a new dawn or poisoned chalice?
Presented by David HunterProfessor of Health Policy and Management31st October 2013
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School of Medicine Pharmacy & Health
What is Public Health?
Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.
Sir Donald Acheson, former Chief Medical Officer for England (1988)
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School of Medicine Pharmacy & Health
Domains of Public Health
Health protection Health promotion Health service performance
UK Faculty of Public Health
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School of Medicine, Pharmacy & Health
A Tale in Two Parts
Looking backA not too Horrible History of
Public Health
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School of Medicine, Pharmacy & Health
A Tale in Two Parts
Looking forwardNew dawn or poisoned
chalice?
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School of Medicine, Pharmacy & Health
Looking Back (1)History tells us that local government played thegreatest historical role in the sanitary revolutionduring Britain’s rapid industrialisation in 1800s Improved housing Cleared nuisances Introduced gas lighting Provided public bathing and washing facilities Implemented infectious disease control
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School of Medicine, Pharmacy & Health
Looking Back (2)
Rediscovery of public health in more recent times Rise of non communicable diseases: cause of
86% of deaths in the WHO European Region – 53 countries, 900 million people
Smoking Obesity Alcohol misuse
Communicable disease control: flu pandemics, sexually transmitted infections
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School of Medicine, Pharmacy & Health
Looking Back (3) From 1974 - 2013 the National Health Service
(NHS) had responsibility for public health Clinical dominance of public health workforce Multidisciplinary public health workforce becomes
a reality (2003): Introduction of UK voluntary register for public health
specialists Faculty of Public Health Medicine becomes Faculty of
Public Health Joint Directors of Public Health appointments between
NHS and local government
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School of Medicine, Pharmacy & Health
Public Health and the NHS: a difficult relationship
While the NHS claimed from the outset to give high priority to the promotion of health…in reality this aspect of the service was never more than weakly developed, notwithstanding claims to the contrary, habitually made in ministerial speeches.
Charles Webster (1996)(Official NHS Historian)
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School of Medicine, Pharmacy & Health
Looking Back (4) Brief renaissance of public health under New Labour: first
Minister for Public Health (1997) Wanless I (2002) and II (2004): 'fully engaged scenario' Joint Directors of Public Health posts: recognition of local
government's role in public health – 'multidisciplinary public health will become a reality' (Blears, 2002)
NICE assumes responsibility for public health evidence (2005)
World class commissioning: focus on population health (2007)
The Marmot Review: focus on SDH (2010)
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School of Medicine, Pharmacy & Health
Wanless’s CritiqueNumerous policy statements and initiatives in the field of public health have not resulted in a rebalancing of policy away from health care (a ‘national sickness service’) to health (a ‘national health service’). This will not happen until there is a realignment of incentives in the system to focus on…tackling the key lifestyle and environmental risks.
Derek Wanless (2004), Government Adviser
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School of Medicine, Pharmacy & Health
Looking Back (5) Persistent tension between focus on individual
lifestyle change (nudge) and government action to improve health (shove): ‘lifestyle drift’ prevails over ‘nanny state’
Responsibility deals Behaviour Insights Team (Nudge Unit) No action on plain packaging for cigarettes or
alcohol minimum pricing
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School of Medicine, Pharmacy & Health
Where are we Now?The coalition programme…involves a restructuring of…public services that takes the country in a new direction, rolling back the state to a level of intervention below that in the United States – something which is unprecedented. Britain will abandon the goal of attaining a European level of public provision. The policies include substantial privatisation and a shift of responsibility from state to individual.
Taylor-Gooby and Stoker, The Political Quarterly (2011)
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School of Medicine, Pharmacy & Health
Reflections: the Negatives
Public health caught up in neoliberal agenda: from the welfare state to the market state
Continuing tension between the nanny state and the enabling state
‘Lifestyle drift’ policy bias, especially evident in England
Medical resistance to non-medical specialists
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School of Medicine, Pharmacy & Health
Source: The Economist, 12 November 2003.
Evolutionary Trends: How far have we really come?
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School of Medicine, Pharmacy & Health
Reflections: the Positives
Acknowledgement of wider public health and its multidisciplinary workforce
Smoking ban – example of government action with public support
Example of evidence informed policy Recognition of local government’s
key role in public health
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School of Medicine, Pharmacy & Health
Looking Forward
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School of Medicine, Pharmacy & Health
Key Challenges
Return of public health to local government (April 2013): realising the potential
New organisation at centre to lead on public health: Public Health England
Making the public health workforce fit for purpose with new skills
Changing leadership styles Applying evidence and strengthening
knowledge to action
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School of Medicine, Pharmacy & Health
Local Government: public health’s natural home
Many people in local government believe it is their organisations, rather than health authorities, that are public health authorities.
Tony Elson (1999)(former local authority chief executive
and adviser to Department of Health)
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School of Medicine, Pharmacy & Health
The Main Determinants of Health
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School of Medicine, Pharmacy & Health
Meeting the Public Health Challenge Investment in public health
Health spend per capita: £2000 per year Preventive spend: £80 per year (4%)
Using ring-fenced public health budget to unlock resources elsewhere in local government
New partnerships: are Health and Wellbeing Boards the answer?
New skills and competencies required Relationship building Political astuteness
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School of Medicine, Pharmacy & Health
Concluding Reflections (1)Is the glass half-empty? Demise of the public health profession as we
know it: future of specialist-practitioner-wider workforce paradigm at risk
End of DsPH as we know them Emergence of a divided and fragmented
workforce split between different cultures Failure to recognise and invest in public
health skills training Devaluing the evidence base in political
world of local government Time of austerity: public spending cuts
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School of Medicine, Pharmacy & Health
Concluding Reflections (2)Is the glass half-full? Transform the way public health is conceived and
delivered Break away from the shackles of a biomedical
model and embrace a social model: from a deficit to an assets-based approach
Develop new skills and competencies – not a case of preserving the old and familiar
Embed new leadership style focused on influencing others engaged in health improvement and wellbeing
Use of ring-fenced public health budget to lever in resources from elsewhere
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School of Medicine, Pharmacy & Health
The Journey Continues– Thank you!
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