By Matt.Ross

05 Feb 2013

As councils take control of public health budgets and staff, the government’s chief medical officer Sally Davies tells Matt Ross why the reforms should enable all kinds of public officials to help take the pressure off the NHS

As an ageing, increasingly overweight and harder-drinking population puts ever more strain on NHS services, public health issues are of growing importance to the Department of Health (DH) – yet the department is currently giving away control over almost all of the NHS’s public health staff and funding. It’s a counter-intuitive move that throws into stark relief just how much policymakers’ assumptions have changed under the coalition: five years ago, a big push on public health would have involved top-down targets, formal cross-Whitehall mechanisms, civil service-led initiatives and national funding pots, but today’s DH is handing most of the responsibility and resources for improving public health to local authorities.

Many career civil servants, steeped in the belief that nobody else can quite be trusted to maximise public benefit, would be deeply uncomfortable with such a plan – particularly given that councils are under no obligation to adopt the same public health priorities and techniques as the DH. Professor Dame Sally Davies, however, is not a career civil servant: the chief medical officer spent more than 30 years in clinical practice, teaching and research before joining the civil service in 2004. And most of the factors that shape public health, she argues, can’t be altered by central government actions: these days, public health is about “how we live our lives – and that takes in urban planning; our interactions with each other; loneliness; wellbeing,” and a host of other factors. With public health issues now reaching far wider than the traditional triumvirate of no smoking, limited drinking and healthy eating, what’s required is a “much more holistic approach” – and that means passing the lead role to those best placed to occupy it.

Traditionally, public health professionals have been employed within the NHS, putting them in a setting well-suited to pursuing initiatives such as smoking cessation services. But most of the people who shape relevant local environments and services – those managing green spaces and controlling pub licenses, for example – work for local authorities. With the job of improving public health handed to councils, the theory goes, public health professionals will be far better placed to have a meaningful impact on people’s lives.

Coordinating the local from the central
Of course, in Britain’s highly centralised governance structure, many services are directly controlled from Whitehall – and here, it will be Sally Davies’ job to persuade other central officials to consider public health objectives. Following the abolition of the shared Public Service Agreements, she concedes, she no longer has hard levers to encourage them to do so. “But I’ve never been the greatest fan of regulation,” she says. “I think we get other people on board by making the case and showing the evidence and proving it’s cost-effective.”

Davies is well-placed to gather that evidence: alongside her role as chief medical officer, she’s the DH’s chief scientific adviser and heads up its research & development work. The National Institute of Health Research and the DH’s policy research programme, she explains, are focusing on evaluating the effectiveness of various public health policies, while she regularly sets up workshops that bring together scientists and policymakers to discuss particular public health challenges. “You can really move people on if you talk to them, collect and share the evidence,” she says. “And that’s a way that gives you real traction on the system that will last, that will be sustainable, whereas with a target they only respond as long as the target’s there.” Her task is made easier, she adds, by the public-spirited ethos so common among civil servants: people want to be helpful, because the aim is to “let people live better, longer, higher-quality lives.”

Clearly, though, Davies needs to win minds as well as hearts if other departments are to compromise their own narrow objectives to factor in public health considerations. “You have to look at things from their perspective, and frame it so you get the overlap effect,” she comments. “I don’t think that [the Department for] Transport would listen to us demanding stuff – but on cycle lanes, for example, they need to act on climate change, we need the exercise bit, so how can we help each other?” Right now she’s working closely with the education department, she adds, and will be producing a report this year “on how to give children a good start in life and build their resilience. I’ll be coming at it from a health perspective, but clearly that matters to education just as education matters to health. They’re inextricably linked.”

What’s the government’s business?
Davies would like to see public health issues considered in most fields of public sector work – but is it the government’s job to constantly push, coerce and encourage people to live more healthy lifestyles? “I think we have to help people, whether it’s by ‘nudging’ or on occasions regulation, where their lives come up against other people’s lives,” she says. “So we clearly have to take action where there’s excessive alcohol leading to social disruption.” Binge drinking is a huge and growing problem, as Davies illustrates with a story – both entertaining and horrifying – that would absolutely delight Daily Telegraph readers by perfectly confirming their prejudices about both public sector workers and young drinkers. “I spent a night in two casualty departments a couple of years ago, with a colleague who’d dislocated his jaw on yawning,” she recalls, deadpan. “I could not believe how much of what I saw was due to alcohol. Violence, delirium tremens, bleeding through the mouth because of having rotted the liver. Just horrible! That wasn’t there when I was young.”

Deciding whether and how to intervene is “much more difficult”, she acknowledges, when the health and social consequences are less dramatic: a married couple who share a bottle of wine each night, for example. Yet the evidence is that over time, they’ll do themselves some serious damage. “We need to find ways for people to have social lives without the lubrication of alcohol,” she says – though here, “instead of regulation, we need nudging, we need education. We have quite a lot of evidence that brief interventions, explaining and educating and following up, will help many people.”

What’s required, then, is a mix of different techniques and approaches to improving public health. “I don’t think there’s a magic bullet, and the magic wand will scatter all sorts of things,” she says. “It’s about a patchwork of approaching it in many different ways.”


Choosing the right tools
Many of the soft-touch interventions that Davies hopes will help change people’s behaviour require the support of businesses: she mentions the location of alcohol aisles in supermarkets, for example. And she argues that “there has been good progress” on booze, at least: drinks suppliers are funding the ‘Drink Aware’ campaign, and reducing alcohol content. Few businesses would make decisions that weaken their position in the market in the interests of public health, but Davies argues that “if there’s a level playing field, they’re quite happy to accept whatever”: companies will live with a slight handicap, as long as their rivals do too.

Davies wants to achieve such changes voluntarily, but she doesn’t rule out the use of a less consensual approach. “At the moment we don’t want to regulate, so we’re trying to help [businesses] understand how they can help us to not regulate,” she says. But asked whether she’d be willing to use harder tools such as compulsory labelling or taxation, she replies that “we could well end up there. We’ll take it stage by stage, and we’re giving everyone a chance to move forward.” If the private sector’s voluntary efforts to reduce problem drinking fail, however, “we could end up with a lot more legislation in ten years’ time.”

The precise tools to improve people’s lifestyles, says Davies, are best identified by research and experimentation – but it’s already obvious that many of them are held by councils. “Many people drink because they’re lonely or it’s their way of developing a social life,” she says. “You can’t sort that out from Whitehall, and you can’t sort it out through a sickness service, but you can begin to think about it in communities. Do they have too many off-licenses? Do they have bars and pubs that are open too late? Do certain people need to be seen by ‘stopping alcohol’ services, and how can you best catch them and feed them into that service?”

Movement of the people
Hence, of course, the wholesale exodus of public health staff from NHS bodies to upper-tier councils. “Local authorities have a myriad of tools for improvement that they’ll apply to public health. I think it’s rather exciting that they’re coming in on the game,” says Davies. When public health professionals have direct links with council staff working in areas such as housing, community safety, green spaces and care services, they should be able to have a much greater impact than is possible through the far narrower gateway of clinical healthcare services. What’s more, Davies hopes that from their new bases within councils, public health staff will be able to plug some of the awkward gaps and dissonances that can appear between health and council services. “It will be for local authorities to work out how they want to play it out,” she says carefully, “but if I was a local director of public health I would see it as part of my role trying to join it up and make sure the right services are provided.”

As Davies’ scrupulously hands-off language suggests, the only formal restriction on councils’ use of their new public health budgets – which, as announced last week, will total £5.45bn over two years – is that the money must be spent on improving public health. But that doesn’t mean the DH will be handing over the cash and walking away: “We can’t tell them how to spend it, but we can say: ‘Do you know about this evidence?’ and ‘You do need to spend it on these issues and those issues’,” says Davies. Part one of her annual report, published in December, mainly comprises detailed data on the health of local communities so that councils “can build their own local profiles, see how they compare to other areas, and start to challenge themselves and each other,” she says.

Meanwhile, the DH’s new body Public Health England (PHE) will “build networks of public health teams so they can help each other”, and nag councils where they’re falling behind in particular areas. “We’ll look at the outcomes, and we will every year see how every local authority is doing and feed it back to them,” says Davies. “And where they’re not doing very well or have gone downhill, we’ll be engaging with them through PHE and saying: ‘What happened? Did you not use this bit of evidence? How can we help you?”

The power of persuasion
Asked whether she’s concerned about losing influence over public health staff as they leave NHS management, Davies sounds unworried. “The public health profession have certain standards that go with Faculty of Public Health membership,” she says. “We’re going to, through PHE, provide them with a lot of tools and information and evidence to help them. We’re not going to have a direct route to order them around, but I’d argue that’s often counter-productive anyway.” And what if a council decides to ignore smoking, for example, and focus on tackling obesity? “I would be uncomfortable if they ignore smoking and alcohol and obesity. I think they should make efforts on all those,” she replies. “But there’s not going to be any way that I can force them; only by force of personality.”

Despite all the noise that ministers made about localism a couple of years ago, there are precious few examples of councils gaining big new responsibilities; this, however, appears to be one. And if it does indeed result in better public health and a consequent fall in demand for healthcare, local authorities’ share of DH spending could grow. “Compared to healthcare [NHS budgets] it’s a small amount, but if we can prove it makes a difference then as we move forward we can raise it,” Davies says. “That would be my hope.”

To make that difference, though, councils will need the support of a wide range of Whitehall departments – just as Davies will need councils to embrace their new responsibilities and integrate public health aims into their other work. “I’m very excited about this reform. I think it’ll create real opportunities for local communities, and we’re going to see lots of innovation,” she says. “Public health is going to become everybody’s business. We in this department, at the national level, are meeting other departments, sharing information, discussing shared agendas to make it everybody’s business; and locally, people will be doing exactly the same.”

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