Posts Tagged ‘Healthcare reform’

Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners.  Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost.  Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the   hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are.  Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base.  But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery.  This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

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I went to a breakfast event at the King’s Fund this morning with Conservative Shadow Health Minister Stephen O’Brien MP. He was speaking alongside Sue Slipman, Director of the Foundation Trust Network, and Jonathan Nicholls, who is Research Director for Health and NHS at Ipsos MORI. O’Brien shored up the Conservatives’ public health credentials by outlining some of their policy thinking, should they be elected into Government.

According to O’Brien public health budgets would be ring-fenced by the Tories and he promised “support” for Directors of Public Health. O’Brien is also interested in including public health in all clinical career paths, and floated the idea of doctors spending six months in developing countries during their post-qualification training so that they lean public health principles.

After questions from the floor, O’Brien criticised the use of deprivation indices when calculating public health budgets, arguing that instead they should be calculated on the burden of disease in each area. He also expressed support that some social care interventions e.g. stair lifts for older people should be provided out of public health budgets. The Conservatives also want to change the statutory remit of NICE so that their guidance looks at wider societal costs of treatment, something O’Brien pledged to do in their first Health Bill should they be elected.

Snippets of the conversation are available to listen to at the King’s Fund website.

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Sunday 8 November 2009

Early morning in Philadelphia. From my hotel room I watch the sun rising over the Delaware River.

Yesterday I saw a different sun rising – a motif carved on the back of the chair in which George Washington presided over the signing of the Constitution of the United States of America after months of wrangling in 1787. At the time, Benjamin Franklin, sage and polymath, whose knowing presence is everywhere here in historic Philadelphia, observed, ‘now, at length, I have the happiness to know it is a rising and not a setting sun.’

Yesterday I switched on the TV during an ad break. First up was one of the interminable screamers from the NO lobby in the great healthcare reform debate. What about the $800 billion bill? All those inflated taxes? Can they guarantee you can keep your own doctor? Your current insurance company? Can they promise healthcare won’t be rationed? Persuade your congress representative to vote NO for the Public Option.

Then in quick succession: an ad for the statin Crestor to control your cholesterol – ‘if you have difficulty paying for medication, Astra-Zeneca may be able to help;’ and Reddi-Wip real ready-whip cream – dessert just isn’t dessert without Reddi-Wip.

Today I switched on the TV and everything has changed. The House of Representatives has passed its sweeping healthcare reform bill by a narrow margin – 220 votes to 215. Although it still has a few hoops to jump through before it becomes law, the way is now paved for the biggest extension of healthcare insurance coverage since the introduction of Medicare 40 years ago. The vast majority of the 46 million Americans without insurance will, by law, have to be covered. The federal government will offer its subsidised insurance scheme (the Public Option) in competition with the established health insurers. Radical change will happen through a largely market-driven shakedown within a framework set by government.

Later today I will be attending the Grand Opening of the Annual Meeting of the American Public Health Association – a colloqium several thousand strong, held this year in Philadelphia’s magnificent convention centre which, rather like Manchester’s, was once a busy railway terminus.

You can guarantee the place will be abuzz with talk of the healthcare vote. The atmosphere will be electric. It will light up the whole conference. I doubt there’ll be a soul there who isn’t absolutely thrilled at the prospect of such a huge change to US healthcare. It is truly momentous.

Barack Obama’s powerful pre-vote speech invoked the call of history – rather in the same vein as the ringing statements of the Founding Fathers here in Philadelphia.  And, fingers crossed, it seems to have been answered. As Ben Franklin might have said, methinks the sun, at long last, shows promising signs of rising.

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