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By Alan Maryon-Davis

The public health white paper promises to ‘improve the health of the poorest fastest.’ Health Secretary Andrew Lansley has said that closing the health inequalities gap is a top priority, echoing the Marmot Review – ‘more must be done to tackle the causes of the causes of ill-health.’ To this end he has set up a cross-government committee on public health and has proposed a shift of responsibility for health improvement onto local government, along with a ‘ring-fenced’ public health budget. Joined-up at the top and bottom.

So far, so good. Many would agree that local government is the natural home for the public health and wellbeing agenda. It’s where the big local decisions about social determinants take place and where a properly coordinated approach could really pay off. Localism in action.

The flipside of course is that the Coalition’s Health Secretary, with one deft move, will be off-loading this most stubborn of health challenges. Despite massive investment by the previous government, the inequalities gap has continued to widen. In taking on this agenda, local authorities might find themselves accepting a poisoned chalice.

If that was apparent before the Chancellor’s spending review, how much more so it is now we know the breadth and extent of Osborne’s austerity drive. Massive cuts in benefits and public services, soaring unemployment, a deep-frozen NHS and the rise in VAT, all add up to millions more people in difficulty – a situation which, according to the Institute for Fiscal Studies, is bound the hit the poorest hardest.

We know that maternity problems, infant ill-health, low uptake of childhood immunisation, poor oral health, child and adolescent mental ill-health, accidents and violence, depression and suicide, cancer diagnosis and heart disease, and the debilitating dependency of old age are all strongly linked to social deprivation. We can surely expect a huge upsurge in demand on the NHS – at a time when services are already overstretched.

As ever, it will be the disadvantaged who will miss out. The health inequalities gap is bound to widen and no amount of shifting the public health deckchairs, as envisaged in the public health white paper, can stop it. Indeed the distraction and planning blight that comes with the wider NHS reorganisation laid out in the Health & Social Care Bill can only add to the barriers faced by disadvantaged people.

The Health Secretary no doubt sees all this, but is determined to push his changes through, despite a barrage of opposition from many quarters. His view is that, whilst things will be tough in the early years, there are green Elysian Fields beyond. In the meantime, we can help him to get it right by responding to the White Paper consultations and cajoling our MPs to amend the Bill as it goes through Parliament.

A key issue is the ring-fenced budget for public health, particularly for the health improvement element that will be passed to local authorities. We don’t yet know the size of the ring-fenced allocation at national level, although a figure of about £4billion has been bandied about. That sounds a big number – but by the time the many millions have been taken out to support the work that the Health Protection Agency is currently doing, and the National Treatment Agency for Substance Misuse, and national campaigns, and various other central initiatives, the amount distributed to local level will be much truncated.

And then that local pot gets divvied up between the Public Health England unit, public health support to GP consortia, prevention activity by GPs, immunisation, screening, drugs and alcohol, child health checks, health visiting, etc etc – the list goes on. So, what will be left to hand over to local authorities to tackle the health and wellbeing agenda? Not a lot, I suspect. Local authorities (and their Directors of Public Health) will be taking on a huge added responsibility with very little resource to throw at it. More for less indeed.

And those LAs struggling to improve their health outcomes because of challenging demographics could find themselves further disadvantaged by the Health Minister’s proposed ‘health premium’ scheme. The intention is to reward only those LAs who ‘make significant progress’ towards better outcomes, including reduced health inequalities. But those of us who have worked with multi-deprived populations know how difficult this can be, despite heroic efforts, without major demographic change. Although we’re told the health premium assessment would take deprivation into account, there’s every chance that yet again it would be the more disadvantaged populations who miss out on any extra funding. So much for improving the health of the poorest fastest. No, as bright ideas go, I can’t help thinking this isn’t one of them.

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