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Public Health

The prevention green paper, five out of ten

Thoughts.

What others said

The Kings Fund press release is unflattering. The blog that followed highlighted the difference between rhetoric and reality.

The ADPH response was in a similar space, commenting on some positive aspects but overall it falls short in crucial areas.

The LGA highlighted the paper containing some ambitious and interesting ideas, but it is a missed opportunity to make the most of councils’ role and expertise in meeting our shared vision for a healthier nation

The story on HOW it got out is probably far more interesting. A similar story in the Guardian

 

My first pass

My initial skin led me to a comment it is basically more of the same old same old – Precision this, genomic that, personal responsibility, predictive prevention (whatever that means). There’s a lot of unfounded, un evidence based of actually debunked ideas in there. The notion that greater personal responsibility for health would lead to big gains was last laid to bed in the 90s. In many respects it might be characterised as a contemporary reboot of Our Healthier Nation from the early 90s, but with gizmos and genomics.

I’m sorry or have to say it, as I know many exceptionally skilled civil servants will have worked hard on it, but I didn’t find that it lit my imagination with new possibilities.

My second read

I re read it. There ARE some important ideas in there. There IS much to cheer content wise, and many eye catching proposals. Whether they ACTUALLY make it over the line given the seeming opposition of PM and those other corporate, commercially, ideologically opposed factions is debatable.

Whats NOT in it, or bits that are misframed are arguably more important?

From a local government perspective it is rather thin gruel as was prominently said.

Here i dwell on some of the things that concerned me

 

Framing

1.What’s there is overly NHS oriented model of “prevention”. The narrative is over located “prevention” in “health”…. We should frame in far broader context of economy and social justice of which “health” (read NHS) is one component part

2.There is passing acknowledgment of cross government approach being needed. Ideally this should be the responsibility of the Cabinet Office, not DHSC (this is played out locally with public health responsibilities in local government). Where’s the input of HMT, Home Office, DfT, DfE, DHCLG, DWP, others…. All have highly legitimate roles in “prevention”, whether in a health gain context or other contexts.

3.There will be mid framing of this in the minds of senior players. “Prevention” will be seem a subset of the big important stuff in the NHS. We don’t have a “treatment” green paper.

4.It’s largely framed as a list of stuff vs way of organising thoughts and action. A “thing or set of things to commission”, it isn’t a “service”, it’s a way of thinking about things. It can and should be applied to all aspects of an organisations activities.

5.The word prevention causes problems – talks about asset based approaches, but then falls into trap of “designing services around user need” – this is not asset based.  This blog from NLGN is good on this

6.“Put prevention at the heart of decision making” – what does this actually mean for, say, economic development?  This really needs unpicking, and probably new measures defining to change the questions we ask

7.Not clear enough on what we mean by living in poor health – this is not about cancer by and large

8. A lack of any coherent narrative around inequality in health (certainly beyond the NHS oriented model)

9.“Which health and social care policies should be reviewed to improve the health of people living in poorer communities, or excluded groups?”  I don’t think it’s principally the health and social care policies that are the problem

10.An Absence of looking for win wins – “Policy priority is helping people to achieve a healthier weight, eat well and stay active”  This should mean major commitments to active travel, with pay offs on e.g. clean air, also on congestion and thus economic growth

Individualisation vs social policy

11.How it is landed will play into the wrong public narrative that prevention is about precision, genomics not social policy. Need to expand public understanding of the role that government can play to improve health outcomes – beyond NHS funding and limited regulation of unhealthy commercial practices or environments.  

12. A lot is narrowly focused on lifestyle / individual level interventions and individual responsibility (often at the expense of upstream structural policies). Need to more explicitly acknowedge and address commercial determants of health at policy level. Not focused on behavour change, but toxic environment. Obesity is an entirely normal response to the environment around us, and isnt about “lack of willpower”. See this link from Harry Rutter.

13. The same can be said of SDOH……. Back to whole of govt approach?

14.The paper greatly underplays asset based/ community oriented stuff, coherent place based responses – due to focus on “lists” and topics / conditions of interest. The passing reference to Wigan at the end is very helpful…. But arguably might have been an orgainsing theme. the response needs to demonstrably understand the literature about shifting the focus from paternalism to asset based models

Resourcing

15.But continued evisceration of local govt (no let up in sight) and ongoing cuts to PH Grant funded services in that context are not consistent with the narrative (that’s being kind)

16.The Impact of austerity induced stripping of preventive interventions isn’t covered. Has had massively differential impact on those most vulnerable at individual, family, community and city level. Data on this crystal clear

17. If local authorities are so important you need to fund them properly – without that all those assets that are crucial to promoting health will wither away.  Also a social care green paper would be nice

Many others have made these points. It IS the elephant in the whole paper

Implementation

18.There’s limited to no focus on PLACES, and a lot of focus on silo responses by institution, by “topic”, or service by service. Place based stuff is massively underplayed – doing the right thing for people in a place, agnostic of institution. The duty on local government is to improve well being and to improve health and not “provide some services or interventions”. This is underplayed.

19. Everyone wants “more prevention”. Few are actually making investments. Dave Buck has already pointed out, key will be what follows inc local gov funding settlement, NHS Plan, green paper and what of that gets to spending review. Build the organisational machinery, finances, targets so this becomes the norm and default

20. A response needs to demonstrably understand the literature on complex adaptive systems. Apply this to policy. This stuff can’t be commanded and controlled

21.It CAN be done, but not for free. The study by Ben Barr and others on the impact of a deliberate strategy. Admittedly with Heavy funding, focused effort, careful targeting, coverage of high impact interventions, Study on life expectancy gap, and the Infant mortality gap

Specifics.

22. As I say, lots of specifics to cheer. But many concerns, I’ve focused on the latter.

23. Some of the specifics I wasn’t as keen on

24. Lack of focus on the environment – not green, but the space in which action is taken

25. Screening section – screening has downsides too.  There is a point about recommendations being developed in coordinated way. Erm….. the NSC?

26. Health Checks – why is there no option to “stop it, it is poor value for money”?

27. Nature based interventions as part of the strategy for preventing and treating mental ill-health – yes, this is a good thing – but again parks and green spaces are a victim of LA cuts – and generally access to green space is inversely related to deprivation – so not clear this will deal with inequalities

28.  On active travel again – absence of challenge to the rest of government – commons transport committee report on DfTs modelling out today says its skewed in favour of motorists, will this change? (p.25)

29. Smoking “Given the pressure on local budgets, government is considering other ways of ensuring people can get the help they need” – that pressure remains a choice not a necessity and that choice could be changed whenever government felt like it

30. Breathing space around debt is a good thing and should be supported

31. Social prescribing – it remains the case that the NHS approach to this is effectively to support the writing of prescriptions without supporting the thing that is prescribed – analogous to just not paying for drugs anymore.  This is not sustainable.  Social prescribing is not free – you can’t just broker relationships, you have to fund the actual activity too.

32. Cold homes etc – what role have welfare changes played in this?

 

What SHOULD it focus in on?

33.If I HAD to write about specific things from where I sit in my place they would be these – 1. Ensuing the economic strategy is focused on health as a determinant of economic performance. 2. First 1001 days. I might stretch that a little further and get into school improvement / education attainment. 3. ACEs – whole of govt approach. Scots well ahead. Ditto Welsh. 4. Person centred model of care delivery, or in other words an asset based approach. Individual level (frontline care), neighbourhood and city level (ABCD etc). 5 Building well being into all policy.

34.Our own approach to “public health” is basically (in order of importance) 1) reframing, redefining approach to inequalities; 2) addressing the social determinants of health by building health into all policies; 3) addressing the commercial determinants of health; 4) ensuring robust arrangement for health protection; 5) ensuring we fulfil the legal duties of the DPH and the mandated services within the PH grant. We have quite a “wide” interpretation of the term “public health”.

Institutional traction

we can do more do to help local authorities and NHS bodies work well together?  Starts at the top. It seems obviousl that height DHSC nor NHSE don’t “get” LAs. They will need to allow for more shaping from local areas and less top-down direction.  LAs won’t come on board to be told what to do by NHSE

Fundamentally – this should be a cabinet office green paper, not a DHSC one.  

There’s an opportunity to put some support behind HWBs again as core players. This would signal a significant acknowledgement and shift in balance

 Of course we should all max out on the powers of local govt. on powers, the general power of competence and duty on wellbeing gives all the powers an authority would need. Resrouces to execute powers is a dealbreaker. See above points. Understanding and harnessing of those powers is also important.

The Welsh stuff and the NZ approach. Welsh Statutory guidance on the future generations act is excellent I’ve seen it Framed as the most important bit of “public health” guidance  you will ever see

These are only quick thoughts

I’ve tried to be glass half full, but keep looking at the bottom of the glass.

The rhetoric is ok in parts, inadequate in others. The reality will require ceasing and putting right the emasculation of local government and a true whole of government approach to health.

 

 

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2 replies on “The prevention green paper, five out of ten”

the aim is to prevent mental illness.

an allegory could be someone who wants to travel from A to B.

the public health community are insisting on giving that person all sorts of wide perspectives and thoughts on potential forms of transport including jets, ferries, etc etc

why not just actually give that person a bicycle

i.e. propose a specific, do-able intervention

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