The NHS Plan is not the saviour of Public Health. Nor will it be delivered without it. A presentation to an invited discussion on system issues in public health

1. Major System issues in Public
Health
The Long Term Plan will not be delivered without,
nor be the saviour of, Public Health
17th January 2019
Professor Jim McManus, FBPsS, CPsychol, CSci, FFPH, FCIPD
Vice President, Association of Directors of Public Health
Director of Public Health, Hertfordshire County Council

2. • The NHS Plan confused by some as a Major
Public Health Tool
• That “Prevention Vision”
• Reorganisation of functions
• Let’s Review Commissioning without putting
any money in it
• Nostalgia and “Glory Days”
• A Population Health Management discourse
focusing solely on Clinical measures
Weapons of mass distraction

3. Teenage Pregnancy – 60% drop since
1998. Why should you care?
• Multiagency –
CANNOT do public
health without
each other
• Shows what Third Sector,
LAs, Schools and NHS can
do together
• every young mother
returning to Education,
Employment and
Training saves agencies
£4,500 a year
• For every child prevented
from going into care, social
care saves on average
£65,000 a year

4. • Individual Responsibilty doesn’t work at
population level. Never Has
• Has been ditched by most developed and
developing economies
• Remains enshrined in England
– Our Healthier Nation 1998
– Choosing Health 2004
– Prevention Vision 2018
The bulk of prevention sits outside the
NHS

5. A County Lifecourse Offer
Perinatal health
Mum’s Vitamins
Health Visiting
Eye and ear tests
Family Centres
Education
CAMHS
Ed Psychs
Fostering
Culture, Libraries, Sport, Planning, Waste Disposal, Transport, Road
Safety, Economy, Environment, Waste, Sexual Health, , Social Care,
Addiction Treatment, Carer Support
Social Care
Youth Connexions
Youth Justice
Education
Safe and Well
Enablement
Safe and Well
Economy
Carers Support

6. The NHS Lifecourse Offer
Immunisations
Vaccinations
Screening
Paediatrics
GP
Urgent Care
Elective Care
Accident and Emergency, Primary Care, Diagnostics, Hospital, Mental Health Care,
End of Life Care
Primary Care
Carers Health
Checks
Long Term
Conditions
Urgent/Elective
Primary Care
Frailty
Rehabilitation

7. Key Point
The World Bank Priorities remain our goal
The NHS Plan is not and never will be the
answer to Public Health issues facing England.
Other UK governments have seen this for their
countries

9. https://www.local.gov.uk/social
-determinants-health-and-role-
local-government

10. Major Issues
• The dual standards discourse
of outcome
• Funding
• The Spending Review
• Fragmentation – been there
since 2005
• Powers
• Contradictory discourses
– NHS Plan
– Clean Air Strategy
– Serious Violence Strategy
World Bank Priorities
1. best start in life
2. Enable all to maximise their
capabilities and have control
over their lives
3. Education, training,
employment and good work
for all across the whole
lifecourse
4. healthy living standard for all
5. sustainable places and
communities
6. Strengthen role and impact
of prevention
Focusing on a wider game….

11. 70% of causes of ill health are social or
environmental - 100% of solutions in
NHS Plan are clinical
• Will make a contribution but will not deliver what we
need
• Discourse that “local government is not delivering”
• Yet worst performance is in Section 7A performance
THE NHS PLAN

12. • Analysis due to be published in February shows
80% of public health outcomes down to local
authorities have either improved or stayed stable
since Transfer
– Contrasts sharply with Section 7A Outcomes
• Added Value of our sectors from evidence
– Housing
– Schools
– Nutrition
• Most DsPH atttribute this to partnership with
Providers
• NHS England outcomes meanwhile have slipped
Yet….Impact and Value

13. • NHS England
– Style Issues
– Parallel processes
– Wasted costs
• PHE
• Systems approaches
– Some places are better at eating parts of the
elephant than others
Culture and “Partnership”
These distract us from
the working effectively as
a system to address the
real priorities

14. • Prevention needs a systems approach to work
– Focus and differentiation not control enthusiasm
• Prevention needs LAs and 3rd Sector to work
• Cost and demand IS being displaced to NHS and
Police
• We are building unsustainability into the system
• Procurement and Partnership
System Issues

15. • Individual Responsibilty doesn’t work at
population level. Never Has
• Has been ditched by most developed and
developing economies
• Remains enshrined in England
– Our Healthier Nation 1998
– Choosing Health 2004
– Prevention Vision 2018
The bulk of prevention sits outside the
NHS

16. • National Diabetes
Prevention
Programme versus
local programmes
• National Child
Measurement
Programme
• Sexual Health
• Teenage Pregnancy
• Primary Care
Outcome Variations
Local government and Third Sector do
it better than the NHS, and cheaper
451,910 455,234 455,368
440,145
423,352 422,147
300,000
350,000
400,000
450,000
500,000
Number of new STI diagnoses in England
2012-2017
2940779
3100928
3140492
3227254
3323275
2,700,000
2,800,000
2,900,000
3,000,000
3,100,000
3,200,000
3,300,000
3,400,000
2013/14 2014/15 2015/16 2016/17 2017/18
Total number of attendances at sexual health
services 2013-17

17. Liver Disease Premature Deaths

18. NHS Funding 2018-2024 (£bn)
2018-19 2019-20 2020-21 2021-22 2022-23 2023-24
114.6 121.8 128.16 134.4 141.08 149.01
0
20
40
60
80
100
120
140
160
2018/19 2019/20 2020/21 2021/22 2022/23 2023/24
Additional Pensions funding
Growth in real terms after inflation
Cash terms funding

20. There is an NHS Facing task: Reducing the need and
spend curve: Preventing avoidable spend in public
service
Highest cost.
Reduce
and delay
Need here
Reduce or delay need here
Intervene here before need
escalates
Volume of
spend
Severity of need
Existing curve
Potential curve

21. Thank You!
Jim.mcmanus@hertfordshire.gov.uk