Support from next door, not advice from above

It’s not that often that I sit on a platform with Professor Mike Kelly, Director of the Centre of Public Health Excellence at NICE on my right and the Rt. Hon. Stephen Dorrell MP, the Chair of the Westminster Health Select Committee, on my left. Especially when I have the job of explaining Scotland and its health and social care system to a well informed and diverse London audience – and in only 15 minutes. This possibly unique experience happened to me on July 13^th at a summit held at The King’s Fund on Public Health System Reform

This was one in a series aiming to review the English public sector reforms, in this case concerning public health. The driver to this, the White Paper, Healthy Lives, Healthy People: our strategy for public health in England instructs local authorities to take the lead in public health through existing Health and Wellbeing Boards, that bring together the NHS, council staff, elected members and others, to commission and provide some NHS services, social care and children’s services for local communities.

All the speakers, from those wholeheartedly supporting the reforms – step forward Anne Milton MP, Parliamentary Under Secretary of State for Public Health and Tim Baxter, from the Public Health Development Unit in the Department of Health – as well as those more pragmatic about yet another set of massive system change, confirmed unsuspectingly what I wanted to say.

My brief was to explore how Scotland differs from the rest of the UK in terms of health governance; the links between the Government, the NHS and local authorities; the way we do partnerships and the way we think about the public sector. By the time I spoke the contrast was more than obvious. One of my arguments was that Scotland always was different in health policy and in how we organised to address public health and to tackle health inequalities, but devolution has brought that into stronger relief.

As Scott L Greer, Assistant Professor of Health Management and Policy at the University of Michigan, Senior Research Fellow at the London School of Economics, and renowned author on territorial issues and health policy notes, much of that diversity relates to the (now very different) politics of the devolved governments and of Westminster. As he commented in his Nuffield Trust report ‘Health and Intergovernmental Relations in the Devolved United Kingdom’ (with Alan Trench) ‘Policy-makers in health have an extensive range of powers in each jurisdiction, and so devolved policy-makers enjoy extensive autonomy in health policy (especially in Scotland)’.

Within Scotland, all governments since devolution in 1999 have prioritised – and acted upon – public health and the importance of reducing health inequalities depending on the wriggle room available to them. The UK Government’s responsibility for major policy areas like defence and welfare has undoubtedly made governance around health important in Scotland. Some of this is for plainly obvious reasons, as well as because of the centrality of other factors including public affinity for, and wide spread employment in, the public sector.

The very direct links between the Scottish Government and the NHS and local authorities are critical as I mentioned in my talk at The King’s Fund. Flat systems mean arguably closer accountability and potential collaboration across the system, and a variety of strategic partnerships aiming to implement national policy have developed in Scotland in recent years. There are a range of views on their success, with the recent Audit Scotland report sending some strong messages on the functioning of community health partnerships for example.

Speakers from England described attempts to move closer to a health and social partnership model, with enhanced Health and Wellbeing Boards possibly evoking Community Planning Partnerships. But it struck me how challenging – and counter-intuitive – this will be to deliver alongside the English NHS that, despite the still quiet aftermath of the recent pause, is based on an internal market, ‘consumer’ choice and competition. Commitment towards improving public health and understandings of the devastating impact of health and social inequalities seems genuine from key players, but as one questioner asked the Minister from the floor ‘If Health and Wellbeing Boards are going to be doing joint commissioning, based on an outcomes framework, might it be better if they were based on shared outcomes?’

Evaluating the importance of partnership as a process as well as a method of achieving something greater than the sum of its parts is the test by which many partnership structures are judged, and the role of Public Health England in this instance appears huge.  Delegates expressed concerns about public health as a speciality and whether its broader interpretation of health, and understandings of the social determinants, are fully aligned to this new culture. The fact that the governing board of Public Health England is not currently required to include anyone registered in public health appears more than an oversight, as a recent letter from the Faculty of Public Health to Andrew Lansley set out.

The next few years will see significant change in how healthcare is delivered in England, and how it interfaces with social care. How Public Health England, which will be part of the UK Government, can manage the massive level of resources and the wide range of players will be fascinating to watch – from a safe distance well across the border. As one delegate said, in relation to the UK system, ‘it’s more about support from next door, not advice from above’.