Healthy Lives, Healthy People Better Health, Fairer Health

1. Healthy Lives, Healthy PeopleBetter Health, Fairer Health

2. Thematic similarities and differences • Mechanisms for change • Agreements & conflicts • Opportunities & threats • Credibility

3. Themes • Economy, Culture, Environment • Mental health & wellbeing • Tobacco • Alcohol • Obesity, diet, physical activity • Prevention, fair & early treatment • Early life • Mature & working life • Later life • A good death

4. Papers to come • Winter 2010/11 • health visitors; • mental health; and • tobacco control. • Spring 2011 • Public Health Responsibility Deal; • obesity; • physicalactivity; • social marketing; • sexual health and teenage pregnancy; and • pandemic flu. • Autumn 2011 • health protection, emergency preparedness and response.

5. Also to come: • Child Poverty Strategy (HM Government); • Drugs (HM Government); • Public Services Reform White Paper (HM Government); • Alcohol pricing and taxation (Her Majesty’s Government); • Response to the consultation Rebalancing the Licensing Act – on empowering individuals, families and local communities to shape and determine local licensing(Home Office); • Crime Strategy (Home Office); • Social Mobility White Paper (Cabinet Office); • Welfare White Paper (Department for Work and Pensions);

6. Also to come: • Special Educational Needs and Disability Green Paper (Department for Education); • Munroe Review of Child Protection (Department for Education); • Graham Allen Early Intervention Review (Department for Education); • Local Transport White Paper (Department for Transport); • Road Safety Strategy (Department for Transport); • Natural Environment White Paper (Department for Environment, Food and Rural Affairs); • Sentencing and Rehabilitation Green Paper (Ministry of Justice); • Skills Strategy (Department for Business, Innovation and Skills).

7. Thematic differences • Includes a focus on: • Health protection issues • Drugs • Sexual health • Does not include: • Emphasis on regional policies (notably economic) • Emphasis on environments as shapers of choice – far more focused on individual choice • Role of the NHS • Differences relate more strongly to • the philosophy of strategy • mechanisms of influence

8. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

9. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

10. Research • NIHR will continue to take responsibility for the commissioning of public health research on behalf of the Department of Health, working with partners whose actions affect public health. Public Health England will work closely with the NIHR in identifying research priorities. To further develop public health research the Department will: • establish an NIHR School for Public Health Research – conducting high-quality research to increase the evidence base for effective public health practice. This school will draw on leading academic centres with excellence in applied public health research and evaluations and place emphasis on what works practically and can be applied across the whole country; • continue to promote a public health focus within the NIHR and fund, from within the Department’s Policy Research Programme, a new Policy Research Unit on Behaviour and Health; and • ensure that Public Health England provides the necessary resource to support the cost of public health interventions that are undergoing research outside of the NHS.

11. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

12. Social marketing • Central government will sequence social marketing for public health through the life course so that, at each stage in a person’s life, there is a meaningful and trusted voice. We will also scale back the number of brands that we support. We will trial new ways of changing behaviours, using emerging ideas from behavioural science, such as the use of social norms, changing defaults and providing incentives. We will publish a social marketing strategy, setting out our plans in more detail, in spring 2011.

13. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

14. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

15. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity – the BIG SOCIETY? • Governance

16. Mechanisms • Policies and planning • Research and development, analysis • Advertising and social marketing • Service redesign & funding • Performance management of services • Lobbying activity • Governance

18. Governance • Existing structures are not fit for purpose since: • They reflect a system that includes a regional administrative tier • Support for RAGs cannot be sustained under existing arrangements • RAGs cannot advise an RDPH if there is none • However: • Some things will continue to be done better and more efficiently at a supra-district level

19. Agreements • Life course approach • Shift of emphasis away from the NHS • Ring fenced (identifiable) budgets • Focus on evidence • Cross-sectoral and upstream emphasis • Importance of well-being and autonomy • Marmot support • Many specifics (key drivers of ill-health and inequalities) • “Nudge” thinking echoes what we have been doing

20. Nudge Compulsion De-normalisation

21. Conflicts • No regional working • Civil service ethos? • Avoidance of regulation • Potentially excessive trust in choice and markets • Much looser on performance

22. Opportunities • Genuine upstream opportunities • Closer positioning should allow greater influence on key effectors in local policy • Ring-fenced budgets (double-edged) • Continued focus on inequality and child poverty

23. Threats • Loss of NHS influence • Agenda dominated by NHS change • Loss of population perspective in favour of individualism • Austerity – threat to public and third sectors • Downgrading of public health as a specialty • Loss of staff / lack of skills / damaged morale • Incoherence • Bad decisions • Credibility of policy

24. Credibility • Radicalism is essentially structural rather than content-related • Excess winter deaths • “The Warm Front scheme will also continue until 2012/13, providing grants to improve housing warmth and sustainability” White Paper Nov 30th 2010 • “Warm Front payments suspended” Daily Telegraph Dec 15th 2010 • “There are also some activities that it makes sense to do once at national level rather than repeat many times over at local level” – paragraph 2.26 • Inclined to dress political choices (health visitor numbers, Olympic ‘legacy’, convenience store roll-out etc) as responses to evidence

25. Credibility • Uses theoretical structures that are not in accepted use • Weak on the role of the NHS • Central management of policy • Equivocation on point of sale advertising • Closeness to industry (e.g. Knighthood for the CE of British American Tobacco, closeness of some senior ministers to tobacco and alcohol) • Cessation of NICE programs / shelving of evaluations:

26. Removed from the work programme: • Preventing unintentional road injuries among under 15s: education and protective equipment • Preventing unintentional road injuries among young people aged 15 to 24 • Spatial planning for health: local authorities and primary care trusts • Tobacco - how PCTs and local authorities can combat markets in illicit products • Tobacco - how retailers can provide information and support when selling nicotine replacement products over the counter • Tobacco - how commissioners and providers can develop and implement policies on smoke-free homes, cars and other vehicles

27. Suspended: • Social and emotional wellbeing of vulnerable pre-school children - home-based interventions; and: • Social and emotional wellbeing of vulnerable pre-school children - early education and childcare (To be combined and reviewed once the Prime Minister's taskforce on early interventions has reported.) • Contraceptive services for socially disadvantaged young people; and: • Personal, social, health and economic education focusing on sex and relationships and alcohol education (To be reviewed following the publication of the White Papers on Public Health and Schools) • Preventing obesity using a ‘whole-systems' approach at local and community level (to be reviewed as part of the obesity strategy / work programme.)

28. Under review: • Increasing fruit and vegetable provision for disadvantaged communities • Identification and management of overweight and obese children in primary care • Preventing domestic violence: guidance for the police, social services and the NHS • Reducing infant mortality among children born to women aged under 20 and living in disadvantaged circumstances • Developing transport policies that prioritise walking and cycling • Using the media to promote healthy eating: guidance for policy makers, food retailers and the media • Identification and weight management for overweight and obese children: community based interventions • Tobacco - smoking cessation services provided by NHS secondary care providers for patients with long-term and chronic conditions in hospital and the community

29. Confirmed: • Skin cancer prevention: information, resources and environmental changes • Increasing the uptake of HIV testing among black Africans in England • Increasing the uptake of HIV testing among men who have sex with men • Type 2 diabetes - preventing pre-diabetes among adults in high-risk groups • Type 2 diabetes - preventing the progression from pre-diabetes among adults in high risk groups • Identifying and managing tuberculosis in hard to reach groups • Hepatitis B and C: ways to promote and offer testing to people at risk of infection • Tobacco - harm reduction approaches to smoking cessation for PCTs and NHS Stop Smoking Services • Tobacco - commissioning and providing smoking cessation services for people using smokeless tobacco

30. Conclusion • Many overlaps with content of BHFH • Sustaining focus will be difficult • Who will own and support infrastructure? • Financial arrangements • National policy in practice may differ from what is being anticipated