DEREK WANLESS is the man who persuaded the Treasury to invest an extra £40 billion in the NHS by 2007/8, so his report on public health, which was published at the end of February, was both eagerly and nervously awaited.
In the event, Wanless part two – while getting plenty of media coverage – generated few dramatic headlines. There were at least two reasons for this. First, the report is very much about what needs to be done to get the public health “delivery chain” working better. Its recommendations are important and make lots of sense but analysis of the machinery of policy implementation isn’t likely to excite lay people. Second, the report is markedly reluctant to make firm recommendations in areas where there are other reviews going on – for example, the Department of Health’s review of arm’s length bodies and the consultation on a new public health white paper.
It’s useful to go back a step so as to put the new report’s conclusions into context. The original Wanless report depicted three scenarios: slow uptake, solid progress and fully engaged. The fully engaged scenario saw high levels of public engagement in health, a responsive NHS – particularly on disease prevention – and a more efficient use of resources. Wanless argued that fully engaged was the scenario to aim at: it would cost more in the short to medium-term but it would provide better value in the longterm through better-than-trend increases in life expectancy, and improvements in health status, and an NHS more orientated towards keeping people healthy.
Crucial to achieving the fully engaged scenario was effective – and cost-effective – action on preventing disease, tackling the wider determinants of health, and reducing health inequalities. These themes became the remit of the second Wanless review.
The conclusions of the new report in a nutshell are that current activity could set us on course for the solid progress scenario but that a “step change” will be required to get us to the fully engaged scenario. A recurring refrain is the failure to turn a substantial body of public health policy statements into effective action – we’ve known for 30 years about the major drivers of public health, but health policy is still about the “national sickness service”.
There are over 30 recommendations in the report but they cluster around certain key themes. One of these clusters is around the need for more evidence about the effectiveness of public health, in particular its cost-effectiveness. The HDA’s evidence base is already providing evidence on what works to prevent ill-health. The HDA fully endorses the report’s vision of a future where choices about the balance of investment in prevention or treatment can be made on the basis of comparable information about the cost-effectiveness of both options.
Importantly, our evidence base also flags up the gaps and weaknesses that should be the focus for further research. So we support Wanless’s call for a more structured and coherent approach to public health research, almost mandatory economic evaluation of public health initiatives, and clarity about who should be responsible for developing the evidence base on cost-effectiveness. The HDA would welcome an extension of its remit to undertake cost-effectiveness studies and has already started work on appropriate measures of effectiveness across interventions.
Another cluster of recommendations is about the performance management of public health. Wanless wants all levers that will transform the NHS into a genuine health service to be pulled, hence his recommendations that government should define quantified objectives for three and seven years ahead, that strategic health authorities (SHAs) should have a stronger role in performance managing the public health function in PCTs, and that the new health care inspectorate – the Commission for Healthcare Audit and Inspection (CHAI) – should be robust in assessing the public health performance of SHAs and PCTs.
Particularly pleasing is the report’s endorsement of the contribution of local authorities and a “joined up” approach to performance management. For example, it wants councils’ local public service agreements to include health and health inequalities targets. It sees the inclusion of community health targets in the comprehensive performance assessment (CPA) for local government as highly significant. And it calls for performance management of partnership working by both PCTs and councils.
A feature of the report that has attracted attention is the discussion about how people’s lifestyles can be changed. Wanless acknowledges the importance of the wider determinants of health, but focuses on major lifestyle risk factors – smoking, physical activity and obesity. “Full engagement” means giving people access to high quality, personalised information, advice and increased support to take vital health and lifestyle decisions. The report steers a skilful course between nanny state and Pontius Pilate in arguing for a principled approach to improving “health literacy”: government should engage in debate with the public and be open about its reasons and aims when proposing to use policy instruments to change behaviour.
This final Wanless report has created the climate for the new public health consultation. The whole Wanless process has opened up great possibilities for public health. But it also challenges public health organisations and professionals to do better over the next 30 years than they have in the last 30.
