Public health faces a fresh start

Public health faces a fresh start It's year zero for a new public health world. How have things changed since the transfer of responsibility?

Since the transfer of responsibility for public health to councils about five months ago, directors of public health in England have worked in upper-tier local authorities.

My job is in Hertfordshire, a county of 1.1m people, with 37 settlements, 10 district councils and a public health system that was really designed for unitary local government.

Some of us are very new to local government, and in a variety of places we are tasked with leading our local authorities and partners to deliver improvements to the health of the population. It can feel both exciting and slightly scary.

For most of the peers I have spoken to (around 45 in the last six months) about how transition has gone, this is essentially year zero for the new public health world.

We are all busy taking over NHS contracts and getting them where we want them to be, while grappling with the fact that for many of us the finances don't stack up without considerable support from partners.

Most of us need some support in adapting and applying our skills and portfolios as leaders. We are learning how to become capable and expert officers working well with strong political leaders. For some of us the journey is smoother than others and we recognise our local authorities have had to work hard too to make this happen.

The challenges facing us are significant. We need to do more to give our children a healthy start in life.

Our working age population is not as healthy as it needs to be to reach old age without considerable cost to the public purse from disease-related disability. The inequalities in life expectancy and disease free life expectancy between richest and poorest and for people with learning disabilities, offenders and people with severe mental health challenges sometimes feel like they're ineradicable.

However, I still think the opportunities are immense, and that they far outweigh the challenges. My peers here and in other councils tell me, as I also hear from partners locally, that there is a real realisation across NHS, county councils, district councils, third sector and criminal justice sector we are all in this together.

In Hertfordshire we are already building a public health partnership with district councils, third sector, Healthwatch, NHS, police and crime commissioner, probation and university as core partners. I know I cannot deliver public health without them.

So where are we going?
Everyone seems to have slightly different starting points but public health teams and partners seem to be getting everything in order. The best partnerships take consideration of the following:

• The opportunity to apply and test thirty years of theory and evidence on health inequalities . Our current public health challenges are a complex manifold of structural, system, behavioural and environmental challenges. Everyone has a bit of the answer. One thing the new – if fiendishly complex – system seems to be doing is spurring people to relationships not structures as a way of building public health strategies and systems.

• Public health must be put at the heart of local leadership. This is a massive opportunity for elected politicians as well as officers. How well we do this is a test of our mettle and a sign of our success in local government.

• We need to get back to people-centred public health, where we build the new system around peoples' lives and experiences, and support people to do things for themselves and with each other. Community agencies come into their own here.

• The potential of the new system needs to be considered. The sheer scale of expertise and influence which Public Health England can lever at national level and the similar scale of local delivery which directors of public health and partners can make happen at local level bode well, if we each remember clearly what we are best at.

• A number of areas are getting to grips with how to layer public health interventions across populations (targeting young smokers as well as manual and routine workers, for example) and across time (short term interventions to get people into public health services, with longer term behavioural solutions to keep people resilient.) This can only be promising.

• Networks are springing up. Counties are talking to each other about making public health work in two-tier areas. Districts are talking about their contribution. Public health teams are benchmarking themselves against each other on topics like school nurses and excess deaths. It might be informal, but it's happening.

All of this requires an enduring vision, and an ability to see beyond two years. But all of it is a sign that public health is alive, broadening its influence and alliances and recruiting new advocates.

You may find this naïve, annoyingly up-beat, hopelessly idealistic or perhaps grimly determined in the face of reality. And perhaps all that is true. But if you find a better way, I'd love to hear it.

Jim McManus is director of public health at NHS Hertfordshire and Hertfordshire county council. The Guardian