The National Institute for Health and Care Excellence (NICE) will publish quality standards for public health, starting with smoking, alcohol use and obesity.

The Institute will work with experts from Public Health England to develop standards for prevention and treatment at the public health level, now the responsibility of local government.

It is anticipated that the implementation of these standards will help to reduce the burden of diseases related to tobacco, alcohol and obesity on the NHS.

They will be based on existing NICE public health guidance, but will be focused to drive and measure improvements in public health outcomes.

Smoking, excessive alcohol intake and obesity are linked to both acute and chronic ill-health, and medicines feature in the treatment of all three conditions – with Lundbeck’s drug to prevent alcohol abuse, Selincro, being a major new example.

Speaking at NICE’s annual conference, Under-Secretary for Quality Lord Howe said: “Public health quality standards alongside and integrated with those for health and social care will provide a key tool to support Public Health England, local authorities and the wider public health community in achieving excellence.

“Our vision is over the next five years there will be a growing portfolio of NICE quality standards covering all the domains in all three outcomes frameworks.”

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, commented that the new public health quality standards “will be a valuable tool for local authorities as they take on their new public health functions, and for Public Health England.

“By bridging the interface across health, social care and public health, NICE public health quality standards will help support integration across the three sectors.”

Local councils need to do more to cut sexually transmitted infections and reduce the number of unwanted pregnancies to improve levels of sexual health, the Government has said.

Ambitions outlined in the Government’s sexual health framework include greater efforts to prevent STIs and HIV infection and ensuring rapid and easy access to appropriate services.

Anna Soubry, Public Health Minister, said that despite improvements “sexual health in England could be a lot better.”

From 1 April, local authorities will be allocated a ring-fenced budget for improving the public health of their communities. The Government hopes this change in funding – combined with its framework – will improve local sexual health outcomes.

Although there has been a reduction in the level of teenage pregnancies across England, latest stats show an increase in new HIV infections and that rates of gonorrhoea and syphilis are increasing in some age groups.

The Government’s framework also highlights the need for an increase in the number of people in high-risk groups tested for HIV; the creation of an honest and open culture where people can make educated choices about relationships and sex; and for counselling to be available to women who request an abortion to discuss available options and choices.

“We want to encourage a culture which enables people to make informed decisions free from stigma, coercion and abuse,” said Anna Soubry.

“With the launch of Public Health England, there is a real opportunity for local councils to make renewed efforts to improve the sexual health of their communities.”

Health Secretary Jeremy Hunt has published strategy documents on tackling premature mortality and cardiovascular disease (CVD).

The DH strategy on premature mortality calls for improvements in the prevention, diagnosis and treatment of cancer, heart disease, stroke, respiratory disorders and liver disease.

The CVD strategy emphasises treating CVD as a single family of diseases with integrated NHS treatment, and making wider use of NHS Health Checks.

Hunt pointed to a current report in the Lancet, according to which the level of premature deaths in the UK has fallen in the last decade but remains higher than in most of Europe.

He claimed that the measures outlined in the two strategy documents could save 30,000 lives by 2020.

Key actions outlined in the CVD strategy include:

• Providing integrated and co-ordinated care by treating CVD as a single family of diseases, and ending the pattern of ‘silo consulting’.

• Using NHS Health Checks to improve the prevention and management of CVD with targeted advice and support.

• Ending the postcode variation in treatment of CVD.

• Better detection and management of CVD risk factors such as atrial fibrillation.

Peter Hollins, Chief Executive of the British Heart Foundation, commented: “We welcome the Outcomes Strategy. It has all the ingredients to tackle the threat posed by cardiovascular diseases, which remain the major public health challenge of our time. We are particularly pleased to see the emphasis on an integrated approach to patients with multiple conditions.”

The strategy document on avoiding premature mortality argued that over half of premature deaths (under the age of 75) could be prevented through more effective public health.

It highlighted the need to address the increasing prevalence of multiple morbidities, where individuals suffer from two or more major conditions.

Alongside action on risk factors and lifestyles, the strategy called on the NHS Commissioning Board to facilitate early diagnosis and “access to the right treatment”, with consistency of outcomes between hospitals.

The document did not explain how, with hospitals that meet clinical targets but overspend facing closure, the emphasis on treatment quality would be funded.

The Government’s reform of public health funding means that the deepest spending cuts are occurring in the most deprived areas.

Public health budgets for local authorities are now correlated with average age rather than poverty, so the funding for 2014–15 has shifted towards wealthy areas where life expectancy is higher.

As commentators have observed, this policy – developed by former Health Secretary Andrew Lansley – appears designed to improve the relative public health provision enjoyed by Conservative voters.

Two-thirds of local authorities have seen a drop in their public health budgets of up to 43% relative to the levels set by the outgoing PCTs.

Lansley argued that basing public health funding on levels of deprivation was relevant only to a minority of patients – those “on long-term benefit” – rather than communities in general.

His analysis was recently contradicted by Duncan Selbie, the new Chief Executive of Public Health England, who stated: “Where you’re born is still the biggest determinant of how long you live.”

One of the wealthiest local authorities, Richmond upon Thames, has seen its public health budget rise to £40 per head where the outgoing PCT had set a target of £33 per head.

By contrast, Waltham Forest had a budget target for public health of £67 per head, but has been allocated only £42 per head.

Nicola Close, Chief Executive of the Association of Directors of Public Health, commented: “There’s only one health budget, so the more that is pushed towards public health, the more that has to come out of the zero sum budget from the Treasury.”

A spokesman for the Local Government Association said the two-year settlement would enable councils to “cover their statutory services”, but perhaps not to deliver the full anticipated public health service.

Urgent action by public health authorities is needed to address the rising prevalence of liver disease in England, the Chief Medical Officer has said.

Professor Dame Sally Davies noted that in the last decade, the incidence of liver disease has grown here by 20% while falling by a similar amount in Europe.

The CMO’s first annual report also highlighted the need for better access to healthcare and better public health surveillance as priorities.

The report is intended to guide and inform the public health strategies of local government and the new Health and Wellbeing Boards.

Drawing on international data, Davies commented that liver disease “is the only major cause of mortality and morbidity which is on the increase in England whilst decreasing among our European neighbours.”

The main causes are heavy drinking, obesity and undiagnosed hepatitis infection, but late diagnosis contributes to poor outcomes – so the report calls for a combined preventative and early intervention approach.

Variations in access to healthcare were also highlighted, with diabetes monitoring a particular area of concern – only 50% of people diagnosed with diabetes receive all nine NICE-recommended annual tests.

Public health surveillance was a third priority emphasised by Davies, who called for better information on significant but non-fatal diseases such as musculoskeletal and skin disorders, cognitive and sensory impairment, and incontinence.

In addition, she warned, cutting costs on public health surveillance could leave populations exposed: “The history of public health suggests that it is not enough to prepare for the health problems we already know about.”

Strikingly, Davies praised the contributions of the cancer registries and the Health Protection Agency – both due to be abolished in 2013.

Health spending is falling across Europe, leading to neglect of public health strategies, the Organisation for Economic Co-operation and Development (OECD) has warned.

The OECD report observed that austerity measures are leading governments to focus spending on acute care, while preventative strategies such as immunisation and smoking cessation are neglected.

Health spending per person in the EU has fallen from an average annual growth rate of 4.6% between 2000 and 2009 to −0.6% in 2010.

The UK is typical, with a drop in health spending of 0.5% in 2010 after a decade of annual growth at 4.9%.

Other countries further along the austerity road show a steeper decline – for example, health spending in Ireland fell by 7.9% after a decade of 6.5% growth.

As Shadow Chancellor, George Osborne stated in 2006 that Ireland’s economy was a model the UK should follow.

The OECD report notes that smoking and obesity are the major risk factors for cardiovascular disease, which caused 36% of all deaths in Europe in 2010.

Obesity rates have doubled across Europe since 1990, now at 17% of the population – and 25% in the UK.

“Governments under pressure to protect funding for acute care are cutting other expenditures such as public health and prevention programmes,” noted the OECD.

“In 2010, on average across EU countries, only 3% of health budgets were allocated to prevention and public health programmes in areas such as immunisation, smoking, alcohol, nutrition, and physical activity.”

The effects of this neglect of preventative healthcare will be seen in the coming years, the report warned.

The NHS Outcomes Framework 2013/14 has abandoned the draft document’s aim of setting ‘levels of ambition’ in relation to the outcomes.

The decision to avoid setting specific targets mirrors the NHS Mandate, which requires the NHS Commissioning Board to aim for “measureable improvement” across a range of objectives.

Like the final NHS Mandate, the new Outcomes Framework contains new objectives for improving the treatment of dementia and mental illness.

The key changes to the NHS Outcomes Framework include:

• The overarching indicator for reducing potential years of life lost includes a new measure referring to “children and young people”.

• The indicators for cancer survival are widened to include “all cancers”, in order to ensure that rarer cancers are not overlooked, as well as “all cancers in children”.

• To strengthen the focus on dementia care, there are new indicators for the diagnosis rate and the effectiveness of care in “sustaining independence and improving quality of life”.

• The indicators for mental health care include a new measure promoting access to psychological therapies for people suffering from depression and anxiety.

• A new ‘placeholder’ indicator focuses on improving “people’s experience of integrated care”.

The NHS Outcomes Framework sets the clinical objectives for CCGs to follow in commissioning services that meet these objectives as well as the financial targets set by the NHS CB.

The 2013/14 Outcomes Framework, for the first time, will appear alongside new outcomes frameworks for public health and social care services.

What does the Public Health Outcomes Framework reveal about the DH’s vision?

Public health is no longer the sole responsibility of one single organisation. Government reform through the Health and Social Care Act outlines how local authorities, the NHS, clinical commissioning groups (CCGs) and, more importantly, Public Health England (PHE) have now been tasked with improving the health of the nation. So how will it work?

PHE is the new, integrated and professional health system designed by the Government to be more effective and to give clear accountability for the improvement and protection of health within the community. The main function of PHE – along with its partners in the health service and in wider society – is to deliver support and enable improvements in health and wellbeing and to design and maintain systems to protect the population against existing and future threats to public health.  The new body brings together experts from a range of organisations, such as the Health Protection Agency, under one umbrella and gives local authorities and CCGs control over the public health budget – believed to be in the region of around £5.2bn – to improve regional requirements.

Public Health Outcomes Framework
For the first time public health will be measured against a devised framework allowing councils and the Government to track improvements and to take action where systems are failing.  From April next year, councils will be given access to a ring-fenced budget to tackle public health inequalities in the local population and meet Government targets. Councils who make the most improvements against desired outcomes will be rewarded with a cash incentive. 

Former Health Secretary Andrew Lansley said that the decision to move the public health budget away from Whitehall to local authorities was “absolutely right”.  He said: “We are giving local councils the money, the power, the right expertise and information to build healthier communities. Every area of the country is different so councils will be able to decide what the most important public health concern is for them and spend the money appropriately.”

A public health outcomes framework for England, 2013–2016 sets the context for the revised system from local to national level with one simple vision: “to improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest”.

It builds on the white paper Healthy Lives, Healthy People – published at the same time that PHE was established in December 2010 – and reveals that outcomes will be measured by a broad range of 66 indicators chosen by experts and grouped into four domains. The framework has two high-level targets: increasing healthy life expectancy, and reducing differences in life expectancy and healthy life expectancy between communities.

The Department of Health said the main outcomes “reflect the focus we wish to take, not only on how long we live – our life expectancy – but on how well we live – our healthy life expectancy, at all stages of the life course.”

Domains, objectives and indicators
The domains, which each have individual objectives, are:

• Domain 1: Improving the wider determinants of health
• Domain 2: Health improvement
• Domain 3: Health protection
• Domain 4: Healthcare public health and preventing premature mortality.

The framework makes it clear that although responsibilities have been moved away from central Government to local authorities, the NHS will still “remain critical to protecting and improving the population’s health” and “NHS clinical contribution is therefore central” to driving improvements.

In order to do this, the framework aligns with the Adult and Social Care Framework and the NHS Outcomes Framework through a series of shared or complementary indicators. The DH says that it intends to create an alignment with the outcomes framework through a series of set shared indicators that straddle domain 4 of its framework and the first domain in the NHS alternative. The shared indicators will be on premature mortality from specific areas of cancer, cardiovascular disease and liver disease.

The first domain in the public health framework has the objective to make “improvements against wider factors that affect health and wellbeing and health inequalities”. There are 19 indicators included, ranging from children in poverty to employment for those with long-term health conditions, including those with a learning difficulty/disability or mental illness and people with a mental illness or disability in settled accommodation.

Yet it is possibly in the other three domains where the pharmaceutical industry can exert greater influence and offer support. The objective of Domain 2 is to ensure “people are helped to live healthy lifestyles, make healthy choices and reduce health inequalities.” The 24 indicators here include a number that are relevant to pharma. These range from successful completion of drug treatment to cancer screening coverage and recorded diabetes- and alcohol-related admissions to hospital.

Improvements in these indicators will, in the main, be led locally by clinical commissioning groups through schemes devised or introduced to drive standards of public health.

Domain 3 has just seven indicators – although the framework says these are “critical” to protect the public’s health. Its target is to ensure “the population’s health is protected from major incidents and other threats, while reducing health inequalities.” Indicators that focus on Chlamydia diagnosis, vaccination coverage for the population, people presenting with HIV at a late stage of infection and treatment completion for tuberculosis are of clear significance for the pharmaceutical industry.

Domain 4 aims to reduce the “numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities.” Several indicators stand out as far as Key Account Managers should be concerned. Indicators including mortality from causes considered preventable, mortality from all cardiovascular diseases, and mortality from cancer, liver disease and respiratory disease call out for pharma’s expertise in creating innovative pathways of care, and of course its products.

The DH makes it clear in the framework that it is the responsibility of all healthcare providers to deliver improvements in indicators in this domain. 

Other uses
As well as driving standards of public health, the framework also supports health improvement and protection at all stages and across the life course of the population, especially in the early years. A further purpose is to provide a mechanism for transparency and accountability across the public health system. “As governance and accountability for Public Health England, local government and the NHS differ from each other, so will their relationship to demonstrating performance towards improving public health outcomes,” the document says.

Crucially, it will be for local authorities, in partnership with health and wellbeing boards, to demonstrate improvements in public health outcomes through progress against the indicators included in the framework that best reflect local needs, included in Joint Strategic Needs Assessments (JSNAs) and reflected in Joint Health and Wellbeing Strategies (JHWSs), to achieve cash incentives. Here, the DH expects specific progress against measures in the framework being “built into” JSNAs and JHWSs. These documents should be easily obtainable and accessible for KAMs, allowing an insight into local priorities which can then be targeted.

Although the framework has been planned for a three year period until 2016, the DH has confirmed that it will be refreshed annually “as data improves, technical capability across the public health system develops” and as it maintains an “aligned approach” across the NHS and local authorities.

Indicators will also be developed in order to create a complete set of baselines to support local service planning within the coming weeks by public health observatories, local authorities, the NHS and the Department of Health.

The DH accepts that “public health is such that the improvements in these outcomes will take years – sometimes even decades – to see marked changes”. But with budgets already in place to help tackle regional issues, pharma is perfectly placed to assist in driving public health outcomes in the short, medium and long term.   

How will Public Health England bring together the NHS and local government?

Public Health England (PHE) is the national executive agency of the new public health system, which will be driven by local government. PHE will be responsible for improving public health and reducing health inequalities through a range of local policies aimed at reducing health risks to individuals and communities.

From 1 April 2013, when PHE becomes a statutory body, public health services will shift from the NHS to local government. PHE will take £4 billion (5%) of the annual NHS budget with it, and will form an economic and organisational bridge between health and social care.

Like the NHS Commissioning Board, PHE will provide national leadership and guidance for local organisations but will not control them. According to Duncan Selbie, its Chief Executive designate, PHE will combine “a national voice with local action”. It will bring together experts from newly-dissolved public health bodies such as the Health Protection Agency and the National Treatment Agency.

Local authorities will commission public health services, employing local Directors of Public Health as ‘health ambassadors’ to lead discussions on public health spending. To engage with this locally-controlled system, PHE will develop public health outcome indicators and a ‘public health premium’ incentive system.

PHE’s broad function has been defined as “helping people to lead healthier lives”. That covers a wide range of interventions, from driving health awareness campaigns to a more practical role in vaccination programmes. In terms of impact on behavior, PHE will follow the Nuffield ‘ladder of interventions’ model, which relies on using evidence-based arguments rather than regulatory controls.

Leaders, not bosses
PHE will operate through 15 centres across the four regions identified by the NHS CB: North, Midlands and East, London, and South. This structure articulates the national role of PHE with local authorities: the regional bodies have more responsibility for national initiatives such as health emergency response, while the centres are more involved with local initiatives such as specialised commissioning.

The senior leadership team of PHE, like that of the NHS CB, will combine medical and commercial expertise. The medical leadership will consist of a Director for Health Protection, a Director for Health Improvement and Population Health, and a Chief Knowledge Officer. These will be supported by a Chief Operating Officer and Directors for Strategy, Programmes, Finance and Corporate Services, and Human Resources.

Chief Executive designate Duncan Selbie promises that PHE will offer the new public health system “leadership without hierarchy”. Selbie is an experienced NHS leader who was recently Chief Executive of Brighton and Sussex University Hospitals NHS Trust. He has been described as ‘popular’ and ‘likeable’, despite being a man of relatively few words. Notably, he survived the 2005 crisis of NHS governance under Sir Nigel Crisp with his professional credibility intact.

PHE is currently engaged in setting up its board and management team, and in matching roles between the old and new public health systems.

Health of the nation
The underlying medical goals of the new system are defined by the Public Health Outcomes Framework (January 2012), which groups outcome indicators into four domains:

1. Improving the wider determinants of health – improving against wider factors that affect health and well-being.
2. Health improvement – helping people to live healthy lifestyles, make healthy choices and reduce health inequalities.
3. Health protection – protecting the population from major incidents and other threats.
4. Public health and preventing premature mortality – reducing the numbers of people living with preventable ill-health and people dying prematurely.  

Selbie’s document My vision for Public Health England (July 2012) states that the agency “will lead nationally and enable locally a transformation in the health expectations and, in time, outcomes of all people in England”. He promises a focus on “collaboration” to provide a national voice for local public health expertise in councils, and says PHE will achieve “transformation” by changing people’s behaviour.

PHE’s three directorates, described in a separate factsheet, indicate the agency’s chief responsibilities:

• Health protection – concerned with reducing infectious disease and environmental harm. PHE will lead the field epidemiology service, the national immunisation programme, and emergency preparedness, resilience and response. It will also be responsible for investigating and managing environmental hazards such as radiation and chemical exposures.
• Health improvement and population health – concerned with reducing health inequalities and improving preventative healthcare. PHE will advise NHS commissioners on policies for disease screening and specialised commissioning, and will use social marketing to achieve behaviour change. It will promote innovation in this area of public health, reaching out to all providers and commissioners of health and social care, with the long-term goal of achieving improvement across the first, second and fourth domains (see above) of the Public Health Outcomes Framework.
• Knowledge and intelligence – concerned with delivering “a new national evidence and intelligence service” to support assessment of public health need and track performance against key outcomes. PHE will seek to raise the national standard of disease registration, and will work in partnership with NICE to assess the effectiveness of treatments in improving public health. Notably, cancer registration will migrate from the NHS to PHE by April 2013, when PHE will launch a new Cancer Registration Service to “collect consistent high quality, near real-time data” on all cancers diagnosed in England.

Making communities safe
The health protection functions of PHE bear a complex relationship to the NHS. The agency will investigate risks to public health including infectious disease outbreaks, and assess the availability and effectiveness of drug treatments for these threats. PHE will take over the functions of the Health Protection Agency, which will impact on the health protection activities of CCGs, the NHS CB and local authorities.

For example, PHE will have a strategic role in immunisation. The NHS CB will commission vaccination services, but PHE will set their quality standards, assess their performance, fund and manage the development of new programmes and the extension of existing ones, and even purchase, store and distribute the vaccines; while CCGs will commission treatment of infectious disease and work with PHE and local authorities on outbreak control.

It is not surprising, therefore, that the Faculty of Public Health has expressed concern about the “complex new arrangements” for disease control and warned that the system will require “excellent communication and very close collaboration between GPs and their teams, public health staff and hospital services”. This, rather than changes in people’s lifestyles, is most likely to be the area on which the effectiveness of the new public health system is judged.

Pharma and public health
Public Health England may only have 5% of the NHS budget, but its impact on prescribing and other NHS services should not be disregarded. The agency will act as a communication network and body of expertise to guide the new public health system within local government – which in turn will influence and work collaboratively with CCGs and primary and secondary care providers.

PHE’s impact on immunisation and disease control is likely to be particularly important. However, in keeping with the Government’s ‘nudge’ approach to unhealthy lifestyles, it is unlikely to intervene decisively in ‘lifestyle’ and ‘wellness’ issues.

Where the pharmaceutical industry can contribute in concrete terms to PHE’s agenda – for example, by providing better immunisation solutions or affordable drugs that help to prevent serious illness – it may find the agency a willing ally that can impact on GP and hospital prescribing.

At other times, it may find PHE inclined to promote non-drug solutions to public health issues, especially in terms of behaviour change; the industry needs to engage constructively with these issues.

As well as public health outcomes, PHE will be concerned at all times with helping the NHS and local government to save money. Pharma will thus have opportunities to align itself with PHE’s agenda by offering solutions that reduce the cost of public health improvements.

The “broader view” of councils means they will manage public health better than the NHS has, according to Public Health England (PHE) leader Duncan Selbie.

The NHS has been too concerned with acute care, whereas local government has a better grasp of disease prevention, Selbie argued.

PHE’s new Chief Executive said the agency would not try to manage the performance of councils, but would focus on achievement of the Public Health Outcomes Framework targets.

Speaking to the Health Service Journal, Selbie – who has 30 years’ experience in the NHS – stated that elected councils have “more experience, more maturity” than NHS organisations.

Since the NHS took over responsibility for public health from local government in 1974, he said, “we still have the same gaps in life expectancy” because the NHS is unable to address the reasons why “where you’re born is still the biggest determinant of how long you live”.

Councils, Selbie claimed, have a “much broader view of the world” and a longer record of improving public health through housing, sanitation and other strategies.

Whereas the NHS is always “focused on illness”, councils are better placed to address questions around lifestyle and mental health, and so to “unleash an energy and concern about improving health”.

Echoing statements made by the NHS Commissioning Board about CCGs, Selbie said PHE would let councils decide how to improve public health: it would assess outcomes, not processes.

PHE intends to work with NICE to determine whether the regulatory body is able to set quality standards for public health, he said.

Despite the economic pressures on local councils, he claimed, the new public health system was “in a stronger place to do better” than the old.