The discussion explored the fundamental question of what is meant by public health. Participants agreed on a wide definition, beyond the targeting of services and protection, encompassing a range of active measures for health improvement. It was suggested that public health could be helpfully conceptualised in terms of "three 'e's" - engagement, empowerment and environment – all of which would be required in an effective strategy.
All agreed that in order to drive down health inequalities, public health strategies must be tailored to individual groups in society. This rejection of a traditional 'one size fits all' approach was hailed as a "seismic shift" in how practitioners approach health inequalities. A broad preventative approach, moreover, should mean that health policy is concerned, as one participant put it, with "what happens in the house, in the workplace and in our streets". Our aim, it was suggested, should be fostering "communities that are promoting good health".
Such a definition challenges the perception of public health within the Department of Health, but also within every department of government and across the private and voluntary sectors. Discussion focussed on both the policy and political challenges associated with a public policy shift in this direction.
It was noted that for 60 years the dominant vision of the health service has been one based on the role of major healthcare units centred on big hospitals. The promotion of good health, it was suggested, remains a second order priority for a Department of Health that is fixated on hospital performance targets, for 18 week waiting times or 4 hours spent in A&E, for example. This focus on acute care meant, among other things, that the physical distance between primary care services and poor communities was far greater than for acute services. A vital step in narrowing health inequalities all recognised would be a focus on increasing the provision of primary care in poor areas.
Within this environment, it was felt, the role and status of the Minister of Public Health was overly constrained. The vast range of responsibilities accorded this portfolio and its relatively junior position vis-à-vis the Secretary of State for Health were highlighted. One participant suggested the creation of two secretaries of state within the Department of Health – one for acute health care services and one for public health – as one way of enhancing the priority accorded public health within the department.
Participants also discussed the need to broaden the public health agenda beyond the Department of Health, which one participant suggested, referring to the Nuffield Council studies, might assume a "stewardship" role. It was suggested that the department might need to reconsider its language in order to successfully engage others. Some participants raised the idea of 'wellbeing' as an alternative to 'public health', though not all were convinced that this conveyed the essence of the required approach.
The roles and responsibilities of a variety of stakeholders were discussed, ranging from government departments responsible for welfare, education, planning and transport; local authorities and city councils; schools and universities; and leisure services. Demonstrating the significance of the public health agenda across government, rather than one public health minister in the Department of Health, one participant thought there should be one in every department. All participants agreed that all national government policies should be proofed for their impact on health inequalities, by requiring every policy to carry out a 'health impact assessment'.
At the local level, the importance of local area agreements and local strategic partnerships were seen as crucial. One participant recommended that broader public health standards should be established in performance assessment frameworks for local authority chief executives if decisive action was to be driven from the top. Good examples of partnerships between local authorities and local health services, schools and colleges were reported, developing innovative programmes, such as screening carried out in high profile venues like football stadia.
Many participants noted the difficulties in engaging with the private sector. One participant reported efforts made by her PCT to work with the local chamber of commerce that had achieved only limited results. Given the importance of, for example, the food and leisure industries to the public health agenda, greater guidance was called for on the best ways to engage the private sector.
All participants agreed on the need to share best practice of public health strategies across this range of stakeholders. In relation to the tailoring of messages to target groups, participants commented on the emerging use of techniques employed by direct marketing companies to guide their work. Importantly, this was seen as yielding new ways of sub-dividing the population. Rather than a traditional public health focus on categories such as black and minority ethnic (BME) groups, marketing categories offered a more sophisticated analysis of the factors which will affect an individual's health behaviour.
It was suggested by a number of participants that there was a lot that could be learned from how health NGOs campaign, advocate and convey messages. A note of caution was sounded, however, about the dangers of patronising and stigmatising marginalised groups through an overtly targeted approach. Rather than treating such groups as powerless, attention should be paid to the clinical decisions being taken, particularly in GP surgeries. Echoing calls made in the opening seminar of the series, the importance of making a shift in professional culture through more explicit measurement and monitoring of, for example, referrals from primary to secondary care, was again highlighted.
Indeed, the importance of good evidence to guiding best practice was again discussed. Noting that evidence could be just as much a barrier to as a facilitator of good practice, as had arguably occurred in the case of exercise referral schemes, participants were keen to tackle the drag in the system that saw 3, 4 or 5 year waits for even priority areas of research to become available. It was suggested that a system of fast tracking funding where pressing issues requiring research quickly should be implemented. Similarly, it was recommended that systems for evaluation be built into projects at their outset.
One participant, however, questioned whether the right evidence would ever be enough to legitimise a major shift to a preventative public health approach. While a consensus had seemingly developed in the seminar rooms of health practitioners, it was suggested that the argument still had no resonance with the public at large. It was suggested that much more needed to be done to win the public argument for change and so grant the government permission to act in this area. A concerted effort at the next election to communicate ten health stories that had nothing to do with the NHS was suggested as one idea for doing this.
Such a public narrative would inevitably be confronted with the tension between the role of the state as an advocator and promoter of good health and the freedom of the individual to make choices about their own lifestyle. The characterisation of the 'nanny state', it was felt, should be challenged, with a careful balance required to establish a broad vision of public health with sufficient flexibility to reach out to individuals' particular circumstances.
Seeing this tension in terms of a trade-off between the rights of individuals and the interests of society as a whole, one participant suggested greater conditionality could be introduced to encourage other-regarding behaviour. It was suggested that child benefits could be linked directly, for example, to the uptake of immunisation (with some provision for exceptions).
Numerous examples of public health strategies that have worked with marginalised groups were raised, and further suggestions offered – from tax relief for going to the gym to free swimming provided by local authorities for under-16s or the economically inactive – demonstrating once again that there would be no one silver bullet for narrowing the gap in health inequalities, but many. The challenge it was recognised will be to open the public political space necessary to scale up such interventions to achieve a significant narrowing of the inequality gaps.
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