The responsibility and resources for public health and tackling health inequalities should lie with local councils rather than with the NHS, argues an expert in this week's BMJ.
Professor Tim Blackman of Durham University says that partnerships between local government and the NHS would then become a true meeting of the two sides of health prevention and treatment.
There is little doubt that inequalities in health are difficult to tackle, he writes. In England the gap in life expectancy has continued to widen, and the government's strategy for health inequalities is now more akin to redistributing health than to redistributing income or wealth.
Drugs seem to offer an opportunity to redistribute health, and quickly. The looming 2010 target for narrowing the life expectancy gap in England by 10% is focusing effort on pharmacological interventions, such as statins and antihypertensives, among people in their 50s and 60s.
Although extending these treatments as widely as needed is laudable, having so many people taking drugs can hardly be regarded as a public health achievement, he says. Yet the NHS is proving remarkably good at these approaches.
The reason for this, he explains, is because the NHS is a sickness service, which is what it is good at and what it should focus on.
Every attempt to push public health up the NHS agenda gets undermined by acute services trumping public health in budgetary, political, and media contests, or additional tranches of money getting diverted to priorities that are always more urgent than the slow and unglamorous interventions needed to improve the public's health.
So where should the responsibility and resources for public health and tackling health inequalities lie, he asks?
The obvious answer is with local councils, beyond the appetite of acute services, beyond the quick fix of statin prescriptions, and in the clarity of a single organisation with clear accountability and leadership as an agent of public health.
He suggests that the extra resources could come from acute care. Local councils would then decide whether to transfer it back to the NHS or to use it, for example, to cut the local waiting list for social housing or to improve school meals.
Whatever it did, it would have to be mindful of its health inequality targets, which would now lie clearly with the local council as its responsibility, he concludes.