Poor levels of health in the population will put considerable pressure on the NHS that risks swamping the government's efforts to meet targets and achieve solid gains through its sizeable injection of money. Not surprising, then, that former banker Derek Wanless's report on long term funding challenges for the NHS, which was published last year, struck a chord with ministers and advisers.¹ In his 2003 budget the chancellor invited Wanless to provide an update of the long term challenges in implementing the fully engaged scenario.² This scenario was the most ambitious and optimistic of the three scenarios described in Wanless's first report and has been endorsed by the government. It contains heroic assumptions about the ability of people to take greater responsibility for their health, and services to transform themselves through efficient use of resources and a high rate of uptake of technology. A dramatic improvement in health status is anticipated with life expectancy going beyond current forecasts. But the real appeal of the scenario for the government lies in an estimated saving to the NHS of some £30bn ($47bn; €43bn) if it succeeds.

The plea of the former health secretary Alan Milburn for a better balance between prevention and treatment in health policy seems to have gone unheeded.³ The government remains preoccupied with downstream acute care. The call for a “sea change in attitudes” has not happened. Public health remains marginalised and lacks capacity, especially in primary care trusts, to challenge effectively the prevailing orthodoxy. Yet the outpouring of policy statements testifying to the grim picture of the nation's health continues. The latest is an action plan designed to promote “often minor changes in the way... services are provided,” in the hope of “making today's inequalities a thing of the past.”⁴

The action plan concedes that “health inequalities are stubborn, persistent and difficult to change.” But they are also widening “and will continue to do so unless we do things differently.” The health gap between rich and poor is growing in line with the income gap, and a generation of overweight and underexercised individuals is maturing.

The scenario will be unpicked and developed in the progress report on which Wanless is engaged, to identify cost effective public health interventions. But the review contains two further key features. Firstly, it will be concerned with assessing how public health policy is formed. Secondly, it will examine national and local governmental arrangements for delivering the public health agenda set out in the NHS Plan (chapter 13) and in subsequent guidance and targets.⁵ This means Wanless's reach will go well beyond the NHS and embrace local government, regional bodies, and others engaged in health improvement and tackling health inequalities.

With his private sector background, Wanless is regarded as someone the government can trust. He is respected and listened to. His progress report, to be completed by late February, will be presented not just to the chancellor but also to the prime minister and the health secretary. It will therefore be less easy to arrange a quick burial for the report in a departmental silo.

An unexpected champion of public health, Wanless is critical of the government's short term preoccupation with acute care and hospital beds. His update on progress offers the public health community an unprecedented opportunity to influence and shape future health policy. He wants to engage in an active dialogue with public health practitioners and others with important things to say. Whether those working in public health are up to the challenge may be more of a problem. Public health practitioners are still coming to terms with the latest NHS reorganisation. Split between the regional government offices, strategic health authorities, and primary care trusts they are struggling to keep the spirit of public health alive. Networks to overcome isolation and fragmentation are patchy and uneven.

Wanless will wish to satisfy himself that the present decision making structures for producing and implementing plans to improve health and tackle inequalities are “fit for purpose” and that sufficient resources are available in terms of capacity and capability. Whether the Department of Health is the best location to provide leadership for public health—an issue that exercised the House of Commons health committee in its review of public health—is something Wanless will wish to explore.⁶ He will also want to be sure that the evidence for public health interventions exists and is robust. He felt hampered in his first review by the poor state of evidence in public health. Concern about weaknesses in the evidence base could become counterproductive and an excuse for inaction.⁷ Lack of evidence is not the central issue. As the World Health Report 2002 of the World Health Organization makes clear, deaths from cardiovascular disease could be cut by 50% if the political will to act was there.⁸ Only when governments cease to worry about being labelled the “nanny state” will they stand any chance of providing much needed leadership. In the United Kingdom this seems even less likely at a time when devolution (the “real localism”) and individual choice are dominant themes.⁹