President's Blog

January 2012 - Back to the Real Job

Part of the promised tranche of public health policy papers arrived with the last of the Christmas post so we now have a fairly clear idea of what the new public health system is going to look like. The combined efforts of the public health organisations have improved the initial proposals for Public Health England and for local government public health and it is useful to reflect on the significant improvements which have been made to the system.

Contrary to earlier expectations, we now have a strong steer that local government will have responsibilities across all three domains of public health; that Directors of Public Health are to be appointed as chief officers (with the strong expectation that they will usually report directly to the LA Chief Executive); and that all public health specialists will be properly trained, accredited, and registered (whether they are from a medical/dental or any other background). Many of us would have liked to see a unified public health agency or for PHE to be established as a special health authority with proper independence from Government but these aims haven’t been achieved so it is now down to the public health profession to find ways to make the two parallel systems work effectively to improve and protect the health of our communities.

I was impressed with the responses that DsPH made to our recent survey of English members. Although there is still a lot of concern about reorganisation and about transfer of finance and staff to local authorities, there is a strong desire that we get back to the real task of public health; improving health and tackling health inequalities. The global economic crisis is unprecedented in the working lifetimes of current DsPH and I am hopeful that 2012 will see the public health community moving beyond a preoccupation with structural issues and working to develop a coherent public health response to the consequent health threats; we all need to collaborate as effectively on this agenda as we have on system reorganisation.

Public health specialists have a strong track record of finding solutions to difficult challenges. The redesigned public health system is far from perfect but the framework has been set. Our professional duty to the public is to make the new system work and to deliver better health outcomes; our duty to ourselves and our staff is to manage the transition to the new system as smoothly as possible. It’s time to get back to the real job of improving health and wellbeing.

November 2011 - BOGOF: 2 public health systems for the price of 1?

A major flaw in the current proposals for public health in England is that national policy is driving us down a route of creating two systems rather than the single, integrated model which PH professionals and commentators have universally advocated. PCT based public health functions are moving to local government while Public Health England is being fashioned by grafting the cancer registries, NTA, and PH Observatories onto a largely unreconstructed HPA. The adverse consequences of this bifurcation are becoming apparent as the suite of PH policy documents is developed. The three most significant are:

1. It is almost impossible to avoid duplication of functions across organisations. It is slowly dawning on the architects of the new system that functional lines cannot be neatly drawn between LG and PHE. Current proposals are that PHE will provide support to the NHS, will develop voluntary sector capacity, and will communicate with the public on health improvement and health incident issues; all tasks which would seem to be natural territory of DsPH in local authorities.
2. Important issues are falling into the gaps between the two systems and accountabilities are wholly unclear. The health protection function will have LAs preparing and quality assuring plans and HPA+ (sorry, I mean PHE) providing technical support/expertise but nobody can say where the leadership will sit when there are outbreaks/incidents, the coordination of vaccination and immunisation programmes is unclear, and screening programme QA and incident management details are still awaited or being ignored.
3. The dichotomy of systems extends to the specialist public health workforce; there are two separate workforce transition plans in development and two completely separate pools of staff who will have different destinations, remit, professional accountabilities, and terms of service. DsPH and consultants in PCTs inevitably work across all areas of public health including health protection but they now find themselves on the side of a sharp dividing line which delineates a move to local government system with no opportunity to consider whether their skills and expertise might fit better within the parallel PHE system. Rafts of well-intentioned principles have been drafted but noticeable by its absence is the rather obvious one that the person with the most suitable skills and experience should move to the most appropriate job.

Civil servants are doing what civil servants do best; beavering away to try to iron out these inconsistencies, duplications, and governance failures but my sense is that we are going to end with a very damaged system. It will then be for us as public health professionals to do what we always do best; develop local relationships and arrangements to make sense of the systems. If you see a BOGOF offer in your local Tesco I suggest you look carefully at the details to see if there is a catch; in this case I’m struggling to see how the cost of two public health systems can possibly be less than the single purchase we should be making.

August 2011

The drip drip dripfeed of public health policy has continued with the arrival of the White Paper policy update a couple of weeks ago. The lobbying efforts of the public health organisations have had some impact and the emerging picture of Local Government responsibilities brings us much closer to the integrated public health system which we have been advocating. In particular, it is a relief to see that Local Authorities will have duties in the area health protection and will have to provide public health specialist support to the nascent clinical commissioning groups – the devil, as ever, will be in the detail and a cascade of further updates is anticipated as we move into the autumn. Many DsPH have been cheered to see the explicit government expectation that, in their future role will be chief officers in local government; this really strengthens our hand in local negotiations around public health structures.

For the last two months I’ve been working part-time in my county council and the NHS/LA cultural differences are striking. One aspect is the fascinating and challenging dynamic of working with elected members, while at a more prosaic level I grapple with an IT system which regularly quarantines my e-mails; anything relating to sexual health, nursing duties, or teenage pregnancies is consigned to a virtual black-hole in County Hall and results in an automated ticking off for sending “possibly rude” e-mails.

I’ve been impressed by the energy and passion which the current crop of public health trainees are showing in their efforts to shape the new public health system. Immersed as we are in the immediacy of change processes, it is easy to forget that our time in leadership roles is relatively short so it is always a pleasure to see future leaders emerging. The question of whether the locus-shift to local authority will mean that public health will become a predominantly non-medical specialty is increasingly debated:; the multi-disciplinarity of the current workforce is a great strength of the public health community and we need to find ways to ensure that our medically qualified colleagues retain equivalent status to consultants who continue to practice in the NHS. I haven’t seen a solution to this yet but it is a key issue which I will be raising with the Chief Medical Officer who will need to address this if she is to deliver her role as the leader of the public health system.

June 2011

May and June have been dominated by support to the work of the NHS Future Forum which Steve Field is leading. The group has met three times and, in common with other members, I have also been trying to attend as many “listening events” as possible. There has been a fair amount of scepticism about what the Forum will achieve; ultimately it will be for Government to respond and to lay out the consequent changes to the Health and Social Care Bill, but from my perspective it has been good to see that the process has been entirely independent and it has been a pleasure to work with a group of talented and committed professionals from across the (entirely artificial) management/professional divide.

The main changes to the Health Bill which the public health community is suggesting are that:

• Public Health England should be independent of government and so should not be part of Department of Health;
• specialist public health capacity should be consolidated in one organisation rather than scattered across several;
• DsPH need to work as senior members of Local Authority corporate management teams if they are to be effective;
• all public health specialists should be properly trained and accredited;
• all health and social care agencies should have a duty cooperate on health improvement initiatives and to contribute to responses to public health incidents and emergencies.

One thing which has struck me forcibly during the various meetings with politicians, select committees, policy advisers, and the public is how little understanding there is of what Directors of Public Health actually do. The three domains concept (health improvement, health protection and healthcare public health) has little resonance with these groups so public health clearly needs to find a better way to articulate its role. Stories work well; highlighting the role that Directors of Public Health played in coordinating the health and social care system during the flu pandemic has proved a much better way to communicate our function. I’ve repeatedly seen anxiety levels start to rise when I point out that it is wholly unclear as to who will provide this type of system leadership in the future.

A particular highlight during May was the ADPH annual conference and AGM which we held at the Victory Services Club in London. We had the best attendance we’ve seen for many years and, instead of lots of formal presentations, we used panel sessions which allowed far more scope for interaction from everyone. The day started with concerns that public health feels like it is entering “the Somme” but ended with the more upbeat allusion that we might be turning an “El Alamein” corner. We concluded the day with an inspiring closing leadership address from Tony Jewell (Chief Medical Officer for Wales).

April 2011

No prizes for guessing what has been on the collective mind of Directors of Public Health (DsPH) recently; the consultation period for the Public Health White Paper (Healthy Lives, Healthy People) ended this week so we’ve all been busily agreeing and compiling responses. There is a high degree of consistency across the responses from various public health organisations; in large part this is down to the leadership which Lindsay Davies at the Faculty of Public Health has shown in pulling together the various professional groupings under the aegis of the Public Health Medicine Consultative Committee. I signed off the Association of Directors of Public Health (ADPH) response on Tuesday; interesting to note that in all the discussions over the last 3 months I haven’t encountered a single DPH who demurs from the wisdom of Local Authorities taking on the leadership for health improvement and reducing health inequalities. The main concerns at the moment are the risks of fragmentation which could stem from implementation of the White Paper proposals; the public health workforce needs to be kept together but could end up with health improvement staff working in local authorities, health protection specialist deployed through Public Health England (PHE) and the specialists in healthcare public health working for either the National Commissioning Board (NCB), GP consortia or private sector companies. If this is allowed to happen then the specialty of Public Health will be very damaged and there will be huge risks to recruitment, retention, and training. I hope the responses will influence the shape of the new Public Health system now that the consultation period is over but it’s vital that we move more quickly to implementation planning if we are to tackle the uncertainty and negativity that inevitably stem from prolonged change management.

History is important; we need to understand the pitfalls of the past if we aree to avoid them in the future. Public health moved from local authorities to the NHS in the 1974 reorganisation; I’ve been reading up the history of the time and meeting with some of the surviving Medical Officers of Health to understand their perspectives on the reasons and consequences for the changes at that time. One review that I’ve read summarises the problems with the MOH role in the 1970s; criticisms were that they were busy building large empires in the local authority, that their annual reports lacked impact, that they failed to tackle deep-rooted vested interests which militated against the health of their populations, and that they were seduced into hospital administration. There will be interesting lessons to be drawn for the new world of Health and Wellbeing Boards, Joint Strategic Needs Assessment, and the Responsibility Deal.

Frank Atherton