What do you learn in 160 years?

October 24, 2016 in President's Blog by Andrew Furber

The Association of Directors of Public Health (ADPH) and the Royal Society of Public Health (RSPH) had a birthday party this week. 160 years ago saw the formation of the Metropolitan Association of Medical Officers of Health that, after various mergers and demergers, led to the existence of ADPH and RSPH. You can read the details for ADPH here.

The history of changing epidemiology, organisational changes and personalities is fascinating. The first Medical Officers of Health were appointed to control communicable disease. Non-communicable disease is now the major cause of ill health and mortality, but influenza, Zika, Ebola and antimicrobial resistance serve as reminders that we ignore infectious disease at our peril.

But what has the last 160 years taught us about the role of the Director of Public Health (DPH)? Well, here are my 5 Ps:

  • Place – DsPH and our predecessors have always worked within a more or less defined geographical place. Structural reorganisations have often changed the boundaries, but the principle that the DPH has responsibility for all that affects health in a given locality has endured. Today we know it as system leadership.
  • Population – inequalities are nothing new and DsPH have always advocated for the entire population, and especially those who are excluded or disadvantaged.
  • Persistence – public health is a long game; a marathon not a sprint. Whilst we should grab quick wins and be fleet of foot in responding to public health incidents and opportunities, progress in improving the health of the public is probably best measured in decades.
  • Politics – DsPH have always had to sway national and local politicians, and be astute in influencing the politics which occurs within every organisation. This is perhaps the attribute which is most difficult to acquire.
  • Passion – usually this is the reason people aspire to become Directors of Public Health, and without it you won’t last long.

ADPH has captured these attributes in the Director of Public Health role description. These characteristics have endured for 160 years. The nature of the health and wellbeing challenge will no doubt change, but having someone who can lead the response for the people in a place is unlikely to alter.

The bigger picture

June 9, 2016 in President's Blog by Andrew Furber

The job of a DPH can be so full on that it can be hard to create the space to think strategically, compare notes with colleagues and get a sense of the bigger picture. This is one of the opportunities ADPH events provide and one I certainly appreciated at our recent AGM and Policy Workshop.

It’s hard to have a public health policy discussion in these times without reference to finance, and our workshop was no exception. We heard from CIPFA of the forthcoming work with HM Treasury and others (including ADPH) on the development of a ‘prudential code’ for investments in prevention activity. If successful it could transform the way the public sector thinks about prevention (as the current code transformed capital investments). For years we have made the business case that public health interventions offer outstanding value for money. Whilst we’ve had some success I don’t think any of us could say we’ve seen the level of funding commensurate with the potential return on investment. It is time we went further and considered the bigger picture of how public sector finances operate and how we could influence that.

We also took some time to reflect on our quality improvement work. In England this is captured within our Sector Led Improvement programme. In other countries it takes different forms but with the same end – ensuring we continually improve our practice. Hearing how others do it is always an inspiration and we were presented with some fine examples. We also had our first virtual presentation at an ADPH event! Gill Richardson’s short video on the opportunities to improve the health of the public through the Well-being of Future Generations (Wales) Act was excellent. ADPH will be increasingly looking at how we can use technology to hear from members throughout the UK.

As someone who struggles for inspiration when writing my annual report, I always enjoy seeing how others go about it. Our Annual Report competition this year had a step change in the number of entries (thank you if you sent yours in). Congratulations to this year’s winners and all those shortlisted. Receiving a copy of your report even if you don’t want to be in the competition is really helpful for ADPH to understand your local priorities.

The final session of the day looked at housing (in its broadest sense) and health. It was terrific to hear from Neil Hamlet and Jim McManus on how progress was being made in Scotland and Hertfordshire respectively. Housing is fundamental to health in many respects, but it was the issue of multiple disadvantage that was the focus for our discussion. The evidence was summed up well by Julian Corner from Lankelly Chase based on their Hard Edges report. This seems to me to be a real opportunity for DsPH to make a difference as we see the bigger picture and are not limited to a single sector response.

Our AGM, which was my first as President, was heartening. We thanked those who were leaving the Board and Council for their service, and welcomed our new recruits. It is encouraging that there are still people who are prepared to step up to the plate and support our collective work in this way. It was also good to accept Janet Atherton as a new Honorary Member, the highest honour ADPH can bestow. Recommendations on membership expansion and subscriptions – vital issues for us but always difficult to judge correctly – were supported. It was especially welcome to hear from members that they felt this was precisely the time when we needed to work together through ADPH to advocate for the work of DsPH.

Jeanelle deGruchy did a brilliant job of chairing the Policy Workshop and Nicola Close and the ADPH staff team were exemplary in all the (largely unseen) preparation which was required to make the day such a success. Of the evaluation forms submitted 100% of respondents said the day was a good use of their time and that they have learnt something new. The session on housing and disadvantage was considered the most useful part of the day which inspired some of the members to look more closely at the issues related to housing and homelessness as well as how they link with devolution. Also the session on sharing best practice was considered useful by 96% of respondents many of whom decided to look further into the SLI and ways of developing it within networks. Other actions following from the discussions included watching the Cathy Come Home film, reviewing the Suicide Safer Communities Accreditation and checking on the numbers of health visitors and school nurses locally.

One of the downsides however, was the overall low number of DsPH attending which, we admit, was a missed opportunity for networking and discussion. Therefore, I wanted to ask you now to take a moment and mark your calendars for the following events coming up:

19th October – ADPH 160thAnniversary

8th November – ADPH Annual Conference

In summing up the day I was struck by three things. Firstly the overwhelming case for early intervention – multiple disadvantage often has very obvious, and preventable, origins. Secondly how DsPH are ideally placed to champion the place-based approaches required to resolve our most difficult issues, whether multiple disadvantage or public sector finances. And finally, the value of sharing good practice. ADPH often puts out requests for good practice but we don’t get much back. Partly this will be that DsPH are too busy to write it up, but perhaps we sometimes feel it is not good enough. Have no such fear – everyone loves a sharer. Only by hearing of such examples can ADPH really make the case for the impact DsPH are having locally. If you can think of ways in which ADPH can make such sharing easier please let me know.

Get out more!

November 10, 2015 in President's Blog by Andrew Furber

Reflections on the ADPH Annual Conference 2015

As things get busy and finances more difficult, it can be hard to avoid becoming inward looking. But perversely these are the very times when it becomes most important to look outwards. The DPH role can be quite an isolated one if we are not careful. It was therefore encouraging that our Annual Conference on 2nd November was oversubscribed.

Part of the conference’s attraction was no doubt the excellent speakers we had lined up. Dr Anna Dixon, Chief Executive of the Centre for Ageing Better, kicked us off with the challenge and the opportunity of our changing demography. She rightly questioned some of the negative language around older people such as ‘bed blockers’ and ‘demographic time-bomb’. As a ‘what works centre’, the Centre for Ageing Better will be looking for evidence on how people can age more healthily, with more financial security and be more socially connected. Please send any ideas you have for action or where evidence is needed to ceo@agebetter.org.uk.

A panel discussion, chaired by Tim Allison, with key figures from Public Health England, NICE and the King’s Fund led to a lively debate around the tables on making the economic case for public health. Public health comes out incredibly well on any objective economic assessment. Over 70% of the public health interventions assessed by NICE are cost effective, and 15% are cost saving. Return on investment is the icing on the cake, but it isn’t the cake. The point was made throughout the day that whilst the economics of public health are important we shouldn’t oversell it. The compelling moral and policy arguments are just as crucial. Prevention and early intervention are the right things to do. Economic analyses often don’t reflect inequalities, and to rely on them alone could lead to inequitable outcomes.

In his first engagement as the newly appointed chair of the NHS Confederation, Stephen Dorrell proved to be an inspirational speaker to energise us after lunch. He was very clear on the value of public health – the promotion of health and not the treatment of illness should be our national priority. He described the role of public health as putting “a bit of yeast in the mixture” and saw devolution as an opportunity to change the way government works both nationally and locally. Stephen said he failed to see how public sector reform could work without considering health and care, given the scale of this sector.

On the relationship between public health and the NHS, Stephen Dorrell described two main opportunities. Firstly, challenging unacceptable variations on important health issues such as stroke or diabetes. And secondly, challenging the way NHS resources are used so that the NHS becomes more efficient and equitable, for example, in caring for those with multiple, complex needs.

Devolution was the topic of our final panel debate and table discussion. Mary Black from the Public Health Agency in Northern Ireland described the considerable progress that has been made in their devolved arrangements despite the very difficult political context. There are important lessons to learn from Northern Ireland, and Wales and Scotland, as England begins to think about devolution.

Deborah Cadman, Chief Executive of Suffolk County Council, talked of how public health had become a central ‘change agent’ to the way they do business. The Joint Strategic Needs Assessment is a key driver, and demand management a crucial strategy in their effort to reduce costs and improve outcomes. She noted that ‘making good on the public health opportunity’ was one of Simon Steven’s five tests for government.

Steven Pleasant, Chief Executive of Tameside Metropolitan Borough Council, continued this theme. He said that supply side efficiencies would deliver less than half the required savings required by Manchester’s health and social care economy. Better demand management based on prevention and earlier intervention is critical if their devolution deal is to work. Steven also reflected on the scale of the challenge – 80% of people on the work programme have an underlying health problem, and 60% have a mental health issue, none of which is addressed by the programme.

Jim McManus chaired the session and asked the panel to describe the ideal characteristics of a DPH to respond to these challenges. The answers ranged from cloning Suffolk’s DPH (her Chief Executive is clearly and understandably a fan) to moving outside our comfort zone. Steven Pleasant noted that he normally saw DsPH together but not often enough in some of key meetings where some of these big issues are decided. He challenged us all to get out more!

In my reflections on the day I quoted from the opening lines of Charles Dickens’ A Tale of Two Cities, “It was the best of times, it was the worst of times”. In many ways these are extraordinarily difficult circumstances for DsPH across the UK. But my sense from the day and from meeting ADPH members is that we are a resilient bunch. We need to look out for one another so those in the most difficult circumstances do not feel alone. But there is a prize to be had if we can make public health fundamental to the way the public sector works across the UK. To quote Churchill, “Never let a good crisis go to waste”.

Public health: devolution, evolution or revolution?

October 6, 2015 in President's Blog by Andrew Furber

Devolution is certainly the flavour of the month. It has brought new vocabulary such as DevoManc or, my personal favourite, DevoScouse. It even got David Cameron into hot water when he joked that the good folk of Yorkshire couldn’t agree amongst themselves on their devolution deal. Of course, being employed by a Yorkshire local authority, I couldn’t possibly comment.

I’ve just completed visits to ADPH members in Scotland, Northern Ireland and Wales. My visit to Belfast also included meeting the chair of the Directors of Public Health network from the Republic of Ireland (who, I am pleased to say, is keen to collaborate with public health colleagues not only to the north of the border but across the UK). I also met with all four Chief Medical Officers (or her representative in the case of Wales). I thoroughly enjoyed all the visits and learned much. I was encouraged at how much ADPH was valued, as well as by having some time to discuss how we could support our members even better.

And it reminded me that devolution is nothing new for the public health system. We have much to learn from devolved arrangements across the UK, as well as how things are developing within England.

In this short blog I can’t do justice to the differences between public health systems in the four nations. Suffice to say all had areas of strength as well as particular challenges. All those I have spoken to agree that some careful analysis of these differences would help us all and I am exploring how we can get this done. I am keen that ADPH facilitates this so the output is useful to you, our members, as you lead and influence locally.

However, it is equally important that we have the opportunity to discuss amongst ourselves. Our Annual Conference on 2 November 2015 will look at how we make the case for public health, including within the devolution conversation. Please come and share your experiences and hear from those at the devolution coalface across the UK. If you haven’t done so already, you can book your place here. Confirmed speakers include Stephen Dorrell and Anna Dixon so it promises to be an insightful programme.

In England it seems to me that many places understand the opportunity of devolution to improve the health of the public, but some perhaps need a further nudge. At the recent Public Health England Annual Conference, Steven Pleasant (Chief Executive of Tameside Metropolitan Borough Council) described how the key factor holding back Greater Manchester economic productivity was poor health. There is highly likely to be a case for a public health contribution even where there is no appetite to include health services in a devolution deal. ADPH has been advocating at the highest level for the value added by local Directors of Public Health to devolution discussions.

However unstable we think the system is at the moment, we have all been shocked at the circumstances many refugees have found themselves in over recent months. Whilst Syria is the focus of our attention currently, we know Syria is not unique. I am grateful to Abdul Razzaq for pulling together a response from ADPH which can be found here. I know from my conversations with you that DsPH have the necessary capability and are ready to respond. Nationally we have played our part in calling for the response to be expedited and adequately resourced.

As ever, I and the ADPH team are keen to hear from our members, both when you think we’ve got it right and also when you think we could do better. We have an ADPH Board away day on 16 October where we can take stock and also consider the future direction for our organisation.
So whether or not you think public health will benefit from devolution, evolution or possibly even revolution, I hope to see you and on 2 November and hear your views!

Rhetoric and reality?

August 1, 2015 in President's Blog by Andrew Furber

I never imagined that my first official duty as ADPH President would be a call to the Director General at the Department of Health about the £200m cut to the local authority public health grant in England. I am aware of the severe cuts to budgets in Northern Ireland, financial pressures in Scotland and Wales as well as drastically reduced budgets elsewhere within the wider public health system in England. It seems the rhetoric of investing in prevention is not always matched by economic realities.

The Department of Health consultation is now out [Click here] and it goes without saying that we need a strong response from councils and as many of our partners as possible. In particular we need to provide evidence on how this will impact on health outcomes, on NHS services and on costs to the health and social care economy. Whilst the consultation is limited to England, colleagues across the UK will have produced evidence we can use. In turn I’m sure DsPH in England will return the favour and share the learning from managing these cuts.

I have been struck by the unanimous view from all the leaders I have spoken to that these cuts are at best unfortunate and at worst disastrous. Duncan Selbie specifically asked me to convey his disappointment at the cut and his admiration for DsPH dealing with an extremely difficult situation.

As you would expect, myself and the ADPH team have been lobbying both behind the scenes and in public. I know that many DsPH have been rallying the troops within their own localities and this is invaluable. The £200m was announced in parliament and can’t be retracted, but we want to ensure that budgets which support prevention are not cut again.

As DsPH we are, perhaps unfortunately, skilled at salvaging some good things out of difficult situations. Several of you have told me that this cut has escalated conversations with NHS partners about their role in prevention. The NHS England Five Year Forward View sets out ambitions to save money, improve health and increase quality. There are actions the NHS could take on issues like tobacco and alcohol that would tick all these boxes. Again I’m sure DsPH across the UK will have great examples to share.

Ahead of this autumn’s Comprehensive Spending Review, and equivalent processes across the UK, we need to gather and present the evidence that our work improves health and saves the system money.

We also need a strong narrative. I’ve been struck that whilst many people use the word prevention the meaning can vary wildly. Our narrative needs to capture our role in delivering effective population based prevention work in its widest sense. The ADPH Council has its final development session on 15-16 July and will do some further work on this.

On a personal note, despite having to deal with difficult circumstances, I’ve enjoyed my first month as President. I have found that ADPH is very well regarded by the powers that be and as a result I’ve been listened to. I’ve appreciated the messages of support from DsPH and I look forward to meeting more of you over the coming months. I have spoken at several national meetings and in every case making the point about investing in prevention and the pivotal role of the DPH. I have also set the ball rolling on some further guidance from the LGA on the role on local government on some important health issues. Finally I have started the conversation with our trainees about getting them exposed to and involved with ADPH. The aim is to inspire them to aspire to be our successors. As a by-product of this I’ve arranged for one of our trainees to do some work for England’s CMO in WHO in Geneva. I have to confess to being more than a tad jealous.

Please let me know if you think there is anything else I could usefully be doing. My time is limited, but unless you tell me I will never know. I want to make sure my ambition to represent you effectively is a reality and not just rhetoric.

Andrew Furber

July 2015