Memorandum by the British Medical Association
(PH 43)
INTRODUCTION
"Public health is the science and art of
preventing disease, prolonging life and promoting health through
organised efforts of society" (Public Health in England,
1988).
The BMA is both the doctors' professional organisation
and also an independent trade union protecting the professional
and personal interests of its members. More than 80 per cent of
British doctors are members. The Committee for Public Health Medicine
and Community Health (CPHMCH) is a standing committee of the Association
and represents those doctors working in the fields of preventive
medicine and population health who have a key role in the implementation
of the White Paper Saving Lives—Our Healthier Nation.
Public health doctors (directors of public health,
other consultants and specialist registrars in public health medicine)
lead the public health team in health authorities and health boards.
Their role is in four main areas:
— protecting the public health;
— tackling disease and ill health by
promotion of effective—and cost-effective—personal
health services; and
— ensuring mechanisms are in place
to assure the clinical quality of health services.
Public health doctors are trained, after experience
in a clinical speciality, to higher degree level in core skills
and experience across the range of fundamental sciences of public
health. These include epidemiology, health information, statistics,
preventive medicine, health promotion, communicable diseases,
environmental health, health surveillance, development and evaluation
of health services, social sciences, health economics, management
of health services, teaching and research. Many public health
doctors go into this postgraduate training after many years of
clinical experience, often at senior levels in other specialities.
Public health doctors recognise that the health
of the population is predicted as much by factors such as the
cultural, social, physical and economic environment as by health
care. Many of the great improvements in health come from clean
water, better nutrition, good housing and a supportive social
structure. Health care is dependent on factors such as these and
good health care is complementary to them and not a replacement.
For example, at a population level, improving housing may be as
cost effective as many aspects of health care provision.
The CPHMCH welcomes the opportunity to contribute
to the Health Select Committee's inquiry into public health and
would be very pleased to present oral evidence and elaborate on
any of the points raised within this evidence and respond to any
issues the Committee would wish to raise with us.
THE INTER-OPERATION
OF HEALTH
ACTION ZONES,
EMPLOYMENT ACTION
ZONES, HEALTHY
LIVING CENTRES,
EDUCATION ACTION
ZONES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
PLANS
The most important new process proposed in the
green paper Our Healthier Nation was health impact assessment
(HIA), and we believed then that HIA might become as important
to public health as the controlled trial has become to clinical
medicine. However, some aspects of the methodology for HIA are
well established, whilst others need developing, particularly
its application to policy development. We believe that the Department
of Health should support the development of health impact assessment
methodologies, simplify access to databases and monitor the validity
and effectiveness of their contents and also ensure it is adequately
resourced. Nevertheless, there is already a great deal of experience
of HIA, although it has not been so labelled. For example, whenever
any consultation paper from another government department is commented
on by the Department of Health or a health authority department
of public health, a health impact assessment is being performed
which, although may be a fairly superficial qualitative assessment,
is often based on considerable experience. This screening and
scoping perspective is important, but the Department of Health
also needs to develop capacity to undertake deeper, more thorough
appraisals as required of all policies under the Amsterdam agreement
152.
Public health doctors are intrinsically involved
in the operation and ultimate success of many of public health
initiatives. They see them as a very important way of helping
people to improve their health and well being but a fundamental
obstacle to any partnership at local level is that different participants
see themselves as representing different bodies rather than serving
the same population. This is beyond the control of public health
doctors but manifests itself in different ways such as:
— lack of coterminosity—the participants
do not serve the same population;
— budgetary barriers—the participants
see themselves as conserving their own budgets rather than as
using resources optimally;
— narrowing of vision—participants
have limited objectives so feel no commitment to the related objectives
of their partners even when shared programmes would clearly lead
to benefits; and
— limitation of authority—officers
of one agency are seen as external to other agencies.
The CPHMCH believes that the obvious solutions
to these difficulties are to work towards far more coterminosity
between boundaries of health authorities, local authorities and
PCTs and develop much more freedom to move funds between agencies.
Specifically, health improvement plans (HIPs) should be constructed
at the lowest level of population for which a coherent service
can be put together to address a coherent need. They should involve
local people and be a reflection of local priorities, as certain
specific requirements are not necessarily applicable to all localities.
The population level could take the form of:
— the neighbourhood for health promotion;
— the primary care group for primary
care services;
— the catchment area for secondary
care;
— the social services authority for
community care;
— the district council for environmental
issues; and
— the county for tertiary and certain
large scale issues.
HIPs are not simply local commissioning plans;
they require to be professionally led and to focus on service
pathways rather than traditional service units. An external task
force should be established to carry out extensive audit on some
of these programmes.
THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
There is a recognised need to develop the evidence
base on which public health practices. If the Agency is established
to do this, then it has a vital role that could be seen as being
equivalent to NICE for clinical practice. However, to function
in this way, we believe that the Agency needs far more support
from the Department of Health and needs well-established links
with academic networks for primary care and environmental sciences.
The Agency also needs to be given the opportunity to research
developments and initiatives which cannot be evaluated in the
short term, for example, the long term effects of health education
and prevention.
THE ROLE
OF PGCS
AND PCTS
The White Paper The New NHS heralded
a major re-organisation of the NHS and introduced the establishment
of Primary Care Groups (PCGs) and the abolition of the internal
market. PCGs proposed a new structure for the commissioning of
health services, clinically driven and primary-care led. Health
Improvement Programmes (HIPs) are the driving force behind health
service planning and have clear priorities on health outcomes,
and effective practice. PCGs are thus required to plan for a locality
population, working with local communities, other agencies and
the voluntary sector.
The CPHMCH sees the establishment of PCGs and
PCTs and the framework of HIPs as offering real vision for not
only how the NHS might play a part in the improvement of the public
health in the future, but also how the other agencies and local
communities might work together on the wider influences of health.
We also see many opportunities for those working in public health
medicine to develop their roles and demonstrate the value and
attributes of both the overview and the skills of public health
medicine specialists.
In particular we see the development of PCTs
and PCGs as a primary care-led decision-making on planning and
use of resources; and a mechanism for collective decision-making
at a local level over resources within a unified budget. We believe
this has the potential to remove some of the organisational barriers
which have been in place between secondary and primary and community
care, between different provider organisations and lead to the
establishment of a strategic planning framework that is driven
by health priorities. There is scope to strive to develop direct
relationships between health and other policy areas such as social,
environmental and economic; and initiate a major drive on quality
and equity, with a focus on evidence based policy.
The price to pay for all these radical developments
has been another major re-organisation within the NHS and the
initially unsettling effects this can have. This has led to many
professionals (particularly in primary care and public health)
reviewing the part they play and examining where decisions are
made. It is clear that many doctors are being asked to operate
in the areas in which they feel ill-equipped or lacking skills
and experience. For example, GPs becoming involved in the organisation,
management and strategic planning of resources; public health
doctors working at a more local level with primary care practitioners;
to help develop new organisations that appear reluctant to assume
these new wider roles and responsibilities. We would like to see
an organisational development agenda that recognises this.
The creation of this new structure within the
NHS inevitably raises questions as to how the new structures will
operate. We hope the Chief Medical Officer's review of the public
health infrastructure will take account of not only developments
in primary care, but also the whole range of functions of public
health practice including communicable disease control. The CPHMCH
is currently considering the communicable disease control function
and where it should best sit organisationally in the future NHS,
and how it would exert the necessary control across the new organisations.
We have been alarmed by some suggestions that it could be removed
from DHAs and sited within the new public health observatories.
Consultants in communicable disease control need knowledge of
disease and epidemiological skills but also an extensive local
knowledge and close working relationships with other key players.
We hope that the CMO's review of the public health infrastructure
will help to address some of these wider issues but are frustrated
by the time being taken for the review to be completed.
We are also uncertain as to the future of many
community health services with the development of PCGs and PCTs,
for example, community child health services and family planning.
We are concerned that this traditionally underfunded sector of
the health service will continue to struggle within the new organisational
structure and would wish to see ways PCGs could be used to improve
the service rather than fragment it.
THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
The CPHMCH welcomed the appointment of a Minister
of Public Health and recognised the potential value of the post.
We do, however, have some concerns over the seniority of the post
and capacity to influence other Government departments, but this
is no criticism of the two individuals who have held the office
to date and have worked hard to achieve the confidence of those
working within public health. We believe that the role of the
Minister should be developed to a far greater extent across inter-Government
departments so the impact on health of all Government policies
can be measured and assessed. We have met both Ministers and have
worked together with them on public health issues. We very much
hope that this spirit of collaboration and co-operation will continue.
It has been acknowledged that in the past opportunities for collaboration
have been missed and the CPHMCH believes there is scope to develop
this relationship far more, to the benefit of both the health
of the population in general and the medical profession itself.
The CPHMCH has also viewed with concern the
apparent limitations of the capacity and skills base of the public
health department within the Department of Health. We believe
that as a result of its very limited capacity of trained public
health doctors its ability to influence the health components
of other Government departments' policies is compromised. It has
been the Committee's experience that other Government departments
welcome and respond positively to health advice and we deeply
regret the failure of the Department of Health to build upon and
strengthen this.
THE ROLE
AND STATUS
OF THE
DIRECTOR OF
PUBLIC HEALTH
The historical role of public health doctors
is to act as the entrepreneurial advocates for health in their
population. Their task is to identify the changes that are needed
to improve the health of the people and to secure these changes.
These will often be major changes over long time scales and face
considerable obstacles and vested interests ranging from the slum
landlords of the past to the tobacco industry of today. Often
their only power is persuasion of organisations over which the
public health physician has no direct control and to which he
has no direct responsibility, such as local authorities, industry,
political groups, etc. Their prime function, drawing heavily upon
professional knowledge, entrepreneurial ability, creativity, judgement
and risk assessment, has been constant for over a century and
will remain constant, even though their more routine bureaucratic
functions have changed and will continue to change dramatically
as the organisational format in which they work itself changes.
In particular, the work of district directors
of public health and their consultant colleagues includes the
assessment of local health needs and problems, the development
and implementation of health promotion strategies, leading the
authority's work on improving appropriateness and effectiveness
of clinical and non-clinical interventions, developing and sustaining
relationships with authority members, clinicians, GPs and PCTs,
local authorities and the community. They are accountable for
surveillance, monitoring and control of communicable disease,
including the appointment of a consultant in communicable disease
control (CCDC), and they are accountable for the surveillance,
monitoring and control of non-communicable environmental exposures
and all factors relevant to health. They act as the focus for
all local public health advice including ensuring that providers
of primary, hospital and community care, including the voluntary
and private sectors, have access to adequate and appropriate public
health advice.
The CPHMCH strongly believes that the DPH is
not simply a manager of a part of the organisation. The role encompasses
leadership, influence via gaining respect as a professional colleague
and providing an agenda-setting, ideas-generating role for the
health authority. The DPH also acts as an advocate for the population
served by the health authority and an independent professional
voice (without other vested interests) on behalf of that population.
The professional accountability of medically qualified doctors
means they have added value in this role. Through his annual report
the DPH fulfils an independent public audit function. There is
no other part of the organisation (except the Chief Executive)
which has a role across all three functions. Under the leadership
of the DPH, the consultants in public health medicine will carry
responsibility for functions such as needs assessment, public
health advice to specific local authorities, or environmental
protection that are, in themselves, major functions. The fact
that so much of the work of the public health department is achieved
through others, including groups external to the organisation,
may conceal the importance of these functions if a simplistic
head count is the basis of observation.
Saving Lives—Our Healthier Nation
suggested the creation of a new post of specialist in public health
"which will be of equivalent status in independent practice
to medically qualified consultants in public health medicine and
allow them to become Directors of Public Health". When it
learn of this proposal the BMA Annual Representative Meeting rejected
the implication that the core roles and responsibilities of directors
of public health and consultants in public health medicine could
be carried out by non-medical specialists, and insisted that every
population must have an independent public health physician with
the right of free speech and full access to health and local authorities
on all issues affecting public health. Public health physicians
are well used to the concept of multi-disciplinary team working,
indeed most accept that the public health enterprise can only
be conducted in a multi-disciplinary framework. This summer, at
their annual conference, public health doctors called for the
development of a satisfying career structure parallel to that
of public health medicine for those who are not medically qualified;
and also for the development of recognised, rigorous and relevant
qualifications for those following this career path.
We are extremely concerned, however, about the
notion that a health authority or in due course a primary care
trust, might be able to function effectively without a public
health doctor at the heart of its corporate structure. We have
made these points to the Minister for Public health, as we fear
this proposal will undoubtedly have implications for recruitment
to, and retention in, the speciality of public health medicine.
THE EXTENT
TO WHICH
CURRENT PUBLIC
HEALTH POLICY
IS REDUCING
HEALTH INEQUALITIES
The CPHMCH has previously advocated that an
authoritative, strategic, independent standing body along the
lines of the Law Commission or the Royal Commission on Environmental
Pollution be established to report regularly on major public health
issues. This would provide an invaluable support to the Minister
of Public Health. It would also provide the strategic focus on
health sometimes missing in the Department of Health with its
focus on health care and waiting lists and its lack of skills
in addressing key determinants of health such as poverty, cold
damp housing and poor nutrition and pollution.
Task forces may operate at national/regional
or local level. For example, at national level, roles might be:
— to inform the Minister for Public
health;
— to inform all relevant Government
departments on their brief in relation to delivering the public
health agenda;
— ensuring that the public health agenda
is the prime factor in determining government policy; and
— to pull together, define and disseminate
best practice based on evidence in relation to the target areas,
for target-setting and for effectiveness of interventions.
Membership should be governed particularly by
the need for specialist experience and expertise and should include
representation of those with key responsibilities and accountabilities,
key players within and without the statutory sector including
users and community representatives. The BMA and other public
health interests should help to identify the potential membership.
We strongly believe that such a body would be instrumental in
reducing health inequalities and improving the health of the population
across the country.
We have been pleased to see the Government has
identified a number of priorities for action to promote health
and reduce inequalities in the health status of the population.
We have been actively engaged in discussions with the Minister
on some of these key initiatives, including the development of
a national surveillance scheme for monitoring the incidence of
accidents. We strongly support the aim to reduce accidents but
believe this can only be done effectively when accurate statistics
are recorded, and the surveillance is linked to national policy
development and implementation. The model of effective practice
in this area is established in the USA. We also support the intention
to reduce the incidence of coronary heart disease and stroke but
believe that targeting of risk factors and of effective early
interventions will require deployment of additional resources.
We also believe that other projects such as healthy eating initiatives
and programmes to encourage physical exercise are vital to reduce
inequalities in health and must be adequately resources and supported.
We make no apology for continuing to argue strongly
that the fluoridation of domestic water supplies would be a highly
effective preventative health measure and make a significant contribution
to reducing health inequalities. The scientific evidence of the
effectiveness, safety and cost benefit of fluoridation is overwhelming
and demonstrates that it is an effective means of reducing the
gap in dental health between those in the highest and lowest socio-economic
groups. We urge the Government to act now and introduce this major
preventive health measure.
CONCLUSION
"it is better to be healthy than ill or
dead. This is the beginning and the end of the only real argument
for preventive medicine. It is sufficient" (Geoffrey Rose:
The Strategy of Preventive Medicine, 1992).
We would welcome the opportunity to discuss
these points or any other related issues with the Health Select
Committee.
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