(a) The annual report
158. One of the requirements of DsPH is that they
should prepare an annual report on the health of the population,
one of the duties they inherited as successors to the Medical
Officers of Health following the recommendations of the 1988 Acheson
report (the annual public report lapsed between 1974 and 1988).
This, according to the Department, is required to be "a public,
independent report to their Health Authority which will inform
them of the health and health needs of their populations".
The annual report of the former MOH was, according to John Ransford
of the Local Government Association, "an extremely influential
document". It could "brigade resources" and was
"clearly one of the major priorities" for local government.
For all the grandiose aims of the Director of Public Health's
report, we had no sense that these documents carried equivalent
weight. Dr Donnelly of the Association of Directors of Public
Health told us that some DsPH regarded the annual report as a
"retrospective document" a record of the year which
tended to come out "two or three years after the fact";
others produced an in year report which was "forward looking"
drawing on sources other than statutory bodies. It was this type
of document which he favoured. If, as the BMA claims, the annual
report performs a vital "independent audit" function
it is surprising that it allows such extreme variation.
159. In fact, those annual reports which we ourselves
have looked at are bewilderingly diverse. As one independent analyst,
Anne Davies, wrote: "for many Directors of Public Health
they are still the 'annual chore of questionable value', the 'statistical
exercise which diverts resources from other work', which the Acheson
Committee warned against in 1988".
A report by the same author for the Institute for Public Policy
Research found few criteria which allowed annual reports to be
compared, pointed to an erosion in the independent authorship
of the report, noted considerable variations by DsPH as to the
function of the report and a failure to use the report as a strategic
Yet the annual report, according to the Government's White Paper
The New NHS: Modern, Dependable, is supposed to be the
starting point for the HImP.
160. One factor underlying the deficiencies in the
Annual Report might be the differing degrees of seriousness with
which health authorities regard not only the annual report itself
but also the entire public health agenda. A stark indication of
the discrepancies of approach was given in oral evidence from
Dr Donnelly. He told us that some DsPH did not even attend the
annual review of the health authority, and that at many of these
reviews the health status of the population was not even an agenda
We found this suggestion astonishing, and asked Dr Donnelly to
contact members of his association to ascertain the extent of
the problem. Given the time restraints, Dr Donnelly was only able
to contact a little over around 40% of the DsPH in England. But
the results of his inquiries substantiated the claims he made
in oral evidence. Of those who responded only 43% had attended
their annual review in 2000 compared with 49% for 1999 and 56%
for 1998. Only 59% of DsPH indicated that population health formed
a substantial agenda item at the meetings.
The lack of priority accorded to population health at the annual
health authority review meeting, and the fact that over half of
the DsPH surveyed failed even to attend the meeting, suggests
to us that DsPH do not, on the whole, carry real weight within
the health service. We recommend that guidance is immediately
circulated to require DsPH to be present at the annual review
of the health authority and to require population health to be
an agenda item, a requirement made even more pressing by the recent
publication of the national health inequalities targets.
161. We note that the Government is currently
reviewing the impact of the annual report of the DPH.
We believe that the annual report of the DPH should adopt a consistent
format to ensure compatibility of data. It should clearly distinguish
between past trends in epidemiology and key present agenda concerns.
We feel that the Health Development Agency should have an early
input into producing guidance to ensure a far greater degree of
standardisation across the DPH report whilst still allowing sufficient
flexibility to achieve sensitivity to local conditions and needs.
Guidance should be issued on the range of bodies that should be
consulted in drawing up the annual report. For example, Dr Rosemary
Geller, DPH for Shropshire, told us she used the need to draw
up an annual report as an opportunity to visit all relevant organisations
and stakeholders once a year so as to get their input.
We believe that, in drawing up the annual report, the DPH should
record the contributions not only of the statutory sector but
also of local, voluntary organisations.
The annual report of the DPH ought to be a critical document
in the formulation of the joint HImP and Community Plan.
(b) Joint appointments
162. The fact that the DPH is an executive member
of the health authority, whilst "many people in local government
believe it is their organisations, rather than health authorities,
that are public health authorities",
yields a genuine tension. Elsewhere we discuss the pros and cons
of relocating public health in local government. But we feel such
a seismic change may be unnecessary if local authorities and
health authorities have a stake in both in terms of appointing
DsPH and responding to their findings. In their memorandum the
"In a few areas of the country, where boundaries
permit, DPH posts have been established as formal joint appointments
between local authorities and Health Authorities. It is anticipated
that joint appointments will lead to greater involvement in the
local decision making process, influence the allocation of resources
for public health in local authorities, and help to ensure that
there is alignment between local authority Agenda 21 initiatives
with Health Authority activity under Our Healthier Nation."
163. Dr Andrew Richardson, a holder of the first
joint HA/LA post in Solihull, submitted a memorandum to us. He
was appointed jointly by the Health Authority and Solihull Metropolitan
Borough Council. He worked out of council offices and had chief
officer status with the council. In his view, "the location
of Directors of Public Health at the heart of the NHS has inevitably
pulled them away from, rather than towards, those parts of the
wider system that most powerfully influence health". He felt
that DsPH needed to be "eased out of the NHS box" and
that "joint posts might help to place the DPH closer to the
centre of the web of responsibilities, budgets, skills, interest
and power that can impact on health in their locality".
164. Support for joint health authority/ local
authority appointments was voiced by many of our witnesses and
we would regard this as a positive measure.
We are not convinced that the DoH has been sufficiently proactive
in helping this come about. We acknowledge that joint appointments
are much more straightforward in areas where there is coterminosity,
though even here they are the exception rather than the rule.
We would argue, as the Cabinet Office report Reaching Out
suggested, that greater moves towards coterminosity need to be
made. But even where there is not coterminosity we feel that all
stakeholders in local and health authorities ought to be able
to agree a strategy to have a Director of Public Health in post
whom they regard as partly their responsibility.
However, we do not necessarily believe that joint appointments
will bring an end at a stroke to turf wars between local and health
authorities. In this regard we would especially like to endorse
the suggestion of Ken Jarrold that, as well as having structures
to bring about joint appointments of DsPH, other structures had
to be effected to make them jointly accountable
to each authority.
We also maintain a line of argument from several of our previous
inquiries that the DPH should have ready access to those in local
government, placing population health in the immediate context
of many of the factors - housing, the environment, transport -
which most impact upon it.
National Strategy for Neighbourhood Renewal. Back
Local Strategic Partnerships: Consultation Document,
DETR, October 2000. Back
New Commitment to Neighbourhood Renewal. Back
Public Health in England, 1988, p.1. Back
Ibid., pp. 69-70. Back
Ev., p.104. Back
Ev., p.212. Back
Ev., p.467. Back
Ev., p.209. Back
Ev., p.212; Ev., p.363. Back
Ev., p.46. Back
Anne Davies, "Annual Public Health Reports" in Perspectives
in Public Health, ed Griffiths S and Hunter D, Oxford 1999,
Anne Davies, Reporting the Public Health, Institute for
Public Policy Research, 1997. Back
Ev., p.539. Back
Ev., p.14. Back
Tony Jewell, "Public Health Practice in Health Authorities"
in Perspectives in Public Health, p.163. Back
Ev., p.14. Back
Ev., p.442. Back
See eg Ev., p.216; Ev., p.479; Ev., p.436. Back
A useful model for joint responsibility, suggested by the Chartered
Institute of Environmental Health, might be police authorities:
"the models established for joint responsibilities between
the police and local authorities for community safety should be
replicated for public health and ... strategic and operational
responsibility for public health should rest jointly with 'health'
and local authorities", Ev., p.390. Back