House of Commons - Health

Select Committee on Health Second Report

Local Strategic Partnerships

148. In an attempt to deal with this plethora of partnerships, the concept of local strategic partnerships was promoted by the Social Exclusion Unit in its strategy for neighbourhood renewal. It envisaged that:

"The new framework for community planning could be used to set in place local strategic partnerships to ensure better joint working in deprived neighbourhoods. These would bring together public sector services - including non-local authority services like the employment service and health - as well as private, voluntary and community sector interests. Their goal would be to work up an agreed strategy for addressing these problems, and contribute to the achievement of the targets to which each service is working individually. Government Offices would support and accredit partnerships. The development of these partnerships would be a key way to recognise and incentivise good local government practice, while supporting areas where joint-working was less well-developed. They could also provide vehicles for the rationalisation of multiple local plans [such as the HImP] and partnership requirements; for the local co-ordination of area initiatives; for the development of local frameworks to support Urban Renaissance; and would go with the grain of other possible new initiatives, such as PSAs with local authorities."[181]

149. It is likely that, in the medium term, all local action zones, including health action zones, could be integrated into local strategic partnerships. A consultation paper was published by DETR in October[182] and further guidance has recently been published. The latest guidance from the Social Exclusion Unit recommends that local authorities are strongly encouraged to set up local strategic partnerships; that the 88 most deprived local authority districts should be required to set them up in order to receive allocations from the Neighbourhood Renewal Fund; and that local strategic partnerships produce local neighbourhood renewal strategies as part of their community planning duty.[183] We urge that health objectives are at the heart of these neighbourhood renewal strategies.

150. We found a great deal of support for local strategic partnerships. John Ransford, head of Social Affairs, Health and Housing at the LGA, commented:

"I think the local strategic partnerships are absolutely key to all this. They are probably the most essential element coming out of the National Strategy for Neighbourhood Renewal in terms of pulling all this together appropriately at the right level."[184]

Ken Jarrold, Chief Executive of County Durham and Darlington Health Authority, agreed that "local strategic partnerships are absolutely fundamental, particularly when linked with this other question of community strategies". He noted that:

"What we have been trying to do so far is have organisations that primarily bring together social services and health and what we really need is member and officer bodies led by the local authorities that provide the focus for this huge range of initiatives."[185]

Mr Elson added his support and hope that "local strategic partnerships will help to create the umbrella organisation or forum that we need to achieve better integration of the planning processes".[186]

151. We understand there is now a respectable body of research identifying the success criteria to ensure effective partnerships. We urge the Government to apply these to its own proposals to establish new partnerships in the form of Local Strategic Partnerships as well as to its 'joined up' policy agenda across government departments. In particular, we recommend that the lessons from the HAZs emerging from the national evaluation are taken on board in the development of LSPs.

THE ROLE OF THE DIRECTOR OF PUBLIC HEALTH

152. Following two major outbreaks of communicable disease (salmonella at Stanley Royd hospital Wakefield in 1984 and Legionnaires' Disease at Stafford in 1985) the Acheson inquiry was established to "consider the future development of the public health function, including the control of communicable diseases and the specialty of community medicine".[187] The ensuing report recommended that a single person should be responsible and accountable for the public health function in each health authority. This named person was to be the Director of Public Health and was allocated specific tasks:

"1.  To provide epidemiological advice to the District General Manager and the District Health Authority on the setting of priorities, planning of services and the evaluation of
outcomes;
2.    To develop and evaluate policy on prevention, health promotion and health education involving all those working in this field. To undertake surveillance of non-communicable disease;
3.    To co-ordinate control of communicable disease;
4.    Generally to act as chief medical adviser to the authority;
5.    To prepare an annual report on the health of the population; (or to quote the former MOH duty 'To inform himself as far as practicable respecting all matters affecting or likely to affect the public health in the [district] and be prepared to advise the [health authority] on any such matter');
6.    To act as spokesperson for the DHA on appropriate public health matters; and
7.    To provide public health medical advice to and link with the local authorities, Family Practitioner Committees and other sectors in public health activities."[188]

Each NHS Region and District has its own DPH.

153. The Association of Directors of Public Health emphasised the high degree of qualifications their members possess. Each DPH will have undertaken training of at least three years in clinical medicine and have spent five further years in higher specialist training in public health and then a period of up to 10 years as a consultant in public health medicine before their appointment as DPH.[189] The Association describes the "core business" of the DPH as combining "medical management with the science of epidemiology".[190]

154. According to the RCN the creation of the role of DPH "did much to pull public health in from the margins of the NHS and to develop the public health medical model specialism" but the focus of the new public health departments became public health "science" rather than "practice" (ie hands-on population based approaches to health in the field).[191]

Powers of the DPH

155. One of the issues raised in evidence to us was the vagueness of the Director of Public Health's remit and the lack of direct power he or she could bring to their job. Our impression is that a good deal was lost with the transfer of the public health function from local government in 1974. On our visits, many of the workers in the field we spoke to told us that the old Medical Officer of Health used to command more attention and had a far more direct role in driving policy. The NHS Consultants' Association described the current situation of the DsPH who tended to work simply as executive members of health authorities:

"Health Authorities remain preoccupied by health services, and the DsPH often finds it difficult to act as a physician for their community ... the effectiveness of the DPH is blighted by the fact that there is no clarity about the role or definition of competencies."

They draw attention to a school of thought that the DPH should be the clinical director of the public health directorate and, as with other clinical directors, this post should normally be held for about five years. The Nuffield Trust raised the issue of whether the post of DPH involved too many dimensions to be effective.[192]

156. Dr Ruth Hussey, DPH for Liverpool Health Authority and an adviser to the Chief Medical Officer told us "The director of public health does not have many powers that are vested in the post. The powers that we have are influencing powers ... I want to see ... models whereby we can have the opportunity to influence through our technical knowledge, our expertise and our advocacy skills".[193] Her comments reaffirm the need to equip DsPH, and possibly all public health practitioners, with the requisite skills to function in the way described. We asked Dr Hussey how proactive a role she took, for example, in interdepartmental discussions over the provision of green space for children's play areas. She described how, if she felt it appropriate she would either approach the Regional DPH, or if it was a sufficiently significant matter, the CMO himself, or else she would pursue "the ... departmental route".

"I am regularly sent consultation documents from the Regional Assembly and Development Agency ... the Regional Offices and the NHS have staff working across that partnership as well. I can either go up the route of the relevant Government department and/or go up the public health route and hope at each level there will be some cross influencing."[194]

We pressed her on how often she would be consulted in this way, but she could only confirm "regularly".

157. The BMA described the historical role of public health doctors as "to act as the entrepreneurial advocates for health in their population". They argued that the DPH assumes the role of "an advocate for the population served by the health authority and an independent professional voice (without other vested interest) on behalf of that population".[195] The Medical Practitioners' Union and the RCN both argued that the DPH has been sidetracked by the NHS agenda, which has had the possibly unintended effect of DsPH losing sight of their core business.[196] Our strong impression is that the current role of the Director of Public Health is too vague and the influence the DPH can bring to bear too little. We were not struck by any real sense that the DsPH were acting in the entrepreneurial way the BMA suggest. The DsPH do not seem to us generally to be providing the necessary leadership in the public health field.

What can be done to make the Director of Public Health more effective?

(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".[197] 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".[198] 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 agenda-setting document.[199] 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 item.[200] 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.[201] 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.[202] 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.[203] 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",[204] 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 DoH record:

"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."[205]

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".[206]

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.[207] 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.[208] 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.[209] 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.