Further supplementary memorandum by the
United Kingdom Public Health Association (PH 23B)
VARIATIONS IN THE PUBLIC HEALTH FUNCTION
ACROSS THE UK AND HOW THESE ARE IMPACTING IN PRACTICE
The UKPHA, as a multidisciplinary, cross-organisational
non-governmental association, has members in all four nations
of the UK and is involved in the development of policy and the
new public health initiatives. We therefore think that much can
be gained from a UK-wide perspective.
To the meaning of "function" we interpret
this to mean public health interventions and professional involvements
in the fullest sense. These range from the specialist professions,
encompassing the work of Directors of Public Health and Health
Promotion Departments in health authorities to Directorates of
Environmental Health (the names of environmental health departments,
and their management arrangements, vary) within local authorities
to partnership arrangements, for example involving Health For
All, Health Action Zones, and more recently HIMPs. Casting the
new wider public health "functions" are also undertaken
by numerous professions, groups and organisations, ranging from,
to take the example of drugs, alcohol and tobacco, from members
of Drug Action Teams to Customs and Excise staff.
At present there are reviews being undertaken,
such as that by Healthworks, in order to develop a fuller picture
of roles and functions in public health. Additionally, many of
our member organisations have themselves been reviewing their
own role and that of their members. These include, for example,
the Royal College of Nursing, the Community Practitioners and
Health Visitors Association and the Faculty of Public Health Medicine.
This is a development area, therefore, and it may require some
period of stability before comments can be realistically made
on how these changes are impacting in practice. Nevertheless,
it can be said that in part change is occurring because there
is dissatisfaction with the fragmentation of role and function
and lack of clarity about objectives. What is clear is that public
health is not one profession but many, and it embraces a multiplicity
of skills and knowledge bases.
Turning to the UK side of this question, there
are differences in law and custom and practice throughout the
UK, and, as a consequence of devolution, different national public
health strategies, variations in emerging institutional form,
and differences in professional emphasis and/or strategies for
This situation is historic and reflects the
contours of national difference within overall UK structures (eg,
the first public health legislation in Scotland fell under the
Police Act and in England and Wales is primarily associated with
the first Public Health Act (1848). Recent devolution has brought
other changes, including four separate public health strategies
(with the NI strategy one of first off but last to be completed).
On the other hand developments in the UK are also influenced by
a mix of international trends and recent, and potentially unifying,
national concerns. For example, the formation of the Food Standards
Agency, which is mirrored in eight other countries of the EU and
by the formation of a Europe-wide body.
One of the recently observed differences between
England and Scotland and Wales is that England has established
the Health Development Agency and national observatories. There
is no observatory in Scotland and this function is likely to be
assumed by the new Public Health Institute. In Wales a new initiative
is also being formed and there Local Health Groups have been formed
with coterminous health and local authorities, a situation which
is not only lacking in England but is manifoldly confused and
confusing. There are outstanding questions over which organisations
in Wales and Scotland (and NI) would assume the new functions
being undertaken by the English Health Development Agency. In
Northern Ireland there are cross-border links being established
through the Public Health Institute, based in Dublin, part of
the Royal College of Physicians. There are regular meetings between
UK health ministers and between civil servants in each of the
departments of health.
These comments only scratch the surface and
the full picture is complex and shifting; moreover, it is likely
to continue along this path in the immediate future. We think
that there is value in mapping these developments and reporting
upon them. This requires a concentrated period of research which
is beyond the time scale of this response which potentially engages
a large number of institutions and organisations. This may be
a matter on which the House of Commons Health Select Committee
might like to formulate recommendations and certainly this is
a task towards which the UKPHA is well-placed to be involved.
The UKPHA believes that the following factors
might be addressed by such a review.
Unifying or common themes, institutions and practices
These might include, for example:
similarities between national public
health strategies (objectives, goals, targets, practices) and
by implication where they diverge; and
UK-wide professional structures.
Dissimilarities in themes, institutions and practices
variance by governmental structure
(the Committee is already examining the combined health and social
services structures of NI);
variance by institutional purpose
(eg the formation of HDA in England versus the continuance of,
for example, the Northern Ireland Health Promotion or the Health
Education Board for Scotland;
variations in law, governance, geographic
boundaries and responsibilities; and
variations in developing professional
practice (eg resulting from tradition and culture or more recent
changes, such as recommendations on specialist professional practice).
Evidence on effectiveness
some of the organisations, institutions
and practices are very new, however, many are not and organisational
reviews may be available; and
the development of the new role assumed
by the HDA or other organisations defined on a UK-wide basis.
Opportunities for collaboration, cross-fertilisation
and information sharing
there is an opportunity to document
exemplary practice from variations across the UK, mindful of differences
in traditional and culture which may limit such transfers;
information sharing across "borders"
and from central to local, is made much easier by new technologies,
as some already by health and public health websites, NHSOnline,
Electronic Library for Health, etc. The UK as a whole may benefit
from a unifying internet "health portal"as proposed
by the UKPHA.
England contains 83 per cent of the
UK population and it would not be surprising if regional variations
were not considerable. There is already the emergence of new more
regionally-identified public health arrangements and networks
(in particular in London).
1. Would a split between the public health
medicine function and the broader public health function make
public health more manageable?
We acknowledge that there are different views
on how to establish better integration and resolve issues of scope.
In one sense there already is a split, in that public health medicine
is a highly distinct island in the ocean of multidisciplinary/multi-agency
public health. There is, however, a need for greater clarity in
the light of the fact that PHM is a professional discipline, a
branch of medicine, and a function, or more correctly part of
a function, since, in the broader perspective this is carried
out also outside the NHS, for example through environmental health
We support the development of better integration
on a multi-disciplinary, and cross-organisational model. This
would have implications for the "location" of the public
health function within Health Authorities/Boards, the links between
non-medical specialisms and agencies, and general leadership,
support for, the broader public health agenda. On the matter of
public health medicine, a key consideration here is the changes
in the size and role of Health Authorities. Only a decade ago
many of these served populations of as little as 100,000. Now
many serve over 500,000. This means that DPHs can have far larger
teams of experts immediately to hand, in addition to resources
such as the internet.
To summarise, we think that there should be
an exploration of different models of management and location,
clarification of the scope of the public health functioninto
perhaps its medical and non-medical elements, and clarification
of the role of public health medicine as one part of the full
picture of the public health function. Clarification, we hope,
will lead to better integration and more effective joint working,
and not further fragmentation.
2. In your opinion, does the Director of
Public Health have to be medically qualified or is it sufficient
for medical expertise to be available to put it colloquially,
do doctors have to be "on top" or "on tap"?
There is no need for the Director of Public
Health to be medically qualified, any more than would be the case
for a Director of Social Services to have a social work qualification.
It is essential that the Director of Public Health has sufficient
skills and experience to meet the demands of the task and that
a range of skills are available, including medical expertise,
social science, statistics, etc.
3. What skills does a modern Director of
Public Health need? Are these different from their predecessors
in the past? If so in what ways?
The most effective DPHs in the past were those
who had offered foresight, judgement, the ability to work with
politicians, the skills to bring to bear on deep-seated problems,
etc; hence there is little reason for the desirable range of skills
to be any different. We also have to acknowledge that we are living
now in a post-deferential society with more emphasis on communication
and participation. In addition to technical skills, therefore
are political, presentation and communication skills and a work
environment that requires a strong inclination towards multi-disciplinary
and cross-organisational working. Therefore, there is a need for
DPHs' skills to change in order to take all these factors into
account. Additionally, there are other issues of scale and scope:
the enlarged populations they serve;
the far fuller multi-agency public
health agenda they, and their HAs, are encouraged or required
to participate in (HIMPs, HAZs, etc);
the far closer integration of public
health and other policy domains; and
"joined up thinking" (in
relation to poverty, pollution, lifestyle choices).
4. Does the Association consider there to
be a tension between the core business of public health much of
the management workload of DPHs? Is there a risk of the urgent
always driving out the important?
We are not sure if this question is intended
for the UKPHA.
5. Are Directors of Public Health appropriately
trained for their job? Are there any skills deficits? If so how
might these be filled?
Unless a full research programme is carried
out the answer to this question would be anecdotal. The answer
is probably for some, but the real question is the level of support
for multidisciplinary working.
6. Is there a general skills deficit in public
health, and if so who, apart from health professionals, if so
how should we be training?
Yes, in individuals but no, not if the multidisciplinary
team is the model. The arrangements should cover training for
everyone but health professions but should be training all the
obvious skillsalong with input from social scientists,
geographers, epidemiologists, environmental scientists, community
development workers, transport strategists, etc, etc.
There is a need for a range of levels of training,
whose requirements in terms of students' prior education, work
experience and role, and the course's study time, and tuition
fees, are tailored to identified audiences in all sectors. Qualifications
such as MPHs must be just part of this.