APPENDIX 23
Memorandum by East Sussex, Brighton and
Hove Health Authority (PH 42)
1. This is a submission from East Sussex,
Brighton and Hove Health Authority to the Commons Health Select
Inquiry into Public Health. We welcome the opportunity to contribute
to this inquiry and have structured our comments around the Committee's
Terms of Reference.
2. HEALTH ACTION
ZONES, EDUCATION
ACTION ZONES,
HEALTHY LIVING
CENTRES, HEALTH
IMPROVEMENT PROGRAMMES
AND COMMUNITY
PLANS . . .
This is a complex and evolving area and in some
ways it is hard to draw firm conclusions. However, it would be
wise to review the effectiveness of these initiatives once they
have been evaluated. Not withstanding this observation, it is
clear that there is significant commitment from this Government
to cross cutting themes and this is welcomed. Such approaches
are critical to improving public health and to the delivery of
the public health function. They also emphasise the importance
of partnerships and collaboration both centrally and locally.
However, there is some tension between the Health Improvement
Programme and the Community Plan. The Local Government Bill identifies
the duties of local authorities to promote the social, economic
and environmental well being of their communities—but it
is not clear whether the HIMP or the Community Plan is the over-arching
plan for any local area. Conflict over this would not be helpful.
It would be useful to develop explicit guidance about the relationship
between the two plans. Options include a specific section of the
Community Plan on health improvement—or to have health improvement
as a cross cutting theme within the community plan.
3. THE ROLE
OF THE
HEALTH DEVELOPMENT
AGENCY
We welcome and support the Health Development
Agency. The development of a clear evidence base for community
based public health interventions should lead to both improved
public health practice—and as importantly, greater credibility
for public health interventions within both the NHS and local
government sector. However, there are areas of overlap between
the HDA and organisations responsible for standards in public
health practice; and these will need to be addressed.
4. THE ROLE
OF PRIMARY
CARE GROUPS
AND PRIMARY
CARE TRUSTS
PCGs and PCTs have clear responsibilities to
improve public health—but to do this they will need greater
capacity and capability. As a generalisation, they are often committed
to public health—but it is not clear whether their understanding
of the complexity of the public health function and of public
health issues is as developed as it needs to be. At the moment,
there is some inevitability to this because of the focus of the
NHS on health care. However, it is clear that the PCTs will not
be effective public health organisations unless they actively
develop their public health capabilities.
In doing this, the trick is to ensure that all
organisations (including PCTs) have effective public health leadership,
and that the appropriate level of responsibility goes to each
organisation.
5. THE ROLE
AND STATUS
OF THE
MINISTER FOR
PUBLIC HEALTH
There is no doubt that the status of the Minister
for Public Health has decreased over the course of this Government.
This is widely seen as a significant problem and echoes the difficulties
created because of the absence of national inequalities targets.
The development of such targets (which could be created—but
which have been avoided to date) and accountability for delivering
them linked to the Minister for Public Health would undoubtedly
increase both Government and local organisations' attention to
major public health issues.
6. THE ROLE
OF THE
DIRECTOR OF
PUBLIC HEALTH
The role of the DPH is complex in relation to
its span, range of skills and the consequences of having a degree
of "independence". There is no doubt that the best Directors
of Public Health pull this off effectively and exert wide influence
in the interests of public health.
In general, it is helpful to have a clear focus
for the public health function and for health improvement—but
there is a debate about where this is best placed. The Acheson
Report (1988) reached conclusions about creating decent sized
public health departments, stopping single handed practice, strengthening
communicable disease control teams . . . The principles around
these issues remain. Fragmentation would be a problem.
On the other hand, there is no doubt that there
are some advantages in placing the public health function and
the Director of Public Health within local authorities. There
would be closer organisational links to other key professional
groups, and the possibility of a greater impact on local authority
policy and actions. Whether the DPH would be more or less effective
in an organisation whose policies are determined more by local
democratic methods is debatable. Arguments can be constructed
either way.
However, there are distinct disadvantages in
moving the function and the DPH to local authorities. These include:
— the risk of splitting the current
public health function and all the disadvantages that flow from
that;
— the real difficulty of delivering
the public health roles which are intimately related to the NHS.
This would be particularly true for work with NHS Trusts. The
agenda around effectiveness, efficiency, appropriateness and equity
is central to the NHS and requires public health skills; and
— the risk of more single handed/isolated
practice.
Perhaps most critically, in a world of partnerships,
there is no benefit in going for a structural change because influence
and impact can be achieved in other ways. One particular way of
achieving this would be to make the DPH a joint appointment between
health authorities and local authorities. Doing this would emphasise
the links—but it may well be that many current and future
DsPH would need a modified sort of training and development from
what they currently have. It would also be helpful to think about
and develop local public health networks which cut across organisational
boundaries to deliver their function.
It is essential to emphasise the important contribution
that the DPH (and the current public health function) makes to
the NHS. There is some evidence that it is Directors of Public
Health who have kept inequalities on the NHS agenda and have constantly
been proponents of the "evidence based medicine" movement.
There is no doubt that some of the skills and tasks of Directors
of Public Health overlap with those of Medical Directors in NHS
Trusts and clinical leaders within PCGs/PCTs, but they inevitably
bring a focus on population health and the population impact of
health care interventions because of their background. It is hard
to see how local NHS policies and services can be developed appropriately
without a significant public health input.
One further important role that DsPH play is
that of being the "top doctor" in the local Health Economy.
They facilitate change, help deal with difficult issues and broker
deals, particularly ones which relate to senior medical staff
in NHS Trusts. This is not a strict public health role, but is
an important one within the NHS.
7. THE EXTENT
TO WHICH
CURRENT PUBLIC
HEALTH POLICY
IS REDUCING
HEALTH INEQUALITIES
It seems likely that this Government focus on
reducing child poverty, the New Deal and strategies on neighbourhood
renewal will have an impact on health inequalities. However, it
is very hard to know if this is the case because there are no
national targets for health inequalities and no national monitoring
of them.
8. Finally, as with many parts of the public
sector, this is a very uncertain time for public health. The arrival
of the Health Development Agency, the imminent report from the
Chief Medical Officer on the public health function, the development
of regional public health development plans and the Department
of Health commissioned work on standards for the public health
function are all shaping the future, but at this moment, creating
uncertainty. It would be helpful to bring these all to a resolution
as soon as possible so as to deliver an over-arching framework
for public health to allow public health capacity and capability
to develop. This would set standards for public health practice
and develop appropriate accreditation mechanisms including ones
that are relevant to sub specialist areas. It would also create
greater clarity for the basis of professional public health practice
and for the roles that individual practitioners play.
5 July 2000
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