Memorandum by Dr Andrew Richards
I understand that the Health Committee is making
an enquiry into public health and its organisational arrangements.
This letter is to ensure that the Committee is aware that in a
number of places some practical action has been taken to move
public health closer to local government, with the creation of
joint Director of Public Health posts. The first of these was
in Solihull, and from 1 January 1999 to 14 March 2000, I held
this post. Funding was shared jointly by the Health Authority
and by the Solihull Metropolitan Borough Council, which also provided
council office accommodation and Chief Officer status to the postholder.
A similar post now exists in Wolverhampton, and there is a joint
Health Authority/Social Services Director of Public Health in
Somerset. These arrangements draw on the practical experience
and example of districts like Stockport and Sandwell, where close
working has been evolving over a number of years.
These arrangements recognise the interest that
local government has in health improvement and the long history
of local government's responsibilities to protect the public health.
They follow a trail of logic from public health's historical roots
through to "Our Healthier Nation" and the current focus
on partnership. These joint appointments are consistent with a
wider movement towards greater integration.
The duty of local government to improve the
social, economic and environmental well being of their communities
dovetails sweetly with health authorities' responsibility to improve
health and reduce health inequalities. It is only an accident
of organisational history that these related goals are vested
in separate places. Joint DsPH can act as a bridge between the
NHS and local government as they begin to pull together to improve
the quality of life in their locality.
Over the last quarter century there has been
an emphasis on public health professionals working within the
NHS. It is no sin to apply one's skills and knowledge primarily
to the needs of one's employer; however, an inevitable but unfortunate
consequence has been an attrition of the application of public
health in fields beyond the NHS. Paradoxically the major threats
to the health of the population are not related to the provision
of health services, but to poverty, unemployment, and an unhealthy
lifestyle and environment. 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. Posts that are not wholly accountable
through the NHS might counteract this gradient.
The experience of such posts is limited both
in time and number. These may be the first public health doctors
to work directly for local authorities for a quarter of a century
and a lot has to be relearned. I believe that while working across
local government as well as the NHS adds to a set of responsibilities
that is already heroic, it is the right thing to be doing. The
Director of Public Health is being pulled in many directions but
I believe that the primary duty is to provide leadership across
a community for those who seek to improve health and well being.
It is irrational that most of the interest, skills and resources
to improve public health are outside the NHS while the Director
of Public Health is locked into it. Within health authorities
some Directors of Public Health have made a substantial contribution
towards improving the quality, clinical effectiveness and efficiency
of health services. This remains important and no doubt they can
do the same for PCTs in the future. But this is simply to use
public health skills and knowledge where they are usefully applied
rather than where they are best applied.
The evidence that the current organisational
structures for public health are successful in addressing the
main public health concerns of today is limited. An ideal solution
may not exist but there are strong arguments that Directors of
Public Health have to be eased out of the NHS box. Joint posts
might help to place the Director of Public Health closer to the
centre of the web of responsibilities, budgets, skills, interest
and power than can impact on health in their locality. This should
help them to provide the necessary leadership for public health
at a local level, which governments and health authorities have
found difficult to make a priority. I hope that in its deliberations
the Committee will wish to consider the place of joint Director
of Public Health posts.
5 July 2000