APPENDIX 36
Memorandum by Dr Tony Jewell (PH 70)
1. INTRODUCTION
1.1 I am submitting this short report to
the Select Committee in an individual capacity. I am a Director
of Public Health and submitted my recent Annual Report for Cambridgeshire
to your committee to illustrate the value of such reports to the
local Health Improvement Programme and the partnerships concerned
with the health of the population. I was invited to submit evidence
and this paper reflects my experience as a DPH.
1.2 As a Council member of the UKPHA I am
committed to tackling inequalities in health through modifying
the underlying determinants of health such as poverty and the
need to see local authorities as key partners concerned with the
social, economic, environmental well being and therefore the health
of their population. Professionally I am committed to reducing
inequalities and through the Cambridgeshire HImP we have forged
close relations with local authority partners.
1.3 There are four central points that need
to be made;
— To deliver appropriate public health
practice in a variety of settings we need a cadre of public health
practitioners who represent a broad multidisciplinary background
who, following appropriate training, are armed with core public
health values and a set of public health competences.
— Such practitioners would form part
of a multidisciplinary public health workforce.
— Public Health practitioners function
at different levels of population and in different organisational
settings.
— Public Health leadership needs to
be keyed in to organisations with a statutory responsibility for
a defined population.
1.4 I have structured this submission using
your terms of reference headings.
2. CO -ORDINATION,
GOVERNANCE AND
THE POPULATION
OF INTEREST
2.1 One of the characteristics of public
health practice is the key question—what is the population
of interest? This can, in the case of an individual with Lassa
fever, focus initially on a single individual with a communicable
disease who needs effective individual management but who poses
a wider public health risk. Starting from such an index case the
wider public health risks are assessed and appropriate preventive
actions taken. These might escalate to international control measures.
2.2 Another important concept in public
health is epidemiological stability, for a specified condition
there will be a relevant population size where the incidence and
prevalence is predictable within reasonable error limits. Rare
conditions may require a national surveillance system and national
treatment centres. Eg some rare genetic disorders and new highly
specialised treatments commissioned by the National Commissioning
Advisory Groups. Others require a regional population of 5-10m
to assess needs and appropriate services. These conditions are
specified by regional specialist commissioning groups. Other conditions
look to smaller populations for example a cancer network looks
at over 1 million catchment population. The process moves down
through Health Authority populations to small populations, such
as Primary Care Organisations where epidemiological stability
is seen for common conditions only (heart disease, arthritis,
depression respiratory infection, contraception).
2.3 Usually the population of interest for
public health practitioners in the UK is defined by health authority
or governmental boundaries. Starting from individuals and communities
these governmental structures, in a rural area such as Cambridgeshire,
are built from three tiers of local government—Parish Councils
and Town Councils, District or City Councils, through Unitaries
and County Councils.
2.4 Above local government we are seeing
the development of regional government and their aggregation to
Nation State. This then progresses to a UK perspective and so
to European (EU), Regional (WHO) and then Global perspectives
(UN). At each level of governance there is a defined population
of interest and sometimes this carriers the weight of statutory
responsibility.
2.5 At each level of governance there needs
to be clarity about the statutory public health function. Nationally
there is a Chief Medical Officer within Government and regionally
there are Directors of Public Health who, following the loss of
statutory regional health authorities in 1996, will increasingly
be aligned with regional government. Locally District Directors
of Public Health are employed by Health Authorities. In an area
such as Cambridgeshire, where there is a County and Unitary Authority
(Peterborough), the statutory body of relevance is the Health
Authority.
2.6 The population of interest in the Health
Authority is now, not only the resident populations of the five
district councils and unitary, but the responsible population
of our seven PCG/Ts. In addition to the County and Peterborough
we have five second tier District and City Councils who make up
the 730,000 resident population.
2.7 When District Health Authorities in
Cambridgeshire were smaller there used to be three DPHs covering
the population of Cambridgeshire. If each second tier local authority
had a DPH there would be six and if each PCG/T had one there would
be seven! One model we might consider is that each PCG/T and its
broadly equivalent District Council should have a named public
health specialist (at present consultant in public health medicine)
who is an Assistant DPH with statutory responsibilities for that
local authority and executive committee responsibility for the
primary care trust population. Such a position could be open to
Public Health Specialists.
2.8 This could, given the PCG/T population
of interest for a Health Authority, be aggregated to HA level.
Such Health Authority populations are of sufficient size to make
Health Improvement Plans credible for NHS planning. For example
for implementing the coronary heart disease National Service Framework
requires a service networks involving primary, secondary and tertiary
care.
2.9 The central point here is that there
is a local, regional and central government hierarchy in government
but the English NHS organisation is often not coterminous below
regional levels. Ways need to be found to build public health
population responsibilities, which are synergistic with local
sensitivity at PCG/lower tier government, while having a sub regional
population of sufficient size to enable effective NHS HImP planning
and performance review functions.
3. HAZ, HIMPS
AND COMMUNITY
PLANS
3.1 The statutory duty of partnership between
local authorities and health authorities has enabled a rapid development
of partnership working directed at ensuring Health Improvement
Programmes represent a shared agenda. The very process has enabled
the development of a shared responsibility within and between
partner organisations. The targeting of specific initiatives such
as Health Action Zones, Surestart schemes and Education Action
Zones was a necessary mechanism to pump prime a targeted approach
to tackling disadvantage. However in the longer term these programmes
need to be integrated into local plans and so reduce the confusion
of accountabilities and the crowding of the arena. All areas have
HImPs and the future model needs to be built on that rather than
the exceptional targeted communities. Resourcing with appropriately
weighted capitation formula will ensure that disadvantaged populations
are resourced fairly to meet their needs from mainstream budgets.
This should extend to small area neighbourhood levels within PCG/Ts.
3.2 With the development of Community Strategies
lead by local authorities much integration can occur at district
level. In County environments like Cambridgeshire the HImP, based
on a larger planning population, can still provide the strategic
framework. Below this level we look to smaller PCG/T/LA levels
to have local partnership arrangements to feed in local needs
assessments and implement locally sensitive plans. This is the
model we are pursuing in Cambridgeshire. By developing a hub and
spoke public health function with our PCG/Ts we can ensure that
work is done at local level and more specialist inputs are provided
at HA and HImP levels.
4. HEALTH DEVELOPMENT
AGENCY (HDA)
4.1 The HDA is an important development
and should be the focus for national expert work on the wider
determinants of health, which can build up an expert evidence
based approach. The current plan to fund regional HDA appointments
is questionable as there is a serious risk that inadequate resource
is housed centrally to do the enormous amount of work needed on
effective health programmes. The new appointments could be seen
as additional health promotion staff in ROs rather than part of
HDA critical mass with questions about their added value.
4.2 The loss of status of Accidents and
Injuries, the fourth national contract in Our Healthier Nation,
is regrettable. This should be a public health programme supported
by the HDA promulgating evidence based approaches to Health Promoting
Schools, Healthy Homes, Healthy Workplaces and a Health Promoting
Environment. A coherent and evidence based approach to effective
health promotion, health protection and neighbourhood renewal
and community development interventions should be the task for
the HDA.
5. PRIMARY CARE
ORGANISATION (PCO)
5.1 I have already identified these new
organisations as key NHS corporate bodies who become statutory
when they achieve Trust status and who have a defined population
of interest. They already have a health improvement responsibility
in addition to providing primary and community care and commissioning
hospital and other services. They need therefore to have access
to skilled multidisciplinary public health support corporately
to work with the Board and management and being represented on
the Executive Committee of PCTs. Their staff with a public health
function such as Health Visitors and General Practitioners need
to have access to public health leadership and specialist support
to help the effort within practice populations be built into coherent
programmes of action eg successful childhood immunisation.
5.2 The registered population of PCOs varies
from about 60,000 to 300,000 with the proposed median of about
100,000. This is made up of units of general practice registered
populations with perhaps 50-60 GPs in a typical PCO. These units
are the building blocks for PCOs equivalent to ward populations
in local government. The public health function needs to work
from within practices, alongside GPs and Health Visitors as well
as within communities and neighbourhoods alongside community development
workers and other key organisations such as schools and workplaces.
The practice based approach offers a rich context for needs assessment,
health service programmes and evidence based practice and will
rely on engaging the public health workers already out there who
are the foot soldiers for local activity and a sleeping public
health resource. These include a variety of public health workers
employed within local government.
5.3 A model of public health support to
PCOs corporately and GP practices and neighbourhoods in the patch
will generate workforce estimates for different types of public
health specialists suited to the different roles and settings.
This builds on health visitors and other public health nurses,
community development and local health promotion specialists to
more specialised public health specialists and consultants in
public health medicine. A coherent network of public health practitioners
can be provided through hub and spoke arrangements which allow
for a critical mass of skilled and relatively scarce specialists
at HA level who support the HImP, HA wide public health information,
training and R&D functions. This hub is linked systematically
to PCOs and supports them corporately while also helping to steer
and support the practice and community based teams.
5.4 The DPH at HA level provides the focus
for public health leadership across the HImP partners and the
Information for Health strategy. This is an integrative function
which helps avoid damaging fragmentation.
5.5 An independent agency would damage corporate
links and independence can be achieved by appropriate development
of academic and other specialist public health units.
6. MINISTER OF
PUBLIC HEALTH
6.1 The Minister of Public Health is an
excellent development within national government. However locating
the Minister as a junior post within the DOH severely restricts
their impact. The post should be at Cabinet level, perhaps based
in the Cabinet Office, with responsibilities that enable a powerful
cross government role.
6.2 The health of the people is the highest
law, wrote Cicero, and this means that the health of the population
is not a subsidiary government objective but arguably the most
important. Why doesn't the CMO's report on the health of the population
get presented to Parliament by the Prime Minister? Why isn't the
success of government based on achieving Our Healthier Nation
strategic objectives of prolonging disability free life expectancy
and reducing health inequalities?
6.3 The success of the Social Exclusion
Unit, which is a relatively small team based in the Cabinet Office
with access and commitment from the Prime Minister, shows how
such a post might work in future. The Prime Minister's personal
involvement in the National Plan provides a political opportunity.
If not based in the Cabinet Office then within a department with
responsibilities for the wider determinants of health such as
the Treasury or DETR.
7. DIRECTOR OF
PUBLIC HEALTH
(DPH)
7.1 The DPH role is of crucial importance
as it is a statutory post with a defined population of interest
and clear links to a statutory body. The regional DPH lost its
statutory body in 1996 but in future is likely to be linked into
the regional government tier.
7.2 District DPHs are currently employed
by Health Authorities with responsibility for a defined population
and the opportunities for close local authority links. For example
the Communicable Disease Control function is based within DPH
departments and have proper officer responsibilities within local
government environmental health functions. In some metropolitan
areas, where there is a reasonable population size and coterminosity
with local authority boundaries, joint appointments between HAs
and LAs are possible. In County areas, as described earlier, the
size of district councils can be very small (East Cambridgeshire
District Council with 70,000 population) and there are up to seven
local authorities within one HA. The model described of Assistant
Directors within PCTs and second tier LAs is possible.
7.3 Whatever the model there needs to be
the link between the DPH and the Health Improvement Programme,
and a statutory body with responsibility for the health of a population.
It is important to acknowledge the part that Chief Executives
and other executive directors can play as champions of health
improvement.
7.4 Departments of sufficient critical mass
to support specialisation, teamwork and training are required.
The statutory function is a safeguard that enables DPHs to have
confidence to challenge local organisations, including NHS organisations
and their chief executives and Boards, where policy decisions
may threaten the public health and to monitor health impacts objectively.
Health Impact Assessment for example need to have that confidence.
7.5 The DPH annual report is an important
vehicle to monitor progress in health improvement and support
information about needs and influence the HImP. It should continue
to be a requirement and be sufficiently resourced.
8. REDUCING INEQUALITIES
8.1 The policy in Saving Lives—Our
Healthier Nation, to reduce health inequalities which is reinforced
in the National Plan, is laudable and it would be nice if we had
agreed measures. Such measures could be used at local levels and
be aggregated to regional and national populations to monitor
progress. We have a variety of measures which record many of the
underlying determinants of health such as income inequality and
neighbourhood deprivation scores. The Treasury will have very
detailed knowledge about income inequalities and the distribution
of income. Measures of income inequality are available and could
be the basis for national targets for redistribution of wealth
and greater equity.
8.2 Public Health measures of outcome have
been put together in datasets such as the Public Health dataset
so that the inequalities can be mapped very clearly across the
country down to very local populations, by area, age, social class,
gender and ethnicity.
8.3 With the development of regional public
health observatories, which should integrate local authority and
health data, there should be data to support sources which can
be aggregated up from quite small populations to local authority/PCO
and HA/County levels. Nationally there is intent to pull the data
together to provide a Centre for Disease Surveillance and Control.
This could be built on the model of the CDC in the USA by linking
to the Public Health Laboratory Service Centre for Communicable
Disease Surveillance and Control (CDSC).
8.4 We have the data to establish the extent
of inequality and set targets to reduce them. A serious political
error was made when OHN did not agree national inequality reduction
targets and we have lost time in developing the most appropriate
measures and interventions to achieve such targets.
8.5 Income inequality measures and indices
such as the Robin Hood index and Gini coefficients are useful
tools. Composite scores such as the DETR deprivation scores are
helpful and offer multidimensional health improvement interventions
to achieve a shared objective. It is likely that we will need
several health outcome targets to take account of life cycle—maternity,
childhood, young people, working age and older people as well
as other types of inequality by age, sex, ethnicity and locality.
Using such data sources we can establish baselines in the wider
determinants of health, set targets and measure progress towards
reducing inequalities.
8.6 The National Plans commitment to develop
such scores and national targets is to be commended and should
be an urgent task for groups such as the HDA to help lead.
9. CONCLUSION
9.1 Over the last 25 years public health
practice has been subjected to a number of reviews and changes.
The multidisciplinary professionals who make up the workforce
share the vision of improving health and reducing inequalities.
What they need now is confirmation of their function and place
in organisations and settings with public health responsibilities.
To deliver the new and exciting agenda their critical mass needs
to expand so that the public health function overall is strengthened.
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