HC 1048-III Health CommitteeWritten evidence from Professor Hilary Pickles (PH 07)

Summary

Public Health is important and we need to get it right.

The organisational changes currently proposed have major dis-benefits, costs and risks.

It would be better to stop and start again than attempt to modify the current proposals.

Introduction and Assumptions

1. There are many actions by the new coalition government which could impact on the health of the public in the short or longer term, not always by design. The actions of the Chancellor may have the greatest impact on poverty and inequalities, and those by the Secretary of State (SofS) for Energy and Climate Change the greatest on the longer-term health of the world populations. The focus here on the changes introduced by the SofS for Health, which enormous as they are, may not be the most important overall to the long term population’s health.

2. This inquiry is looking at plans for public health systems in England as outlined in various recent white papers and the Health and Social Care Bill 2011. At present there is a “pause” in the implementation process and changes are promised. However, this note is only able to comment on the original plans for organisational change and not on any yet-to-be-disclosed amended version. The rhetoric is ignored when appeared not to be delivered by the written proposals. Health protection, health improvement and health services, the three domains of public health, would all be affected.

3. Space does not allow comment on all aspects of the proposed changes, so I will rely on the work of others. I did not contribute directly to the response from the Faculty of Public Health but endorse the written responses to the consultations and the evidence given by the President at the session on the 17 May. Comments I make here are to complement what has already been said.

Essentials for a Good Public Health Function

4. The essence of public health practice is to use evidence-based interventions to better people’s health and well-being. Wherever it is located, the following are necessary for an effective specialist public health function:

Data and other information, on which to evidence decisions and monitor impacts.

The ability to formulate and implement programs to better public health, through direct control or influence.

The independence to act as advocate for public health, carrying credibility with wide audiences.

5. The current system has been through very many upheavals over the years, with all senior service public health specialists having been through at least one previous organisational change if not several. In spite of that, the system worked more or less up to a few months ago, with any defects in the formal structures compensated for by personal links. The Flu Pandemic in 2009, although not of the severity many feared, showed the resilience of the SHA-PCT-NHS-HPA system and its ability to rise to a challenge.

Concerns about the Proposed Changes

6. Each of the three aspects given above in para 4 faces major disruption.

Depositories of reliable data and those best able to do high-level analyses risk being affected, eg through the funding cuts to the Public Health Observatories and to the Health Protection Agency (HPA). Other sources of intelligence are being affected too, eg from the added secrecy created by Foundation Trusts.

Teams and relationships are being disrupted, with concerns about the security of the budgets for essential public health programs.

The essential local advocate, the Director of Public Health (DPH), risks being downgraded in the Local Authority (LA), voices from the HPA risk being muzzled within DH, and the influential regional public health teams are being lost.

Local Authorities and Public Health

7. Local authorities already have responsibilities for the well-being of their populations and in theory it should be possible to make the taking in of the DsPH and their teams work well. LA information staff already work with public health colleagues on local population data. EHOs have long worked with consultants in communicable disease control (CsCDC) on outbreaks. The current proposals may appear a logical extension of the recent joint DPH appointments. However, the devil is in the detail and here things may not pan out so well:

The DPH needs direct reporting to the CEO, with direct access to lead councillors.

Public Health (PH) budgets have to be enough for the task, with an acceptance that others’ budgets help deliver PH too.

Independence of the DPH is essential as is appointment by a committee similar to the current appointment advisory committee (AAC), but risk the DPH being excluded from the inner LA circle.

The role of Public Health England (PHE) in staff based in LAs needs careful thought, maybe with the piloting of different models.

Confirming formal accountability for health protection lies with LAs leaves PHE only with a local advisory role, and potential complications when events cross LA boundaries.

Advocacy by the DPH for excluded and disadvantaged populations may sit uneasily with the views of some local political leaders.

The increased separation from the NHS will make some functions more challenging, eg coordinating the NHS contribution to emergency responses, understanding NHS imperatives, delivering high immunisation rates through NHS staff.

The Health and Well-Being Board risks being a time-consuming talking shop with the real action taking place elsewhere.

There could be tensions in differing terms and conditions of service for those working together but employed by the local authority, DH (PHE) or the NHS. Current NHS employees are likely to want to stay as such.

There may well be lessons from before 1974 and why many Medical Officers of Health were judged unsatisfactory at that time.

Public Health Advice and NHS Services

8. Public health engages with the NHS commissioning agenda at present at a variety of levels. Formal set-piece needs assessments in the annual Joint Strategic Needs Assessment could continue in the new world unchanged. The Health and Well-being Board could “sign off” annual commissioning plans, as advised by the DPH, though the mechanism for and implications of challenging these in any event are obscure.

9. However, much of the nitty-gritty of commissioning seems far removed from this. Increasingly, it is suspected the NHS will be looking at cost-improvement programs, or recovery plans, often in-year and urgent. There will be investigations into unexpected activity in providers, or adverse events for investigation jointly with providers. The thresholds for un-affordably low priorities may need flexing, or clinical pathways redesigned with PH brokering a deal between primary and secondary care. Public health may need to be at the NHS commissioning table as a trusted member much of the time.

10. This sits uneasily with a DPH and team based in another organisation, perhaps with theoretical responsibility for advice to several GP commissioning consortia but without the formal NHS executive director responsibility held by current DsPH. The work program of the public health team will be determined by the LA and be subject to local political influence, potentially inhibiting the giving of frank PH advice, for example on any service refiguring which could be interpreted as downgrading of local facilities.

11. The working of the MOU between PCT and the new HPA when the CsCDC were transferred over showed that “free good” arrangements can be unsatisfactory, as the priorities of different organisations drift apart. Public health advice to commissioning may well be available from elsewhere, eg independent agencies or practitioners, or from GP interpretation of nationally-analysed data. Quality and relevance may be of concern. I have yet to see workable plans for the provision of top-notch PH advice which can be “owned” by GP commissioners.

12. Public health will also be needed in the Commissioning Board and its outposts, not least to assist with the oversight of primary care, and wherever specialised services are commissioned.

13. As the over-hasty dismembering of PCTs and SHAs takes place, and various functions have no natural home, DsPH risk having “responsibility” added to their personal brief, but without the staff or resources to manage them. A glaring defect of the proposals is the added difficulties created by a competitive NHS market for the close working between health and social care, without which we will not be able to manage the growing burden from long-term conditions. When formal accountability lines are lacking in statutes, there has been a recent tendency to make an individual personally accountable, easily interpreted as enabling the centre to dump its responsibilities. The DPH looks like a sitting duck for acquiring various joining –up functions, bridging the LA and the NHS.

The Need for an Intermediate Tier

14. The Regional Directors of Public Health (RDsPH) have been invaluable in bridging LAs and NHS, with the added advantage of close involvement with DH. From my experience in London, any hiatus from an absent RDPH and team would be scary. The mayor and GLA in London will continue some cross-London functions, like emergency planning, but there is much of the NHS agenda outside their brief. The RsDPH have helped with the coordination of many issues affecting the public health, eased tensions between individual DsPH and ensured the right people are in post as DsPH and performing well. Major service reorganisation often requires cross-district action, and without the SHA team may prove impossible to progress. As civil servants the RDsPH are currently constrained in speaking out against the proposals, and in-post DsPH may think it wise not to. Whatever the supposed imperatives of “localism”, my own perspective is that a regional tier of public health is so important it would have to be reinvented- presumably within PHE - if the proposals go through.

Inequalities and the Unregistered and GP Boundaries

15. The population responsibilities of LAs are well-established and there is much case history for dealing with those that are not registered as resident. Pragmatic arrangements have developed with the current NHS where PCT boundaries and registered populations do not marry exactly with those of their LAs. If GP commissioning consortia are smaller units, and patients can register outside a defined practice catchment area, these mal-alignments would become more common, so the essential joint-working between LA and NHS would become even more problematic. A requirement for co-terminosity would be much more sensible.

16. Where boundaries do not match some people and issues risk falling through the gaps. People who are not captured by various head-counts risk added discrimination, so widening inequalities further, with this affecting some areas disproportionately. At present PCTs risk-share over a wide population and ensure all the population gets health services. It is unclear what is being proposed for those that have failed to register with a GP. As budgets become tighter, the natural tendency will be for GP practices to concentrate on the needs of the core registered population. The task for PH as advocate for the disadvantaged looks like becoming more difficult.

Independence of the Party Line from DH

17. Many public health issues are problematic and have no easy solution. Whereas it may be right for public funds to be focussed on the approved mainstream, it can be dangerous to disregard other scenarios. Once a Ministerial decision has been made, civil servants may find it impossible to continue to consider alternatives, and hence prove inflexible to changing circumstances. Health protection may be where this matters most, hence the comfort gained from the independence of the Public Health Laboratory Service, the National Radiation Protection Board and their successor, the Health Protection Agency (HPA). The proposed Public Health England (PHE) would be part of a government department, and risks joining the enforced central group-think. An emerging public health hazard could end up being disregarded or misinterpreted.

18. Some policies of the current government have been criticised, eg the failure to deal adequately with the food and drink industries in tackling obesity and excess alcohol. The public health community needs to be free to add to the evidence base and advocate policies more closely based on that evidence than is the case with the current government line. There are concerns that those employed or appointed by PHE may feel themselves muzzled, even if not formally constrained.

19. The Chief medical officer (CMO) should be the key person in promoting and protecting public health. The holder of this post has a public persona and works across government. Dilemmas from tensions between emerging government policy on public health and the factual evidence should be passable up to the CMO who is in an unique position to influence events. But she may not be able to win the day. She needs to maintain a significant and skilled team reporting to her who are free to give unfettered advice on matters affecting public health. Cut-backs in DH may risk important public health issues not being progressed.

Making the System Work

20. Many of the previous reorganisations to the NHS have not been driven by considerations of public health, with subsequent changes to the deployment of public health resources feeling like afterthoughts. As the architecture changes, new people get appointed in newly-described posts and new relationships are forged. Gaps in the formal arrangements are identified and pragmatic solutions found. The reality of the disruption has not in the past been as bad as many feared, with existing players reappearing in new local organisations and able to continue essential work. The longer there is between organisational changes, the more likely that defects in the design get overcome by practical local arrangements.

21. It feels different this time. Firstly the pace and scale of changes are unprecedented. Secondly there will be no surviving intermediate tier to manage the process and ensure continuity of those cross-cutting functions so important in PH. Thirdly there is a massive budget squeeze at the same time, so no resources for double-running or to pick up functions inadvertently left out. Fourthly there is proposed a major shift of many public health players out of the NHS, to local or national government, and many with other options may choose not to go. Finally, the overall consensus is these changes are ill-thought out and simply will not work. As the acute sector and new GP commissioners run out of funds and LAs are unable to keep up their existing provision let alone increase it to deal with the increasing demand, financial chaos is predicted, and public health and its budgets will be raided, yet again.

22. While the public health fraternity are adaptable and flexible, some challenges may be simply too much. There are many risks from these changes, with important projects having to be disbanded, colleagues in the voluntary sector let down, and needed NHS service changes so much more problematic to deliver. Greatest of all may well be the “unknown unknowns”. When the next pandemic strikes, for example, expect public health systems to be in disarray and unable to deliver what the public expects.

Recruitment and Retention in Public Health

23. It is a time of much uncertainty. The Faculty president told the committee of the very real difficulty affecting those completing training. Going forward, it is unclear what posts will be retained for public health specialists and more junior colleagues. Working within local or central government has restraints which may be unwelcome to those used to the freedom that NHS consultant status brings. I am unclear what the terms and conditions of employment will be, but those within the NHS and its pension scheme may be reluctant to see them go. The net effect is that there could well be many existing or potential future public health specialists who prefer to find other careers than move to PHE or a LA. This may apply especially those who have medical qualifications and options to return to general practice or another clinical speciality.

24. Had I not already retired, I would have left the NHS at this time, unable to bring myself to spout the party line and help staff through changes I feel are so unnecessary and counter-productive. There is still an important public health job that has to be done, and I trust others feel able to continue.

The Alternative Future

25. The proposed changes feel like an unnecessary self-inflicted wound when there is so much real work to be done. Cancel the proposed Health and Social Care Bill and see what can be delivered, more slowly, under the existing primary legislation. Some aspects of the proposed changes have much support, like increasing involvement of GPs in commissioning decisions, and greater involvement of LAs in public health matters. PCTs may need to be recognised in the new clusters, since that clock may not be possible to turn back. If various bodies are to be brought together as PHE, this can be done as a SHA or executive agency or through a more informal collaboration.

26. The real prize in this is not a satisfying career for public health specialists and practitioners, but the health of the public.

About the Author

27. Trained as a physician and clinical pharmacologist, I spent 14 years in DH, then 12 years as a district DPH, interspersed with a year as Director of PH policy at the PHLS as it turned into the HPA. Since retirement from the NHS in 2008 I have worked as an occasional independent PH consultant for the SHA and London PCTs on projects such as service reorganisations, pandemic flu, emergency short-stay admissions, detainee healthcare, and (ongoing) the vetting of low priority treatments and consultant referrals. I am an honorary professor associate at Brunel University.

May 2011

Prepared 28th November 2011