HC 1048-III Health CommitteeWritten evidence from Dr Alison Talbot-Smith (PH 13)

Summary of Submission

Public Health aims to improve and protect the health of populations and to improve health services. Addressing health inequalities is also an important part of what Public Health does. Public Health effectively “treats” populations rather than individuals.

Public Health therefore encompasses three domains—health improvement, health protection and health services Public Health.

By separating these domains, and the organisations within which these functions will be carried out, the proposals fail to recognise:

the interdependencies between the three domains;

the difficulties fragmentation will create for the maintaining an effective, highly trained profession; and

the difficulties fragmentation will create for the training, recruitment and retention of Public Health specialists in the future.

There is a serious risk that this fragmentation will rapidly lead to the demise of Public Health as a profession with obvious risks for the nation’s health.

All commissioning organisations should have a specialist in Public Health as a full member of their board, and should be required to consult and take account of specialist Public Health advice so that best clinical practice is enshrined within commissioning.

Public Health England should be responsible for all three domains of Public Health, and should be required to provide Health Service Public Health input into NHS commissioning organisations.

Public Health England should be an independent NHS body in order to maintain the independence and credibility of the Public Health function, and the ability to work with ALL of it’s partner organisations—Local Authorities, NHS commissioning and provider organisations, and third sector organisations.

The creation of Public Health England within the Department of Health

1. Creating Public Health England within the Department of Health (DH) does not recognise the complexities of the Public Health agenda, which operates across organisational and structural boundaries.

2. The DH is a central policy and regulatory function. In contrast Public Health England will need to undertake effective programme delivery with a strong “locally based” component, that includes local strategic planning and commissioning of services, as well as local intelligence functions—none of which fit within the remit of the DH.

3. Public Health England will—or should—have a duty and responsibility to local populations, widely recognised as being discharged through the independent advocacy role of the Director of Public Health (DPH). It is important that this local independent advocacy is not constrained in any way by political processes nor by central DH policy. The current position of DsPH in Local Authorities and part of a central DH body provides two political and centralising constraints that pose a serious risk to this advocacy function.

4. It should also be noted that as it stands the creation of Public Health England is about a centralised Public Health function—this is true of Health Improvement, Health Protection and Health Intelligence. There is no mention of the vital component that Public Health England will need in order to deliver—ie a viable and effective Public Health workforce at local level. This should not be about DsPH being part of Public Health England, but about Public Health teams being part of Public Health England.

The Public Health Role of the Secretary of State

5. It has been widely recognised that the NHS should be a “health” service and not just a “sickness” service. To achieve this the Secretary of State for Health should have a primary duty in respect of the Public Health function.

6. To be effective this duty must recognise that the Public Health function is more than a sum of it’s parts—to be truly effective it must recognise that it’s three domains are interlinked through complex interactions, and need to be provided in their entirety. This means that the three domains of Health Protection, Health Improvement AND Health Services Public Health (with all three underpinned by the common theme of Health Intelligence) should all be the responsibility if the Secretary of State for Health—it is not possible to fragment the three domains and achieve a fully functioning Public Health function for any of the three.

The Future Role of Local Government in Public Health

7. The driver for placing Public Health in Local Authorities remains unclear to many of us working in Public Health, particularly as DsPH have been working across the NHS and Local Government for a number of years—most DPH appointments are now joint appointments between Local Authorities and PCTs, and in a number of area’s (eg Herefordshire), PCTs and the Local Authority have “deep partnership” arrangements with integrated commissioning of health and social care.

8. Like my colleagues I am fully cognisant of the important role to be played by Local Authorities in the Public Health Agenda, and welcome the emphasis placed upon their responsibility for improving health and well being of their local populations. However “carving up” Public Health and placing the Health Improvement element within Local Authorities is a naïve approach to achieving this, which poses serious risks for the effectiveness of the Public Health function and for the future of the specialty:

Public Health staff are likely to become professionally isolated.

The ability for Public Health to act as an independent and credible advocate for health will be diminished.

Staff may be subject to local political and/or organisational pressures which inhibit their ability to act to improve or protect the health of the local population.

Many DPHs are signalling that they will not be a board level position within Local Authorities, limiting their ability to influence strategic direction of the organisation—and yet this was one of the main reasons for placing Public Health in these organisations.

Local Authority issues could be “rebranded” as Public Health in order to access the ring fenced budget and preventing it’s spend on non local authority Public Health issues.

A real concern is the lack of ability to develop and train the Public Health workforce, in a specialty that is renowned for “growing it’s own”. As part of this there will be a complete lack of career structure for Doctors in Public Health—the reality of the Health and Social Care Bill is that many of us are considering returning to clinical practice.

Removing Public Health from the NHS—with the Department of Health impact assessment of the Public Health white paper recognising that this will reduce the cost-effectiveness of NHS commissioning. In effect placing Public Health into a “silo”.

Reducing the ability of Public Health to embed Public Health initiatives into mainstream NHS commissioning, limiting the effectiveness of the Public Health agenda to change the NHS from a sickness service into a health service.

9. I recognise and applaud the arrangements to try and “join up the system” through the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies. However I would point out that these are all strategic bodies and functions, and there are no mechanisms in the new structures to enable such joined up working at operational level. There is a lot of discussion about “local solutions”, but in cash strapped systems there will be little or no resources for such solutions.

10. The role of Local Authorities in Public Health could be more effectively achieved by partnership working with a co-ordinated Public Health organisation (Public Health England) that recognises and provides all three domains of Public Health. As an NHS body such an organisation would have the ability to attract and retain high calibre staff. Such a body would also be able to work effectively across the wide range of organisational boundaries that need to be addressed to achieve an effective Public Health function—this includes Local Authorities but also includes third sector organisations, NHS commissioners, NHS providers, and a host of non-health organisations.

Arrangements for Public Health Involvement in the Commissioning of NHS Services

11. It should be noted that commissioning is fundamentally about providing quality services for populations (ie balancing the needs of one patient against another), and that Public Health specialists are trained in population health.

12. The DH impact assessment of the Public Health white paper recognises that removing DsPH from the NHS will reduce the cost-effectiveness of NHS commissioning. This will be partly due to reduced ability to embed health improvement into NHS commissioning pathways, but primarily as it takes out the massive body of work currently undertaken by Public Health to ensure commissioning is based upon evidence of clinical and cost-effectiveness.

13. There are no arrangements within the Public Health white paper for Public Health involvement in the Commissioning of NHS Services. There is a DH vision that GP consortia will “commission” this input from academic institutions and commercial organisations, with a belief that Public Health currently obtain a “large amount” of epidemiological data from academic departments.

14. At PCT level we get probably 5% of our data from academic departments, perhaps 40% if you add in central surveillance intelligence and PHO data functions. But this data can be out-dated and is often not applicable locally. The fundamental point is that this is not the Public Health input to commissioning that is responsible for making it more clinically effective and crucially more cost-effective.

15. The component of Public Health input that makes the difference to commissioning is not the data but the application of the data. It is not about commissioning single, time limited pieces of work that become outdated incredibly quickly in an era of modern health technology. It is about the work of the local Public Health specialist—who has been trained in a five year training programme in a host of technical skills so that they can produce but also crucially interpret and apply locally the evidence base.

16. The input of such Public Health specialists to NHS commissioning is wide and varied and is based upon long term relationships and engagement—to develop clinical consensus, systems and policies over months and sometimes years. This can range from the production of “Low Priority Treatment Policies” which include national items but also address local practice, through to providing the evidence base on the most cost-effective services and interventions when re-designing care pathways, including interpretation of local patient flows and data analysis. It can include data and analysis to identify priority area’s for reducing inefficiencies, development of robust and ethical frameworks for prioritisation, investment decisions and dis-investment, and work to ensure “marginalised” groups such as the homeless and vulnerable are not forgotten—these are just some examples of the range of work undertaken by specialists in Health Service Public Health.

17. Public Health works through sustained and dynamic partnership working with GPs/primary care and with hospital specialists—to provide and interpret the “evidence” and work with clinicians to implement it in the local context—it is this local interpretation and local implementation in partnership with clinicians that makes the difference.

18. Can the work of Public Health specialists be replaced by GPs supported by academic or commercial organisations? A key question is where the capacity for this support is going to come from—the academic units are already stretched, and most of the commercial organisations do not have clinicians/Public Heath consultants working for them—they lack credibility amongst clinicians and in many instances their work fails to address complex clinical complexities and local issues. Such support is also expensive—especially when it needs to be iterative because of advances in technology.

19. A more fundamental point is that GPs will get a “static” piece of work—eg a literature review or a suggested service model—when what they need is an iterative and longer term piece of work that responds to changes in the international evidence base and also responds to local change—such as the provider “creep” we see so often as providers change practice to maintain income streams.

20. Crucially, it also requires a technical understanding of the evidence base to be able to discuss such issues with secondary care colleagues on a level playing field. The ability of GPs to engage with secondary care specialists to implement evidence based and cost-effective service change is consistently dependent upon an ongoing partnership between a local Public Health consultant and GPs. This is what currently occurs throughout the NHS—if this is not provided to all GP consortia then I am concerned that they are being “set up to fail”.

21. I recognise the value of “local solutions” in providing Public Health input—but in a cash strapped system failing to specify that Public Health input to NHS commissioning “must” be provided is tantamount to abolishing it. This in effect will deny consortia access to robust, sustainable and good quality Public Health input.

22. Will consortia be able to get Public Health input from their local Public Health department? Under the new structure DsPH/LAs will not be “required” to provide this—this is bizarre since it’s a core component of Public Health and it is currently provided to NHS commissioning. I recognise there will be far more commissioning organisations, but many will be undertaking risk pooling and joint commissioning arrangements for particular topics. The number of consortia is not a barrier to PHE providing this input—a PH consultant working across a number of consortia on common themes represents a major efficiency and cost-saving for the new system.

23. Perhaps more fundamentally, why should consortia have to pay for Public Health input? The UK taxpayer has spent large amounts of money training high quality Public Health Consultants/specialists—this should be provided by Public Health England to consortia and other commissioning organisations.

24. What is needed to achieve ongoing support of NHS commissioning is a requirement for Public Health representation on consortia boards—to influence strategic direction—and statutory provision (free) to consortia of the operational “day to day” work of Public Health consultants and their teams.

Arrangements for commissioning Public Health services

25. Public Health budgets must be clearly-defined, ring-fenced and sufficient to achieve required population health outcomes.

26. The commissioning arrangements as suggested have become complex and almost unintelligible. The Public Health budget will be fragmented and divided through a host of commissioning and funding streams, making it difficult to re-allocate resources in response to changing priorities or population needs.

The future of the Public Health workforce

27. The fragmentation created by the current proposals would make training of future Public Health and dental Public Health specialists extremely difficult. It will have a negative impact on the future recruitment and retention of high calibre Public Health specialists.

28. The training of future Public Health specialists must encompass all three domains to Public Health in order to produce a high quality, effective specialist Public Health workforce.

29. Bringing Public Health staff from all three domains together into Public Health England would ensure an appropriate coordinated system is in place for training future Public Health specialists and practitioners, and for ensuring the ongoing professional development of existing Public Health professionals.

30. National and regional coordination and oversight of Public Health training and workforce planning should be maintained in order to protect the standards and credibility of the profession.

June 2011

Prepared 28th November 2011