HC 1048-III Health CommitteeWritten evidence from Dr Alison Merry (PH 131)

1. I am extremely concerned that the proposals in the Bill will fragment, weaken and ultimately destroy the specialty of public health and will thereby put the health of the public at risk.

2. The proposals will fragment the public health workforce, disrupt the public health system and services, including the ability to effectively respond to an emergency or epidemic situation and undermine public trust and confidence. They will disrupt training in public health and adversely affect recruitment and retention of qualified public health specialists.

3. Public health encompasses three domains: health improvement, health protection and health services. All three domains need to be addressed actively by the public health system if the public’s health and wellbeing are to be protected and improved. If supported by sufficient resources, public health interventions can improve and extend the lives of many thousands of people, saving the NHS and society millions of pounds.

4. It would be possible to mitigate these risks by:

4.1 The Three Domains of Public Health

Embedding all three domains of public health throughout the system, including commissioning. Ensuring the health and wellbeing of people, protecting their health, and reducing health inequalities requires an effective and resilient public health system, which integrates all three domains of public health (health protection, health improvement and health services). The system also requires defined responsibilities and clear accountabilities, effective levers for change, and a sound and trusted evidence base.

4.2 Public Health England must be an NHS Body

Establishing Public Health England as an NHS body providing independent and trusted advice, and employing all public health specialists—and seconding them to local authorities. This would:

4.2.1Ensure that local authorities are supported by expert, embedded public health teams who are employed by Public Health England and seconded to local authorities to work as part of the local Director of Public Health’s team, and seconded to other organisations such as commissioning bodies where public health expert advice is necessary.

4.2.2Ensure public and professional trust and confidence in the expertise Public Health England provides is vital. Creating PHE as an NHS body would establish it as an independent, authoritative source of public health expertise whilst still providing the Secretary of State with a clear line of sight. This would also allow the health protection function to continue essential grant/commercially funded research work—which will not be possible if as proposed it becomes a DH directorate. An independent PHE would be protected to some extent from political or other influence, perceived or actual.

4.3 Directors of Public Health

The Director of Public Health must be qualified and registered and must be positioned within the local authority as an influential, strategic leader responsible for managing the ring-fenced public health budget, and providing public health advice and expertise locally, including to commissioning consortia.

4.3.1Currently, the Bill does not does not require a Director of Public Health to be qualified. This must be rectified urgently in order to safeguard the public.

4.3.2It is essential, particularly from a public protection perspective, that public health specialists, including DsPH, are trained and registered to specialist level in public health.

4.3.3The Director of Public Health also needs to be appropriately positioned with influence and authority within the local authority (ie with direct access to the Chief Executive and cabinet and members), otherwise, he/she will not be in an appropriate position to influence in order to improve or protect the health of the local population. The DPH should be the principal advisor on all public health matters to the LA, including its elected members and the Health and Wellbeing Board (on which the DPH should have a statutory appointment), across all aspects of LA activity.

4.4 Public Health and Dental Public Health Specialists

Public health specialists are trained and qualified to assess the health needs and aspirations of their population. They work across the three public health domains, and make decisions that affect the health of tens of thousands of people. DPHs are the strategic leaders for public health in their area, providing—through their annual report—independent analysis of the health needs of their local population and, equally important, a critique of how well those needs are being met and what more is required. It is vital that these functions continue in the new system. The Bill currently states that the DPH should produce an annual report on the health of their population but there is no explicit duty for it to also describe their health needs and extent to which these are being met. This should be rectified.

4.5 Public Health and Dental Public Health input to commissioning.

The NHS reform programme proposes that the commissioning of health services becomes the responsibility of GPs, through the formation of local commissioning consortia. GP organisations have acknowledged that commissioning health services for entire populations rather than individual patients requires public health skills, expertise and knowledge. It is critical that public health expertise informs all commissioning decisions—and that commissioners have access to timely, reliable and relevant information and analysis. To meet this need, there must be a registered public health specialist, on the Board of every health commissioning organisation—including the NHS Commissioning Board, able to access additional expertise from local and national experts when this is needed. There should also be a duty placed on commissioning organisations, including GP consortia, to work with DPHs and their public health teams on all commissioning decisions to ensure the health needs of their communities are met. It is also important that commissioning groups and consortia work closely with clinical consultants, nurses and allied health professionals to ensure a truly integrated system of healthcare provision.

4.6 Furthermore the system must:

4.6.1secure the continuation of public health training alongside other medical specialties to ensure the long-term viability of the profession;

4.6.2support a sustained period of stability to enable the new system to deliver the ambition of the reform and;

4.6.3ensure effective public health practice through a detailed understanding of the local context, dependent upon good working relationships, built on trust and mutual respect.

5. Public health is everybody’s business—but it requires specialist knowledge and leadership to be effective, to save lives and to reduce disease, disability and dependence.

6. To maintain momentum and reduce health inequalities, it is essential that public health measures are sustained, developed and enhanced, that they are properly resourced and that they are led with authority and expertise.

7. In an era of austerity, a firm government commitment to public health makes sound economic sense. There is a wealth of evidence to demonstrate that effective public health interventions can reduce the need for expensive health and care services. Public health expertise within the health services is also essential if the escalating costs of low benefit health technologies are to be controlled and health services commissioners are to have the knowledge to implement the most effective and lowest cost services.

8. It is important now, more than ever, that public health continues as an attractive specialty to both doctors, dentists and individuals from backgrounds other than medicine. Public health is a competency based specialty and this must be maintained in line with other specialties. There is concern that, for example, LAs do not have the training structures or workforce plans in place to support the development and assessment of the necessary public health competencies across the workforce.

9. It is also vital that in the new system, specialty registrars undertaking public health training have access to the full range of public health experience and settings (such as local health protection units, provider trusts, local authorities) in order to fully develop their specialist public health competencies.

10. To ensure public and profession confidence, public health training must continue to be organised and provided alongside that for other medical specialities with similar arrangements for recruitment, standard setting and quality assurance.

June 2011

Prepared 28th November 2011