HC 1048-III Health CommitteeWritten evidence from Dr Fiona Day (PH 17)

I am responding in a personal capacity.

Thank you for inviting responses to the Health Committee on Public Health. Please find enclosed a summary of my concerns about the proposed changes to Public Health. I am an NHS Consultant in Public Health Medicine, a Fellow of the Faculty of Public Health, and a registered medical practitioner with the General Medical Council.

1.0 Summary

1.1 I agree with the Public Health white paper and the Faculty of Public Health that there are three domains of public health: health improvement, health protection, and health services public health.

1.2 I share the same concerns as the Faculty of Public Health, Royal Society for Public Health, and Association of Directors of Public Health (http://www.fph.org.uk/uploads/Letter%20to%20David%20 Cameron.doc) with regards the proposed changes to Public Health in England and believe that these concerns have been overshadowed by other issues relating to changes to the NHS.

1.3 I have particular concerns about the proposed reforms in the following two areas, outlined in more detail below:

1.3.1Lack of standard setting and professional regulation of public health specialists if employed by local authorities.

1.3.2One of the three domains, health services public health, is integral to health services commissioning and is not an add-on. It is unlikely that this can be delivered from a local authority setting, yet separation from the rest of the Public Health workforce may lead to fragmentation of the public health system.

2.0 Lack of Standard Setting and Professional Regulation

2.1 Like most public health specialists, I am a Fellow of the Faculty of Public Health. This gives the public reassurance in my professional standing, Continuous Professional Development, my qualifications and training and sets the rigorous standards which all members of my profession are required to meet.

2.2 Like all public health doctors I am also fully registered with the General Medical Council and have a “certificate of completion of training” (CCT) therefore all medical advice I give is within the confines of my professional training and covers my licence to practice and revalidation, ensuring that the quality of my work is above a minimum standard.

2.3 I am concerned that public health specialists in the Local Authority will not, as plans currently stand, be mandated to be above this quality line. Public health is a professional undertaking with defined competencies and standards in order to protect the public’s health. Not mandating that public health specialists require this status in my opinion puts the health of the population at risk.

3.0 Health Care/Health Services Public Health Specialists

3.1 I qualified as a doctor in 1996. After 8 years of junior doctor experience including working in general practice, I commenced higher specialist training in public health medicine. This took an additional five years training with associated additional professional qualifications and study. I fully qualified to be a public health medicine consultant in 2010, 14 years after qualifying as a doctor. This is a normal length of time to train to be an NHS consultant in public health medicine. All this time in training has given me a broad and deep understanding of the NHS and the health needs of the population, and I have subspecialised in the area of public health practice relating to NHS commissioning, that commonly known as healthcare public health.

3.2 Healthcare public health specialists’ input into commissioning health services is integral on a day-to-day basis. No-one else has the academic rigour and practical experience of commissioning nor the understanding of the health needs of the population, the evidence base, and is able to balance complex interrelated disease pathways with health economics within the context of finite monies to pay for services.

3.3 A population perspective to health service planning has been integral to the NHS for decades now and has ensured rationing of finite resources in a fair and equitable manner. We have worked alongside GPs, hospital specialists, nurses, other clinicians, social care and NHS managers for years to ensure a multiprofessional clinical input into commissioning.

3.4 It has been suggested during the recent NHS “listening exercise” that GP commissioners would be able to buy health needs assessments from local universities in order to make commissioning decisions. If only it was as simple as that. The reality is that commissioning is a hugely complex juggling act. Health care public health specialists provide leadership and strategic direction as well as managing health service quality improvement projects and programmes.

3.5 I am employed by a large Primary Care NHS Trust in the North of England where I have responsibility for commissioning health services for people with long term conditions (cardiac, diabetes and respiratory). I lead our “QIPP” long term conditions programme, ensuring that a mixture of generic and disease-specific services are commissioned for the needs of our local population. This involves daily decision making around investment and disinvestment, based on the evidence, the needs of the population, resources available, and to reduce inequalities, and with constant reference to clinical colleagues and patients. Whilst we do buy some one off specific epidemiological work from local academics from time to time, this is very far removed from the day to day clinical and cost effectiveness work using epidemiological skills that healthcare public health specialists are involved in, which requires ongoing and sustained work within the NHS.

3.6 I understand that our local GP commissioners recognise that they do not have the time nor the skills of balancing the needs of a whole population with the evidence base with reducing inequalities with commissioning services which offer value for money, and like all other GP commissioners in the country are keen to have public health support in the future. However I do not believe that I can directly influence NHS commissioning from the Local Authority, as is currently planned, and respectfully suggest that it is naive to believe that this could be the case.

3.7 In my personal and professional opinion, without healthcare public health specialists doing the balancing act which they alone are trained to do, the costs of the health service will continue to spiral, services commissioned will lead to greater health inequalities and will be based on good intentions which will fail to meet the many and complex needs of the population. As there are only approximately 200 healthcare public health specialists in the UK. I believe that these specialist staff need to be fundamentally part of the NHS, ie NHS employees and mandated to influence NHS commissioning decisions such as mandatory posts on GP Consortia Boards, or Commissioning Support Units, or through Public Health England so long as it is an NHS authority.

I would be pleased to provide further information on request.

June 2011

Prepared 28th November 2011