HC 1048-III Health CommitteeWritten evidence from the Public Health Directorate of NHS Lincolnshire (PH 19)


1. The Public Health Directorate of NHS Lincolnshire is delighted that the Health Select Committee has decided to inquire into the public health function in England, and has prepared this submission for the Committee. In summary:

We welcome the creation of Public Health England but believe that its roles and responsibilities should be clarified.

We believe that the Health Protection Agency should remain as a non departmental public body, to ensure that it can deliver its roles by working in a fully integrated manner with the NHS, local authorities and universities.

We welcome the enhanced public health role of the Department of Health and the Secretary of State for Health. The NHS should be less of a disease treatment service, and much more in the business of promoting health and disease prevention.

We welcome the enhanced role for local authorities in public health but wish to see the preservation of the independent voice of the director of public health as an advocate for the public’s health, and a strengthening of the powers of the Health and Wellbeing Boards.

We believe that public health specialists are vital to the success of the commissioning of healthcare services. As such, whichever agency employs public health specialists should be required to provide public health advice and support to GP Commissioning Consortia.

We believe that there should be a clear definition of which public health services should be commissioned from within the proposed ringfenced public health budget. This would stop local authorities from diverting this money to spend on their current statutory functions.

We wish to see the work of public health observatories maintained and preferably enhanced.

We believe that all public health specialists should be subject to the same robust mechanism of regulation.

We believe that all public health specialists should be employed by a single agency, and then seconded to work within local authorities and GP Commissioning Consortia.

We believe that measures should be taken to protect the capacity of the specialist public health workforce, during the current reorganisation.

We welcome the Coalition Government’s endorsement of the Marmot Review, and believe that Public Health England and the Health and Wellbeing Boards should be mandated to progress its recommendations.

Public Health England

2. We welcome the creation of a national public health service, Public Health England, but believe that its roles and responsibilities should be clarified.

3. As currently proposed this agency will be part of the Department of Health, and its employees will become civil servants. This is inappropriate as many of its functions (eg those currently performed by the Health Protection Agency) are direct services provided to the NHS and other agencies, rather than the formation of policy. Public Health England should be constituted as a Special Health Authority.

4. There are three domains to public health practice: health improvement, health protection and healthcare public health. Currently, most public health consultants have expertise in defined areas but their work encompasses aspects of all three domains. This allows for an integrated approach to tackling public health issues and problems. This integration of work would be lost if Public Health England were to employ only a proportion of public health specialists. We believe therefore that all public health consultants should be employed by a single agency, and seconded from there to work for local authorities and GP Commissioning Consortia. Such an arrangement would have the additional advantage of ensuring an equitable distribution of public health specialists to all areas of the country.

Health Protection Agency (HPA)

5. We believe that the creation of a single specialist agency able to deliver local health protection services as well as national surveillance and research has been a very successful model. The current status of the HPA as a non departmental public body has enabled it to work closely with the NHS, local authorities and universities. We cannot see what advantages there are to be gained by abolition of this agency and its integration into the Department of Health.

6. An alternative model would be to transfer the public health specialists who currently work in the HPA’s Local and Regional Services into the local authority, if that is where public health specialists are employed. Prior to 2002 all public health staff, including those working in health protection, were located in single public health departments. This co-location of senior staff enabled those public health consultants who did not primarily work in health protection to maintain their skills, which is essential if they are to be on the health protection on-call rota, and ensured that there was surge capacity to deal with major incidents.

Public Health Role of the Secretary of Health

7. We strongly welcome the enhanced public health role of the Department of Health, and in particular an enhanced public health role for the Secretary of State for Health. Since its inception in 1948 the National Health Service has concentrated on the treatment of disease rather than the promotion of health. As we increasingly move away from a model of health service delivery that concentrates on the treatment of acute episodes of disease towards one where the management of long term conditions is much more to the fore, it is clear that the public health role of the department will become increasingly important.

8. Many long term conditions are preventable – for example, Type II diabetes is mainly caused by obesity. There are actions we can take to reduce the burden of obesity, leading to a reduction in the numbers of people with diabetes, and thus a reduction in costs to the NHS.

9. Primary prevention services should be adequately resourced and we support the emphasis in the White Paper on effective use of the current evidence base, and the emphasis on the need for further research and effective evaluation. This should be actively encouraged and supported by Public Health England and NIHR, and where possible research and evaluation from across the country should be supported and good practice shared in a more systematic way.

Local Government

10. The wider determinants of health (employment, education, transport, environment, housing etc) are not under the control of the NHS. Local government can directly and indirectly make a substantial difference in these areas and thus public health staff have always worked closely with local authorities to improve health through influencing the wider determinants of health. Organisational boundaries have sometimes got in the way and thus having senior public health staff employed by local authorities, or seconded to local authorities, would enhance our capabilities to improve health. This will be supported still further by the need to develop joint health & wellbeing strategies, with clear outcome frameworks.

11. We welcome the proposal to make joint appointments of directors of public health mandatory, although of course many areas, including Lincolnshire, already have joint appointments. To be credible with the public, the director of public health needs to have an element of independence from local government; to be able to constructively criticise the policies of their local authority where such policies harm the health of the population. It is worth noting that when medical officers of health (the predecessors of directors of public health) were employed by local authorities their contracts specifically allowed them such a degree of independence.

12. The position of director of public health is key to ensuring that public health is at the heart of all that local authorities do. It is therefore essential that only those staff properly qualified to do this role are appointed. We therefore believe that it should be mandatory for directors of public health to be on the GMC Specialist Register or the United Kingdom Public Health Register. Directors of public health should also report directly to the local authority’s chief executive.

13. We welcome the creation of Health and Wellbeing Boards. These Boards have the potential to be powerful levers to drive health improvement and address health inequalities in each locality. They can only do so however if they are perceived as being at the centre of these reforms. The Health and Social Care Bill should be amended to strengthen their role and powers.

14. We have some concerns that if the whole public health function is transferred to local authorities that the core NHS functions of emergency planning, vaccination and immunisation, and screening, will not be accorded a sufficiently high priority by local authorities, who will almost certainly give a higher priority to promoting the general wellbeing in their area.

Public Health Input to the Commissioning of Healthcare

15. Currently, public health consultants play a crucial role in the commissioning of healthcare: we contribute our skills and expertise in health needs assessment, critical appraisal of published evidence of effectiveness, leading the production and implementation of care pathways, and as credible leaders who can “hold the ring” between primary, secondary care and community service clinicians and providers.

16. Our input to commissioning is therefore crucial to improving the effectiveness and the efficiency of health services. The NHS and Public Health White Papers have failed to understand the vital role that public health specialists play in commissioning. We are particularly concerned at the failure to ensure a future role for public health specialists in the commissioning of specialised services.

17. We believe that it is vital that all GP Commissioning Consortia should have ready access to public health advice and support. This would be best provided from a single agency which employed all public health consultants. If local authorities are to be the employer of public health specialists they should have a legal duty to provide the Commissioning Consortia within their area with public health advice and support, funded from within the ring fenced budget for public health.

Commissioning of Public Health Services

18. Public health services have been a notable success in recent years: NHS Stop Smoking services have played a large part in reducing the numbers of people who smoke, which will lead to a reduction in the burden of illness from this cause.

19. We are pleased that public health will have a ringfenced budget but are concerned that local authorities may seek to use this budget to prop up their statutory services rather than spend this money on true public health services. There could for instance be demands to spend this money on filling in potholes and gritting pavements. It is essential that legislation is very clear on what the ringfenced public health budget should be used for.

20. Preventive services should included as part of the commissioning pathways work of consortia to ensure that there is clinical buy in and support.

Public Health Observatories

21. Public Health Observatories have played a vital role in enhancing our knowledge of health needs, in particular by providing us with comparative data. In each locality we need to know how our needs compare to other areas, and it is impractical and inefficient for analysts in each area to attempt to replicate this work. The role of public health observatories should be maintained and strengthened.

Arrangements for Funding Public Health Services

22. If local authorities hold the ringfenced public health budget it should remain ringfenced, and there should be very strict accountability on what it should be used for. This should include funding the local public health service, regardless of who employs public health specialists.

23. In setting public health budgets care needs to be taken to ensure that all current expenditure is included. Arguably, there should be an increase in the public health specialist workforce to meet all the requirements of consortia and all branches of local government.

Public Health Workforce

24. The training programme for public health consultants is designed to be equivalent, as far as is practicable, to hospital specialities. Entrants have to be medically qualified, or have a good degree and relevant postgraduate experience. The training programme lasts for at least five years, and progression requires trainees to pass a two part exam and to complete defined work-based learning outcomes. At the end of this programme, employers and the public can be confident that public health consultants will have been trained to the highest possible standards.

25. Once the training programme has been completed, medically qualified trainees are eligible to be on the Specialist Register, and are regulated (like all doctors) by the General Medical Council (GMC). Action can therefore be taken to deal with poor performance or misconduct.

26. Non-medically qualified trainees are eligible to be included on the United Kingdom Public Health Register. But this body is much more limited in its powers than the GMC.

27. We believe that all public health specialists, doctors and non-medically qualified practitioners, should be subject to the same degree of regulation and by the same body, to protect employers and the public from poor performance and misconduct.

28. Previous NHS reorganisations have led to a substantial drop in the number of public health consultants. The uncertainties in employment prospects caused by the current reorganisation, and financial restraints, are already leading to some public health consultants seeking voluntary redundancy or early retirement. A further reduction in what is already a very small profession (there are only around 1000 public health consultants in total) will threaten our ability to improve the health of the population, to contribute our part in the commissioning of health services, and to deliver our input to the response to major incidents and emergencies. Measures should be taken to preserve public health capacity at this crucial time.

Government Response to the Marmot Review

29. We are encouraged by the Coalition Government’s support for the Marmot Review and would encourage active support for ongoing implementation of their recommendations. This should be a key function for Public Health England, and a requirement for Health and Wellbeing Boards to progress.

June 2011

Prepared 28th November 2011