HC 1048-III Health CommitteeWritten evidence from Dr Stephen Watkins and Dr Vicci Owen-Smith (PH 23)

Evidence by the Director of Public Health and Deputy Director of Public Health for Stockport


1. DPHs treat populations as their patient, using health advocacy as a change agent, caring for people they cannot identify whose human tragedies reflect in health statistics.

2. Key health issues:


heart disease, cancer and inequalities;

active ageing;

active travel addressing obesity;

strong social networks and civil society; and

early years establishing inequalities.

3. Key health care issues:

rising demand;

alcohol-related hospital admissions;

prevention reducing demand;

optimising resources for greatest benefit;

more efficient patient pathways;

rationing treatments with minor or experimental benefits;

pharmaceutical R&D making new drugs too expensive; and

healthy ageing reducing cost of demographic ageing.

4. Implications:

DPHs serve populations not agencies:

professional independence;

acting across the local authority, NHS bodies and other agencies; and

relating to business, community and voluntary sectors.

Public Health England should be a ministerially-chaired NHS body.

Health values apply across Government policies:

Government departments need Public Health Directors.

Alcohol, active ageing, and active travel need action.

Strengthening civil society is essential.

Without willingness to regulate, responsibility deals will fail.

Health Acts should improve health not just reorganise the NHS.

Local authority NHS involvement should be done properly or not at all:

Doing it properly means:

councils being NHS bodies for health functions;

the NHS including council public health (as in 1948-74);

Health and Well Being Boards having real powers; and

councils receiving non-commissioning PCT duties.

Doing it not at all means:

not transferring public health;

constituting DPHs as NHS corporation soles; and

with both NHS and local government. powers and duties.

Our preference would be to do it properly.

Doing it not at all is preferable to separating public health from the NHS.

Every NHS body needs public health input to its governing body.

A population perspective is needed in commissioning:

NHS funding helps people - wasting it is unethical.

Health care public health organisation must address professional capacity and critical mass:

Direct local input and responsibility to local populations is important.

So is avoiding duplication and working with a population large enough for epidemiological stability.

Health care public health professionals need to work locally but cooperate in larger groups over larger populations.

Dividing funds into prevention and treatment budgets is problematic:

Prevention costs less per QALY than treatment so the financial allocation needs rebalancing.

The Health Premium should apply to small areas to avoid disadvantaging deprived parts of polarised districts.

Community organisers should be employed in public health.

Who We Are/Nature of Evidence

5. Stockport contains the five most affluent wards in Greater Manchester and the fourth worst LSOA nationally.

6. For 20 years it has reduced death rates from heart disease and smoking related diseases more than nationally and reduced inequalities.

7. This progress is threatened by adverse trends in alcohol related diseases in younger people.

8. Locality commissioning originated here. We have a single united Pathfinder consortium.

9. DPHs treat a population as a patient – recognising threats to health and prescribing responses. They care for people they do not know and cannot identify, whose human tragedies are reflected in health statistics. That is our job. Our evidence focuses on it.

10. It is personal professional opinion not corporate evidence. However using the office of DPH implies professional obligations about remit and scientific integrity. Like a judicial decision or an NHS prescription, it is neither personal nor corporate. That public health opinion falls in this category must be understood.

Public Health England

11. Public Health England (PHE) within the Dept of Health (DH) will have a civil service ethos, inappropriately for:

separating delivery from policy;

services directly provided by PHE;

directly commissioning services in more interventionist styles than policy/regulatory roles;

PHE performing duties to the political process and public rather than just Government;

research –using academic contracts, applying for research grants, academic freedom, scientific integrity and the right to publish;

workforce development; and

external consultancy which PHE should offer and charge for.

12. PHE should be an NHS body, without increasing managerial cost or complexity. For direct line of sight ministers could chair the NHS body

The Public Health Role of the Secretary of State

13. Secretary of State should articulate health within Government.

14. Alcohol—Life expectancy will fall if alcohol’s impact on the post-1970 birth cohort continues as it ages. By 2040 two generations could enter dependency simultaneously. Russian experience suggests difficulty reversing an initially neglected epidemic.

15. Government is too timid—We believe in minimum price. It will impact on pre-loading (drinking at home before going out, to get drunk more cheaply) and remove the incentive to drink away from social pressures. Politicians may disagree, but should then pose an alternative.

16. Healthy ageing—As the first generation of men living their entire adult life in peacetime continues to age, the post-war baby boom enters old age and immigration is reduced by economic and policy pressures the choice is a dependent or active elderly population. The difference could be 5% of NHS resources. Active ageing is essential.

17. Responsibility deals—To negotiate seriously with business, public health needs an underpinning option of regulation

18. The relationship to other departments—Each government department needs a Public Health Director (not “DPH” - it serves an agency not a population).

19. Legal proceedings defending public health—The Chief Medical Officer could evaluate the public interest - the Attorney General, legal implications.

20. The duty to promote equality should affect outcomes not just access

21. Health Acts should legislate to improve health—Examples might include alcohol, transport and health, spatial planning or pricing of energy for heating.

The public health voice in major Government issues

(i) The Big Society

22. See later Marmot section

(ii) Health and Safety

23. Locally we distinguish safety from risk-aversion in child protection, defensive medicine and health messages. In safe societies mountaineers use proper equipment, watch the weather, report their route and expected return time and have a mountain rescue service. In risk-averse societies nobody climbs mountains.

24. Health and safety is a public health purpose. Bevan wanted it as part of the NHS.

25. DPHs could be empowered to promote sensible risk management and intervene in absurd bureaucratic risk-averse behaviour.

(iii) The Economy

26. Good health contributes to economic productivity, pleasant and healthy living conditions attract knowledge-based industries, patterns of economic activity influence health, economic dislocation causes health damage, well being measures economic success and disparities between economic and well being indicators might warn of emerging speculative bubbles.

27. A Public Health Director for the Bank of England should work with a Public Health Director for the Treasury and the DPH for the City of London.

Local Government and DPHs

Local Government in the NHS

28. Distinguishing “the health service” from the “NHS” wasn’t done from 1948-74 when local government last provided part of “the health service”. Public and environmental health was then part of the NHS. Bevan had them in mind when he said the NHS would improve the health of the nation. The NHS cleared the slums and cleaned the air. Local authorities will again have a “health service” role. The 1948–74 definition should be restored.

29. Public health’s proposed removal from the NHS contributed to massively declining support for transfer to local government. Involving councils in the NHS should be done properly. In their health service role, councils should be NHS bodies picking up non-commissioning PCT functions and having real powers for the Health and Well Being Board to enforce the health and well being strategy and for Healthwatch. Some NHS managerial resource should transfer.

30. If the transfer isn’t done properly it shouldn’t be done at all. DPHs should be NHS corporations sole with formal roles in local government and NHS commissioning and provider bodies. We could describe how this option might work. It isn’t our preference.

The Role of the DPH

31. The Bill defines DPHs as council officers overseeing public health functions transferred from PCTs. They should primarily be health professionals treating a population and independent advocates for health across public, commercial, voluntary and community sectors.

32. People can better be helped and nudged towards health by doctors or health professionals than by officials.

33. Public health specialists are change agents for the health of the people, using corporate authority and independent advocacy in appropriate balance. Guarantees of professional independence are needed.

34. The following roles require more than corporate authority:

An independent annual professional report.

Advocating public health across council decision making, for example provision of walking and cycling infrastructure.

Health impact assessments of policies, programmes, and services.

Public health advice to other agencies.

Professional views influencing public opinion. From the 1930s to 1950s MOHs argued for clean air. From the 1980s DPHs advocated tobacco control. The town’s doctor must articulate a healthier future and contribute to opinion forming.

Community cultural determinants of health won’t change in response to bureaucratic messages –DPHs must address communities openly and honestly as professionals committed to them.

DPHs must deal with local businesses as experts and custodians of health not as council officers (although council contacts are also useful – environmental health officers locally have done good work with food businesses, including introducing salt shakers with fewer holes in fish and chip shops).

The public health contribution to local professional leadership must not be lost or become a bureaucratic role.

DPHs should be statutory consultees in planning, transport and environmental issues participating according to professional judgment.

When DPHs conduct, or comment on, health impact assessment only professional public health opinion should influence their judgment. Pressures shouldn’t be brought to bear.

35. DPHs must be properly professionally qualified, necessitating statutory provision on appointments processes and qualifications.

36. Secretary of State’s reluctance to protect professionalism or establish appointments procedures was another major factor in support for the transfer (initially widespread) falling to only 11% of public health consultants.

37. This was aggravated by authorities and organisations making comments neglecting or rejecting the broad public health role, undermining authorities (like our own) which value it.

Small Districts and Two Tier Local Government

38. Stockport is a reasonably sized single tier authority.

39. District councils are close to communities. Important public health roles include housing and environmental health.

40. Any population sufficiently distinct to deserve a district council deserves its own DPH. Districts in shire counties should be included. However a full department may be unnecessary. Even larger organisations may share support functions.

41. DPHs in small districts will be part time with a department shared with other districts or, in shire areas, the county. The role could attract part-time applicants or dually accredited doctors combining part time general practice with part time public health or be combined with a consultant role at county level or in a shared department.

Health Care Public Health

42. The NHS should protect and promote the health of the population, and commission services considering the impact on population health as well as individual patients.

43. Services must be matched with identified needs of patients. However, simply responding serially to individuals’ needs (or wants), leads rapidly to uncoordinated services, uncontrolled financial resources, and increasing inefficiency.

44. Commissioning health services systematically needs a population health perspective, considering issues wider than only the identified patient. Integrating health care public health (HCPH) experts into commissioning systems incorporates those issues into commissioning decisions.

45. The HCPH subspecialty optimises the contribution the health care system makes to the health of the people through.

healthcare’s contribution to health;

optimising resources;

applying population perspectives to evidence;

applying evidence to health service organisation; and

assessing and prioritising population healthcare needs.

46. NHS funding helps people. Wasting it is unethical. Resisting NHS resource-optimisation isn’t the moral high ground!

47. Locally our PCT has encouraged patients with wetAMD to use a service utilising the cheaper drug avastin rather than much more expensive lucentis. We have come under immense pressure without national support.

48. In the health bill, GP consortia have a duty “to secure continuous improvement in the quality of services provided to individuals for or in connection with—(a) the prevention, diagnosis or treatment of illness, or (b) the protection or improvement of public health” and “have regard to the need to (a) reduce inequalities between patients with respect to their ability to access health services (b) reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health service”. Separating Public Health from the NHS is unhelpful. GP consortia will require clinical public health expertise and associated resource to discharge these duties.

49. About 200 specialists practise HCPH.

50. Each health and well being board should have such a specialist. GP consortia need direct HCPH input. This can be achieved if local authority and consortium boundaries align and HCPH serves that population not specific agencies.

51. HCPH needs:

a critical mass of analytical intellectual capacity; and

epidemiological stability – a population large enough that predicted needs will not vary randomly to a destabilising degree.

52. To achieve this, whilst retaining local links, locally appointed HCPH specialists should cooperate over an epidemiologically stable population (at least a million) in a team with critical mass (at least four). (This describes team and population size not guideline ratios).

53. NHS providers need HCPH. Public health is needed on their boards.

Funding Public Health Services

54. We perceive dangers.

55. Inadequate ring fencing—NHS providers might increase funding by characterising growth areas as “preventive”.

56. Inadequate funding—funding based on 2009-10 sums institutionalises past underspending. Preventive measures cost considerably less per QALY than treatment services. The system needs re-optimisation.

57. Lack of access to NHS benefits—local authorities funding alcohol prevention programmes need benefit capture to reflect savings from stemming the alcohol-fuelled rise in A&E attendances. We are locally exploring benefit capture to support risk investment through a Social Development Bond.

58. Inclusion of destabilising areas in the funding.

59. PHE might have to pay for changes in NHS practice—Primary care and secondary care should do more prevention. This involves changed practice not new resources but providers might expect payment. We have a local example with breastfeeding, smoking cessation and midwifery. This is an allocation of professional energy, a planning and managerial task rather than a financial burden, which should not have to compete with other spending priorities for actual money. A “money go round” should be set up.

60. PCTs are cutting public health budgets—Many PCTs are cutting public health budgets. Our own has been compelled to do so against its wishes. This may affect ongoing funding and anyway may mean loss of important skills and human resources with local authorities having to start from a position of neglect.

61. Too much resource may be consumed centrally.

62. Will the cost of health visiting expansion be a call on the NHS budget as a whole or on a static PHE budget?

63. Will overheads be included in the budget or will local authorities have to buy back or replace NHS support services such as buildings, training, communications, IT etc where previous public health access has not been accounted for.

64. Errors (or deliberate protection of treatment budgets) could impact disproportionately—The difference between cutting public health expenditure by 25%, keeping it constant or increasing it by 25% is the difference between NHS healthcare efficiency targets of 19%, 20% or 21%, (less than alcohol-induced pressures).

65. Only NHS public health expenditure is protected—An issue locally is the new city-region’s commitment to walking and cycling.

66. Polarised authorities could be disadvantaged if the Health Premium is allocated to districts rather than small areas.

Workforce and Regulation

67. Non-medical specialists, valued colleagues appointed to roles identical to those occupied by public health doctors, should have statutory registration equal to that of medical specialist registration.

68. There should be transitional provisions for people now working on health issues in local government – several people locally deserve transitional allowance towards public health training. At least one is fit to be a consultant.

69. There are public health workforce development needs from transition to new employers and from shortages resulting from past decisions.

70. Government has not fully engaged with this problem. PHE should have a workforce development role, including powers to ration scarce resources and apply training levies.

71. Training must continue within the medical professional training system with a broader range of training placements.

72. If training is disrupted, new entrants are lost, and specialists in their 50s and 60s take retirement from disliking the new arrangements the shortage of specialists could become disastrous.

The Marmot Review

73. Government is responding well with conventional healthcare responses but not in areas, like spatial planning or income inequality, requiring wider action.

74. We welcome commitment to health visiting and family nurse partnership and to screening uptake. We are locally prioritising uptake in deprived areas.

Spatial planning and transport

75. Incoming Ministers wound up a NICE PDG on spatial planning. A new PDG on walking and cycling has a remit excluding transport interventions.

Community development

76. There is strong evidence that social networks and civil society benefit health. Areas in Eastern Europe where membership of clubs and societies was above 46% avoided the alcohol epidemic.

77. Locally people are establishing a voluntary organisation Stockport4Health

78. The BMA in 2010 suggested community organisers in public health.

79. General practices, NHS bodies, local authorities, parish councils or voluntary organisations could provide, according to local interest and commitment.

80. One whole time equivalent community organiser per 10,000 population (on average - more in deprived areas and fewer in affluent areas) and a grants budget of £2 a head in the two most deprived quintiles could cost between £150 million and £200 million, less than 0.2% of the NHS budget

June 2011

Prepared 28th November 2011