HC 1048-III Health CommitteeWritten evidence from the Academy of Medical Sciences (PH 27)

Overview

The Academy of Medical Sciences welcomes the opportunity to respond to the public health inquiry from the Health Select Committee. As the independent body in the UK representing the whole spectrum of medical science, with a Fellowship that includes some of the UK’s foremost experts in public health, the Academy is well placed to contribute to future public health strategy in England. We would be happy to provide additional evidence and advice to the Committee.

Researchers in public health and epidemiology in the UK are amongst the best in the world and they have made valuable contributions to improving the health of the UK population. Enormous potential exists to nurture and develop these strengths. To address future health challenges effectively, a well-rounded strategy that includes public health measures is required.

The Academy welcomes the emphasis that the Government’s White Paper “Healthy lives, healthy people” places on research evidence, the social determinants of health, health inequalities, disease prevention and a life course approach, as well as the creation of a National Institute of Health Research (NIHR) School for Public Health Research and the NIHR Policy Research Unit on Behaviour and Health. However, we are concerned about the scale and speed of the changes proposed. It is essential that adequate time for effective piloting and evaluation is built into a timetable for change.

In this response we will recommend that:

There should be a duty to promote and engage with public health research throughout the new public health structures including Public Health England, the National Commissioning Board, Commissioning consortia, all “willing providers”, Monitor and local authorities.

Public health policy should be informed by evidence from rigorous public health research.

The function of providing independent advice to the Government currently performed by the Health Protection Agency must remain independent from the Department of Health.

The Secretary of State and the rest of the Government should promote knowledge exchange and continuity of public health work.

Public health doctors should be encouraged to engage with the new public health structures and should retain their NHS terms and conditions if employed by local authorities or the civil service.

The development and use of evidence

The field of public health evolves continually as populations and society change. Therefore it is essential that the findings of rigorous public health research inform new policies and practices and are utilised in the necessary ongoing evaluation of existing policies. There should be a cross-governmental understanding of the importance of using public health research evidence in developing public health policies and practices. Furthermore, there should be a duty to promote and engage with public health research throughout the new public health structures including Public Health England (PHE), the National Commissioning Board, Commissioning consortia, all “willing providers”, Monitor and local authorities.

The manner in which public health research is communicated is crucial to our ability to capitalise on the potential benefits. Knowledge exchange between researchers, policy-makers and service providers that is open and bi-directional both facilitates sensitive and relevant research and informs timely and effective policy-making. Institutions involved in public health should play an active role in facilitating this exchange. Without effective knowledge exchange, increased localisation and fragmentation of public health activities can lead to duplication of work. Fragmentation could also make it more difficult for organisations to maintain the critical mass of expertise that will ensure that public health work is of world-class quality.

Where public health interventions are deemed necessary, the level of intervention should be based on the best available research evidence. We are concerned that the evidence to support the use of nudging as a means of improving public health is weaker than that which supports other forms of intervention. The Government should aim to design interventions that are supported by the best available research evidence.

The Government’s White Paper proposed a new Public Health Responsibility Deal that aims to make use of voluntary agreements with business and other partners such as the food and drinks industry. While it is important to engage with a wide range of stakeholders, the commercial interests of such industries can conflict with public health goals and should thus be kept in perspective.

The creation of Public Health England within the Department of Health and the abolition of the Health Protection Agency

Public health research is widely recognised as a fundamental part of healthcare provision. As previously stated, a unified approach to public health is key to effective policies and practices and a commitment to research must run throughout the new public health structure. As the new professional public health service, PHE must lead on promoting and engaging with research.

Independent research evidence is critical for responding effectively to and understanding public health crises. One of the key roles of the Health Protection Agency (HPA) has been to advise the Government on strategies for dealing with public health emergencies, such as pandemic influenza. The research evidence that informs the HPA’s advice can be controversial and it is important that the Government receives unbiased information.

If the role of the HPA as a source of independent research and evidence is undertaken within government, its ability to provide independent advice will be threatened. Therefore this role should be placed outside of the Department of Health.

The HPA is a highly respected research body and a large proportion of its current research funding comes from research councils, the National Institute for Health Research and charities such as the Wellcome Trust. Many of these funders’ eligibility criteria exclude Government Departments. The proposed move to the Department of Health is already threatening the HPA’s ability to apply for and undertake independently funded research.

The public health role of the Secretary of State

Under the proposed public health structures, commissioning of public health services will be divided between different government and NHS bodies. Within these new structures, knowledge exchange becomes more critical to achieve a cohesive approach to public health.

To promote continuity, the role of the Secretary of State should reflect the duties and responsibilities of the entire public health structure. The Secretary of State should lead in promoting medical research—including public health research—and putting evidence into action.

The Secretary of State should also take a lead role in facilitating knowledge exchange between those bodies involved in public health research, service provision and funding. This knowledge exchange should run throughout the Government Structures, with academia and the NHS.

The Academy welcomes the establishment of the Cabinet Public Health sub-Committee. Research evidence from a variety of reliable sources, including public health bodies, the NHS and academia should inform their discussions.

The future role of local government in public health

The Government’s proposal to bring public health responsibilities under local authorities presents a number of opportunities, but several concerns must be addressed in order to capitalise on them. Local authorities should be supported to promote and engage with public health research, especially as they do not have the same history of engagement with this field as other areas of the health system. This will enable them to fully capitalise on the potential benefits of research to patients and communities. To achieve this goal, issues of fragmentation, resource allocation and addressing the needs of public health doctors must be addressed.

Fragmentation and duplication of work by local authorities in different regions should be reduced by encouraging effective knowledge exchange laterally and vertically within public health structures. There should be clear and direct lines of communication between local authorities and PHE regarding public health research, policies and practice.

The Academy welcomes the Government’s proposal to ring-fence local authority budgets for public health. Local authorities are coming under increased pressure to make efficiency savings on already stretched budgets. Efforts should be made to ensure that this does not cause existing local authority activities to be re-branded as public health, diverting funds from genuine public health needs.

The Academy recognises the potential benefits of increased localisation of the public health system, which could encourage a more cross-cutting approach to public health across government. A great deal of activities under the control of local authorities influence public health, such as education and transport. To capitalise this continuity of service, local authorities should be given greater regulatory power in the area of public health.

The Academy welcomes the Government’s recognition that public health doctors are important for delivering an effective public health service at a local level. However, efforts must be made to ensure that those doctors are not isolated from their colleagues in the NHS and academia. If public health doctors are employed by local authorities or as civil servants they will lose their NHS terms and conditions of employment. This could generate a two-tiered workforce, creating disincentives for doctors to specialise in public health. Local authorities can benefit from the wealth of experience that top specialists—such as clinical academics—bring and care should be taken to ensure that public health remains an attractive career choice. Links with higher education institutions for training, validation and research collaboration should be preserved.

Future public health research goals

Extraordinary recent advances in science and technology offer major research opportunities in public health. Priorities for future research include:

The use of large datasets derived from routine patient care.

The use of genetics to provide molecular epidemiology for tracking infectious disease.

The relationship between population level research and genetics such as understanding the interaction between environmental and genetic factors in disease causation.

Pharmacoepidemiology through mechanisms such as the General Practice Research Database (GPRD) and Yellow Card System.

Changing health behaviours using interventions that can be delivered at population, community and individual levels, that can improve population health as well as reduce health inequalities.

Evaluation of public health interventions, particularly those that prevent disease.

Standardisation of research outcome measures and service delivery outcome measures to allow better exchange of knowledge.

Understanding the distribution of disease within the population including the use of surveillance data for research such as cancer registries and community serological surveillance for influenza to understand the distribution of disease within populations.

Epidemiological research into chronic diseases with “softer” endpoints that are more difficult to measure such as musculoskeletal or mental health.

Health services research.

Further research into the social determinants of health including effective interventions to reduce health inequalities.

Investigation of the impact of environmental change, including climate change on public health.

Evaluation of the benefits of sustainable low carbon technologies and lifestyles for public health.

Studying the impact of policies across a range of sectors for public health – e.g. education, social policy, housing, transport.

The Academy of Medical Sciences

The Academy of Medical Sciences promotes advances in medical science and campaigns to ensure these are converted into healthcare benefits for society. Our Fellows are the UK’s leading medical scientists from hospitals and general practice, academia, industry and the public service.

The Academy seeks to play a pivotal role in determining the future of medical science in the UK, and the benefits that society will enjoy in years to come. We champion the UK’s strengths in medical science, promote careers and capacity building, encourage the implementation of new ideas and solutions—often through novel partnerships—and help to remove barriers to progress.

The Academy’s Officers are:

Professor Sir John Bell FRS HonFREng PMedSci (President); Professor Patrick Sissons MedSci (Vice-President); Professor Ronald Laskey CBE FRS FMedSci (Vice-President); Professor Robert Souhami CBE FMedSci (Foreign Secretary); Professor Susan Iversen CBE FMedSci (Treasurer); Professor Patrick Maxwell FMedSci (Registrar).

June 2011

Prepared 28th November 2011