HC 1048-III Health CommitteeWritten evidence from Lindley Owen (PH 45)
Key Points
Protect public health from interference from vested interests.
Create a cabinet level post for public health, separate from the NHS.
Make all local DsPH joint appointments.
Make JSNAs mandatory and include Assets.
Maintain and strengthen Public Health influence on NHS commissioning.
Protect Public Health Observatories.
Implement Marmot’s recommendation of a Minimum Income for Healthy Living.
Introduction
I am director of, and consultant in, public health for a Primary Care Trust in the South West region, and a fellow and examiner for the Faculty of Public Health. I have 38 prior years’ service in the NHS, as a manager of hospitals, director of a health authority, chief executive of a Primary Care Group, director of a Health Action Zone. I am qualified in health service management and a graduate of the NHS national management scheme.
1. The creation of Public Health England within the Department of Health, the abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse
This proposal brings the risk of public health decisions being too closely influenced by political considerations. While arms-length bodies may currently be out of favour, they do provide a degree of distance, enabling the service to retain a semblance of impartiality. Many major public health issues have longer time scales than the electoral cycle. The health consequences of rising levels of atmospheric carbon dioxide being just one such example.
2. The public health role of the Secretary of State
As long as he is also responsible for the NHS, that huge, clamorous organisation will occupy his every waking hour. A separate cabinet post for Public Health is the only way to ensure proper recognition of its importance.
3. The future role of local government in public health
In the South West, almost all Directors of Public Health are joint appointees with their co-terminous local authorities. This means a heavy workload for the DsPH, with up to three Boards to report to, but is really important in helping address the cross-cutting influences on the health of populations. This link should be strengthened under any future changes, with careful attention to both ends; a DPH fully integrated in local government, but who loses influence in the NHS, would be weakened.
4. Arrangements for the appointment of Directors of Public Health
These should, as at national level, provide for a degree of protection for Public Health against undue political influence locally. The former Medical Officers of Health could only be dismissed on the vote of the whole council, a fact which enabled many in the 19th century to drive through schemes such as underground sewage systems, which were very unpopular to many in their day.
5. Joint Strategic Needs Assessment
This is a clumsy and misleading term for a vital process. A safe, healthy future for humanity depends on clean, clear science, and at local level the JSNA is the vehicle. The term misleads because it excludes assets, a fact now recognised as a flaw in the latest guidance. (ID&EA 2011). We need to ask the marketers to come up with a more accurate, accessible title, and make the process mandatory for all local authorities.
6. Health and well-being Boards
Many local authorities in the South West have already established these, but unless they are put on a statutory footing, they risk being ignored or sidelined.
The “Joint” in Joint Health and Well-being Strategies should go beyond health and social care, and include planning, transportation, housing, leisure and agriculture.
7. Public Health involvement in commissioning NHS services
We seek an NHS which is both comprehensive, universal, effective and efficient. Commissioning which meets these four, often apparently irreconcilable requirements, must be underpinned by dispassionate analysis of intervention and outcome which epidemiology provides. Public health professionals at local level and above implement that science on a daily basis. Strengthening public health in local government should not jeopardise that, but reinforce it. The US healthcare experience, of “provider capture” which has led to over-intervention and high cost for the insured population, and the widest health inequalities in the developed world, are a clear warning of the risks otherwise.
8. Public Health Observatories
These organisations, just ten years old, have justified their existence many times over. Not just public health staff, but local government and voluntary organisations turn to the network of PHOs as a vital source of accurate, unbiased, up-to date evidence, presented in a clear and accessible way. Recently their effectiveness has been diminished slightly by budgetary cuts; these should be restored.
9. The Government response to the Marmot Review
The Public Health white paper purported to be such a response, and it did indeed recognise many of the themes of that document. However, it was silent on a central recommendation. Marmot’s team had worked closely with the North West Region, and London, and as a result had identified an important distinction between the statutory minimum wage, and what they term a “Minimum Wage for Healthy Living”. The latter is higher than the minimum wage because Marmot’s team discovered that in Britain today, it is not possible to live a healthy life on the minimum wage. Those, including the London Mayor and many major businesses, who back the London Living Wage, recognise this. The government should do so, too.
June 2011