HC 1048-III Health CommitteeWritten evidence from NHS Sheffield Directorate of Public Health (PH 46)


We 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.

We 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%20Cameron.doc) with regards the proposed changes to Public Health in England and that these concerns have been overshadowed by other issues relating to changes to the NHS.

We have particular concerns about the proposed reforms in the following main areas:

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

One of the three domains, health services public health, is integral to health services commissioning and is not an add-on. It will be very challenging for this to 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.

We believe that the proposed “health premium” is flawed in principle and will be unworkable in practice.

1.0 Thank you for inviting responses to the Health Committee on Public Health. Please find enclosed a summary of our concerns about the proposed changes to Public Health submitted by NHS Sheffield’s Public Health Directorate. The Directorate includes a Director of Public Health, five qualified public health specialists employed at Consultant level, three additional qualified and registered PH specialists who are not currently Consultants, one Director of Dental Public Health as well as over 50 other public health specialist staff.

2.0 Lack of Standard Setting and Professional Regulation

2.1 Most public health specialists are members or fellows of the Faculty of Public Health, and all are required to be on the Specialist Register. This gives the public reassurance in their professional standing, Continuous Professional Development, qualifications and training and sets the rigorous standards which all members of the profession are required to meet.

2.2 We are 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 our opinion puts the health of the population at risk.

2.3 There is also a significant risk that failure to require that Directors of Public Health in particular, but also other Public Health specialists are properly trained and registered, will result in significant inequity across the country, as some Local Authorities will wish and be able to recruit properly trained experts, whereas others may not.

3.0 Health Care/Health Services Public Health Specialists

3.1 Health care public health is a vital domain of Public Health activity, and makes a major contribution both to improving the health of the population, as well as reducing health inequalities. Many Public Health consultants who specialise in this area are first qualified doctors, undertaking junior medical jobs before higher specialist training in public health medicine. This is an additional five years training with associated additional professional qualifications and study. This gives them a broad and deep understanding of the NHS and the health needs of the population.

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 Our local GP commissioners do 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. We believe that it will be extremely challenging to directly influence NHS commissioning from the Local Authority, as is currently planned.

4.0 The “Health Premium”

4.1 We think it is highly unlikely that a “Health Premium”, as described in the Public Health White Paper and associated consultation document, could possibly be made to work, for three reasons.

4.2 There are no outcome measures that are sufficiently robust as overall measures of population health (and hence health inequality, and reduction in health inequality) that are sufficiently responsive at local level in a relatively short space of time, to be a valid tool for this purpose.

4.3 Even if there were, the mechanism would need to take into account other factors on health and health inequalities at population level. For example, economic changes in an area which health services cannot influence. Another example would be the impact of population change, in particular immigration and emigration, both in and out of a district as well as internally, within a district. If these sort of factors are not taken into account, local areas will end up being penalised, or rewarded, simply because of the impact of population change on local health indicators. At present, the impact of immigration and emigration is completely undefined, though undoubtedly real.

4.4 Even if the above problems were overcome, we cannot conceive of any additional incentive that this proposed mechanism would deliver.

4.5 Further, there is a real danger that if implemented, the “health premium” would end up further disadvantaging already disadvantaged districts, since they are the ones least likely to be able to attract it, through no faults of their own.

June 2011

Prepared 28th November 2011