HC 1048-III Health CommitteeWritten evidence from Dr Giri Rajaratnam (PH 49)

Basis of submission: Experience as a public health consultant and director of public health working for deprived communities in Yorkshire and West Midlands. Currently employed as a deputy regional director of public health.

Provenance: The views expressed in this submission are the author’s. It does not reflect views of any organisation that the author is or has been associated with or employed by.

1. Summary

1.1 The current proposals ignore the notion of leadership for health for local communities. The leadership should rest with the Chair of the Health and Wellbeing Boards (H&WB) and the DPH. The accountability should be to both, the Secretary of State for Health (SoS) and to local communities through HealthWatch.

1.2 The DPH as part of the JSNA process should take responsibility for delivering an independent assessment of health and care needs of local communities and make recommendations relating to evidence based interventions needed to improve population health. This should be the primary responsibility of the DPH and should not be compromised by any other responsibilities that may be locally determined.

1.3 In order to deliver this responsibility, the DPH will require access to data (qualitative and quantitative), to local experts from a range of organisations, to local communities and to be able to influence a range of organisations (public, private and 3rd sectors). He or she will require high quality professional staff that have both the scientific and clinical background and are able to interact with people from very diverse backgrounds; from members of the public to specialist scientists as well with Boards and Councils. This team will clearly need employment with an organisation, however, whether it is the NHS or local government is largely irrelevant because in order to deliver this responsibility with credibility amongst the local populace, they will need to be seen as independent of political and other vested interests. Organisational loyalty will need to be lower down the priority than loyalty to local communities.

1.4 Similar principles apply to Public Health England (PHE). PHE needs to be at an arm’s length from DH and the SoS in order to maintain professional independence. This will increase the probability that the outputs of PHE are seen as credible by the population at large, local government, the NHS and the professions. Moreover, PHE needs to be led by the professions and not by career civil servants or the SoS.

1.5 The SoS does have an important leadership role which is about ensuring that the health system works to be benefit of communities. The SoS does not have a management role which needs to be recognised by Parliament.

1.6 Data and information is a fundamental building block of an effective public health system and is vital for both, PHE and the DPH at a local level. There is a danger that the extant meagre resources within PHOs and departments of public health will be further depleted in the name of rationalisation. This must not happen. Both the PHE and the DPH will require considerable analytical support and by this I mean analysts with qualifications/experience in epidemiology, medial statistics or quantitative scientific research.

1.7 The public health workforce is in danger of becoming so fragmented that the integrity of the whole will be lost. It is crucial that if local government is to take on public health responsibilities, it makes an explicit commitment to training (specialist as well as CPD), accept the standards as set out by the Faculty of Public Health and ensure that recruitment is based on the FPH guidance. It is unfortunate that the SoS has indicated that he does not see professional regulation being of importance in public health. I disagree absolutely.

2. Introduction

2.1 Members of the Health Committee will be aware of the definitions of public health as set out by the Faculty of Public Health. The perspective, I wish to take is that of a DPH. I tend to think of public health in terms of:

Health surveillance, where the main output is the Annual Report.

Health policy (local policy development, interpretation of national policy and implementation) and support for commissioning. The key challenge is about translating policies into actions that will improve health and Appendix 1 is my conceptual framework for what this means within a local context. The big barrier has been that financial systems have not been supportive. However, the development of programme budgets makes the applicability of these concepts easier.

Health protection (communicable & environmental hazards and disease prevention, screening, vaccination, etc).

Promotion of health (health improvement).

2.2 Of these four functions, the first three require the specialist skills that training in public health provides. In the context of promotion of health (health improvement), this function can be commissioned and delivered by health promotion specialists working in collaboration with public health specialists.

2.3 I have taken this approach because it makes it easier to operationalise the work of the teams that lead. It also makes it easier to think and act to deliver my contributions to the mission of the health system.

2.4 I think the taxpayer funds the health system in order to: “improve, within the resources allocated, the health of local communities by commissioning/delivering;

Services that promote health and prevent disease.

Services to diagnose, cure and rehabilitate.

Services that enable individuals to have a dignified death”.

2.5 The model of health based on life expectancy, that I tend to use is presented in appendix 2. This in combination with appendix 1 enables a rational approach to tailor public health resources. Specialists in health promotion working with partner organisations, lead on the work to influence life styles. Specialists in public health working across the whole system support the delivery of the right balance of services across the various sectors and the interventions that need to be put in place; some focus on care services whereas others on determinants of health. I have undertaken both types of work and can provide examples.

2.6 There are two important attitudes that public health specialists bring to the table – firstly, the obsession with needing to maximise health gain within the funds allocated by parliament and secondly, the need to have a fair and ethically justifiable process for allocating resources to support the diverse needs of local communities and individuals within those communities.

3. The new public health system

3.1 It is difficult to see how the new system will allow for this sort of refined approach to be taken forward in a coherent manner. The proposals as currently set out imply that the NHS is not part of the public health system. The proposals do state that the NHS has important contribution to make. The proposals take away the need for the SoS to be responsible for the provision/commissioning of a comprehensive health and care services to meet the needs of the people of England.

3.2 In my view, the proposals as they stand, will lead to fragmentation of the health system and will introduce organisational boundaries that will inhibit the overall public health effort. At the core of it, the proposals for public health will at both national and local levels increase the politicisation of the public health system which will be to the detriment of health of the communities in England.

3.3 I am conscious of the privilege in working within an organisational framework based on the notion of “paying according to income and taking according to need”. I agree that parliament through the government of the day as well as local politicians should take a keen interest and how oversight of the extent to which the health system works.

3.4 In my view the need to provide oversight and empower the professions, apply equally to both the NHS and to the new public health system. In doing so, it is important that there is very close interaction between the NHS and the public health system.

4. Local Government (LG) and the DPH

4.1 I think the notion that local government should play a much greater role in aspects of public health is clearly right. It has always been the case that DsPH have worked closely with LG colleagues to influence the whole range of LG functions. I have personal experience of influencing housing regeneration programmes, the transport directorate and the education system. My annual reports covering the period 1996-2010 provide an indication of the successes and failures in the approach that I have personally taken. It is my view that developing good personal relationships offer the greatest potential for influence. In my experience, being part of the same organisation adds very little.

4.2 As a consequence, I cannot see how the current proposals will make any difference to this at all. Why should a DPH employed solely by the LG have any more of an impact than those employed on a joint basis? Indeed in my view, the big risk is that the DPH will be asked to take responsibility for a number of current LG functions that will result in reducing the capacity of the DPH to influence the not just full range of LG responsibilities but also the commissioning system.

4.3 Within the new system, the issue of leadership for health and in particular for reducing inequalities in health outcomes is not made explicit. Indeed the current draft Bill does not make any comment at all on this matter. In my view, the logic of the current proposals would imply that the Health and Wellbeing Board has that leadership and I would strongly argue that the Chair and the DPH take on that particular leadership role. In order for the DPH to deliver that role, he or she needs to be part of both, local government and the local NHS and at the same time, in order to be credible; the individual will also need to be independent of both. This of course is not to suggest that normal lines of accountability should be ignored but it does mean that the individual needs to have a contract with both, LG and the NHS as well as a system for professional accountability.

4.4 If you accept my view of the DPH needing to take on the leadership role for health and in particular health inequalities, then he or she will require a full range of specialists to fulfil that role because it will mean developing expertise on the full range of health and care services. I would suggest that for the DPH to have the greatest impact, the staff will also require joint appointments with both the NHS and local government. In this context, by the local NHS I mean the GP consortia and so on.

4.5 In my view, the DPH will need to develop a very close relationship with both, HealthWatch and the health scrutiny committee within any locality. Within the new approach to performance management, these two organisations will be the main bodies to take a view on the performance of the local health and care services. The DPH in his/her role in assessing the extent to which need is being met will also take a view on local performance and it is my view that there is synergy with the work that HealthWatch and the Scrutiny Committees will do. Indeed for me this would translate into the public health department actively supporting HealthWatch and Scrutiny committee by allocating specialist support.

5. PHE

5.1 I think the critical issue here is that to do with the independence of PHE from government interference. My view is that PHE needs to be at arm’s length of the DH and more importantly, should not be on the same contracts as civil servants. This is because I am told that civil service terms and conditions of service restrict the ability of people to speak out. Although, this maybe reasonable in relation to civil servants, it is totally unreasonable in the case of the professions involved in the health system. In my view civil service conditions of service should not be applied to PHE which should be seen as a clinical organisation.

5.2 Given these dangers and the fact that the SoS wishes empower those in the front line, I am unclear of the rationale for bringing PHE into the DH or for changing the terms and conditions of service.

6. Information and health intelligence

6.1 This is important to both PHE and the local public health department wherever they are located. Currently, there is a shortage of analysts trained in medical statistics, research methods or epidemiology. It is important that we do not compound the current shortage by assuming that by either centralising PHOs or because LGs have information departments, one does not need the current complement of trained analysts.

6.2 My rather extreme view, is that the planning system could be hugely improved with improvements in productivity, if all NHS staff (and in particular those involved in commissioning and delivery) were trained in some aspects of medical statistics and epidemiology. This is not about the ability to add, subtract, divide and multiply but it is about knowing which order to implement those functions in particular circumstances.

7. PH role of Secretary of State

7.1 It is critically important that any new Bill, states explicitly that within the resources allocated by parliament, the SoS will have responsibility for ensuring the availability of a comprehensive health and care services for the people of England.

7.2 The SoS for Health has a very important leadership role, not a management role. He in collaboration with the Health Select Committee should provide the oversight of the system. The individual should set the policy framework, not in terms of structures or rules of engagement but the principles, the values and the outcomes that are expected. The Secretary of State should act as a “critical friend” to those tasked with developing the structures, processes and rules of engagement. I do not believe that the Secretary of State does any of this – he and his predecessors have seen themselves as having an executive function without any of the expertise or experience that one would expect.

7.3 My experience and reading of the scientific literature about the structural changes implemented by Ss of S over the last two decades suggest that they have had very little positive impact on health status. Contrast this with the policies on client groups or diseases such as the national service frameworks. In the vast majority of cases these have had a direct and positive impact on health status.

7.4 I would therefore suggest that in addition to the leadership, the SoS has two other functions:

Working with the other parts of government to ensure that the whole of the government machinery considers the impact on health and in particular, the reduction of health inequalities and takes action to improve matters. In this respect, it is a shame that despite acknowledging that deprivation is such an important factor in affecting health, this government has stepped away from making that a protected characteristic within the Equality legislation.

Identifying areas where the NHS needs to develop policy and implement actions. In undertaking this role, the SoS needs to work closely with the Health Select Committee and the CMO. The SoS should not be developing policy but expect to act as the critical friend to more expert groups set up by the NHS or PHE.

8. Commissioning of NHS services

8.1 Public health specialists have an important contribution to make in the commissioning of health care services. At a technical level, there are two areas where they may take the lead; first, the assessment of needs, demand and supply and second, the identification of cost effective interventions. However, the biggest contribution that public health specialist make is as a consequence of their clinical experience and knowledge, being able from a population perspective, to take a critical view of the scientific literature as well as of the claims made by clinical vested interests.

8.2 My impression is that the majority of the GP Commissioning Consortia see the necessity of having access to support from public health specialists. To make best use of the knowledge and skills that a public health specialist brings, he or she will need to be co-located for at least spend part of their time with the GPCC. Clearly, it can be “bought in”; however, the consequence will be some loss of benefit.

9. Conclusions

Although, I agree with the analysis presented in the Health White Paper and the public health paper, I do not see the logic of how the proposed changes will impact on the challenges identified by the analysis. In my view, the SoS has ducked the real issues that matter in favour of re-arranging deck chairs….. Assuming that the overall shape of the reforms stay, I think the biggest challenge is to maintain credibility of both, the local DPH and PHE with the wider stakeholder group including the local communities. Credibility of the public health system requires the public health system to be separate from the politicians. Without that separation, it is likely that the new public health system will be seen as an extension of the political system both nationally and locally and therefore will lose credibility.

June 2011

Appendix 1

Appendix 2

Prepared 28th November 2011