HC 1048-III Health CommitteeWritten evidence from Dr John Tomlinson (PH 86)

1. Summary

I am submitting this paper in my capacity as East Midlands Representative of the Faculty of Public Health National Board. In this role I am the elected representative of all Directors and Consultants in Public Health across the East Midlands.

The inquiry into Public Health by the Health Select Committee is most welcome. The NHS White paper and Bill are being actively debated. However the Bill and subsequent Public Health White paper has little detail or clarification with respect to a number of really important Public Health (PH) issues.

The information below utilises the Faculty of Public Health (FPH) response to the PH white paper. The response has been produced following a series of national and regional meetings including the East Midlands. Importantly I and others in the East Midlands are fully supportive of the FPH response.

2. What is Public Health

Recommendations

2.1 To ensure that expert support is available for all those concerned with protecting and improving the public’s health, public health should be maintained and developed as a respected, resilient, multidisciplinary profession working across the three domains of health protection, health improvement and healthcare services.

Comments

2.2 Public health is the science and art of promoting and protecting health and wellbeing, preventing ill health and prolonging life through the organised efforts of society.

2.3 There are three domains of public health: health improvement (including people’s lifestyles as well—influences of health), health protection (including infectious diseases, environmental hazards and emergency preparedness) and health services (including service planning, efficiency, audit and evaluation). All three domains need to be addressed actively if the public’s health and wellbeing are to be protected and improved.

2.4 The public health white paper, Healthy Lives, Healthy People, focuses on prevention and protection, making limited mention of the health service domain of public health practice and apparently fails to recognise the importance to health of effective, equitable, accessible and appropriate health services.

3. Responsibility for Protecting and Promoting the Health of the Local Population

Recommendations

3.1 Local authorities should be accountable for protecting and improving the health of their populations at all times, including outbreak and emergency situations.

3.2 Public Health England should support local authorities in doing this. Local authorities should be required to use the skills and expertise of public health specialists to deliver health and wellbeing for their local population.

Comments

3.3 Neither the Health and Social Care Bill nor the public health white paper articulates these responsibilities clearly. This puts the public at serious risk, particularly in emergency or epidemic situations.

3.4 The wider determinants of health (employment, education, transport, environment, housing etc) are not under the control of the NHS. Local government can directly and indirectly make a substantial difference in these areas and thus public health staff have always worked closely with local authorities to improve health through influencing the wider determinants of health. Organisational boundaries have sometimes got in the way and thus having senior public health staff working within or seconded to local authorities would enhance our capabilities to improve health. This will be supported still further by the need to develop joint health & wellbeing strategies supported by clear outcome frameworks.

4. Public Heath England—the New Public Health Service Should

Recommendations

4.1 Be able to offer independent advice to national and local government, the NHS and the public on all matters relating to the maintenance, improvement and protection of health.

4.2 Provide effective, expert and adequately resourced local teams, supporting and working closely with local services, including the director of public health (DPH), on all three domains of public health.

4.3 Be able to provide advice and guidance to the devolved nations where they are unable to access this locally.

4.4 Be established as a special health authority or, if it must be part of the Department of Health, as an executive agency.

Comments

4.5 It is unlikely that these aims can be achieved if Public Health England (PHE) becomes a fully-integrated part of the Department of Health. As currently proposed this agency will be part of the Department of Health, and its employees will become civil servants. This is inappropriate as many of its functions (eg those currently performed by the Health Protection Agency) are direct services provided to the NHS and other agencies, rather than the formation of policy. Establishing PHE as a special health authority or as a distinct executive agency of the Department of Health would offer a more practical and acceptable way forward. There are three domains to public health practice: health improvement, health protection and healthcare public health. Currently, most public health consultants have expertise in defined areas but their work encompasses aspects of all three domains. This allows for an integrated approach to tackling public health issues and problems. This integration of work would be lost if only some public health consultants were employed by Public Health England. By employing consultants and specialists in all three domains of public health and, where appropriate, seconding them to support local organisations—including as part of the DPH’s local team—PHE will be able to ensure that scarce specialist resources are used and developed to best effect. This could also enable consultants and specialists to remain on NHS terms and conditions of service.

Further detail is offered in a recent Lancet Publication (PH in England).

5. The Joint Director of Public Health (DPH) Post

Recommendations

A DPH must:

5.1 Be trained and registered to specialist level in public health.

5.2 Be required to produce an independent, public annual report on the health and health needs of their population.

5.3 Be a statutory member of the Health and Wellbeing Board.

5.4 Be directly accountable to the local authority CEO.

5.5 Have responsibility for managing the ring-fenced public health budget and public health staff.

5.6 Provide strategic leadership for all three domains of public health at local level.

5.7 Have direct access to the local authority’s cabinet and councillors.

5.8 Not be sacked for any reason without the approval of both the local authority and the Secretary of State.

5.9 Have a contractual relationship—which could be honorary—with PHE.

5.10 Be appointed jointly by the local authority and PHE, through a statutory appointments process which mirrors the existing process for DPHs and consultants/specialists in public health – and which is accredited by FPH (as is currently the case).

Comments

5.11 We welcome the proposal to make joint appointments of directors of public health mandatory, although of course many areas already have joint appointments. In order to provide effective strategic leadership for public health, the DPH must be able to influence all aspects of the work of the local authority and the local health economy. The public must also be confident that the DPH is able to provide informed and credible independent professional advice. To be credible with the public, the DPH needs to have an element of independence from local government; to be able to constructively criticise the policies of their local authority where such policies harm the health of the population. It is worth noting that when medical officers of health (the predecessors of directors of public health) were employed by local authorities their contracts specifically allowed them such a degree of independence.

5.12 As currently drafted, both the public health white paper and the Health and Social Care Bill would allow someone without the relevant training or qualification to be appointed as a DPH. We therefore believe that it should be mandatory for directors of public health to be on the GMC Specialist Register or the United Kingdom Public Health Register. There is no requirement in either the Bill or Public Health White papers for the DPH to have direct access to the cabinet, councillors or to the CEO. The relationship of the DPH with PHE is unclear, and the DPH could have their employment terminated without the approval of either PHE or the Secretary of State for Health.

6. Regulation of Specialist PH Workforce

Recommendations

6.1 FPH should be the standard setter for all public health practice in the UK.

6.2 The title “Specialist in Public Health” should be a protected title, required by statute to be registered.

Comments

6.3 Consultants and specialists in public health, including DPHs, give advice and take decisions which have a major impact on the lives of many thousands of people. Although doctors and dentists working at this level must have statutory registration, this is not required for those from backgrounds other than medicine, although their responsibilities are often identical. It is therefore important that statutory regulation applies to all Consultants and Specialists in Public Health.

7. Public Health Training

Recommendations

7.1 Should be organised and provided alongside training on other medical specialties with similar routes of access, standard setting and quality assurance.

Comments

7.2 Public health training is currently organised and funded in this way. It works well and attracts high calibre recruits from a wide range of backgrounds. Dislocation from the “mainstream” would present significant risks for recruitment, retention and quality control. The range of training placements will, however, need to be increased to ensure trainees gain experience in all relevant settings.

7.3 The training programme for public health consultants is designed to be equivalent, as far as is practicable, to hospital specialities. Entrants have to be medically qualified, or have a good degree and relevant postgraduate experience. The training programme lasts for at least five years, and progression requires trainees to pass a two part exam and to complete defined work-based learning outcomes. At the end of this programme, employers and the public can be confident that public health consultants will have been trained to the highest possible standards.

7.4 Once the training programme has been completed, medically qualified trainees are eligible to be on the Specialist Register, and are regulated (like all doctors) by the General Medical Council (GMC). Action can therefore be taken to deal with poor performance or misconduct.

7.5 Non-medically qualified trainees are eligible to be included on the United Kingdom Public Health Register. But this body is much more limited in its powers than the GMC.

7.6 We believe that all public health specialists, doctors and non-medically qualified practitioners, should be subject to the same degree of regulation and by the same body, to protect employers and the public from poor performance and misconduct.

8. Workforce Capacity

Recommendations

8.1 Measures should be taken to preserve public health capacity at this crucial time.

Comments

8.2 Previous NHS reorganisations have led to a substantial drop in the number of public health consultants. The uncertainties in employment prospects caused by the current reorganisation, and financial restraints, are already leading to some public health consultants seeking voluntary redundancy or early retirement. A further reduction in what is already a very small profession (there are only around 1,000 public health consultants in total) will threaten our ability to improve the health of the population, to contribute our part in the commissioning of health services, and to deliver our input to the response to major incidents and emergencies.

9. GP Commissioning and Specialised Commissioning

Recommendations

9.1 GP consortia and their teams should be required to work with DPHs and, through them and their teams ensure that commissioning decisions made by GPs are underpinned by expert PH advice. One way of achieving this would be for the DPH or representative to be a formal member of local GP Consortia Boards.

9.2 Those involved in specialised commissioning should be supported by expert PH advice.

Comments

9.3 The population perspective brought by public health experts and the patient-focused perspective of GPs are complementary. Both are needed for successful commissioning. The engagement of the local DPH and their team will facilitate a strategic approach, rooted in the needs of the local communities.

9.4 Currently, public health consultants play a crucial role in the commissioning of healthcare. We contribute our skills and expertise in health needs assessment, critical appraisal of published evidence of effectiveness, leading the production and implementation of care pathways, and as credible leaders who can “hold the ring” between primary, secondary care and community service clinicians and providers.

9.5 The Public Health input to commissioning is therefore crucial to improving the effectiveness and the efficiency of health services. The NHS and Public Health White Papers have failed to understand the vital role that public health specialists play in commissioning. We are particularly concerned at the failure to ensure a future role for public health specialists in the commissioning of specialised services. We believe that it is vital that all GP Commissioning Consortia should have ready access to public health advice and support. This would be best provided from a single agency which employed all public health consultants.

10. Information

Recommendations

10.1 The new system must ensure that all those working in public health have access to timely, comprehensive and appropriate data and analysis to inform their decisions and advice.

10.2 Arrangements for maintenance of the public health observatory function and cancer registries for ensuring access to health service data need urgent clarification.

Comments

10.3 Reliable data and information are essential to the understanding of health needs, modelling of future scenarios and assessment of impact and efficacy. This is relevant both for service planning and design and for the recognition of and response to hazards and outbreaks. Public health professionals need a comprehensive and intimate understanding of their local population if they are to identify the need for—and to effect—change in any one of the three public health domains. The implementation of Healthy People, Healthy Lives, could result in disruption of existing flows of data and the loss of analytical expertise.

10.4 Public Health Observatories and Cancer Registers have played a vital role in enhancing our knowledge of health needs, in particular by providing us with comparative data. In each locality we need to know how our needs compare to other areas, and it is impractical and inefficient for analysts in each area to attempt to replicate this work. The role of public health observatories should be maintained and strengthened.

11. Teaching and Research

Recommendations

11.1 High quality public health teaching and research, addressing all three public health domains, are crucial to the success of the new system. They must be closely engaged with all levels of public health service and with undergraduate, postgraduate and continuing professional development in all relevant disciplines.

Comments

11.2 Healthy Lives, Healthy People acknowledges the importance of research and the establishment of the NIHR School of Public Health is encouraging. However, local authorities do not have the strong research tradition of the NHS, and public health research and evaluation may be difficult to initiate and maintain in that environment, particularly in the current economic climate. Academic enquiry and rigour are essential components of good public health practice. Links between service and academic staff have often been weak in the past. The new system offers an opportunity to build and strengthen relationships. This will require active support from universities and clarity on the relevant contractual frameworks.

12. Funding

Recommendations

12.1 The scope of the ring-fenced budget must be defined clearly.

12.2 The funds available in the ring-fenced budget must be sufficient to meet the needs for which that budget is intended.

Comments

12.3 There is a risk that the existence of a ring-fenced budget for “public health” will be expected to cover “all” public health interventions when many of these are, and will continue to be, the responsibility of other organisations. The uses to which the ring-fenced budget is to be put must be identified clearly and the size of the budget calculated from a realistic baseline.

12.4 We are pleased that public health will have a ring fenced budget but are concerned that local authorities may seek to use this budget to prop up their statutory services rather than spend this money on true public health services. It is essential that legislation is very clear on what the ring fenced public health budget should be used for.

13. Government Response to the Marmot Review

Recommendations

13.1 PHE and Health and Wellbeing Boards should as a key function actively support implementation of the Marmot review recommendation.

Comments

13.2 We are encouraged by the Coalition Government’s support for the Marmot Review and would encourage active support for ongoing implementation of their recommendations. This should be a key function for Public Health England and a requirement for Health and Wellbeing Boards to progress.

June 2011

Prepared 28th November 2011