HC 1048-III Health CommitteeWritten evidence from Unite the Union (PH 100)

This evidence is submitted by Unite the Union—the country’s largest trade union. The union’s members work in a range of industries including manufacturing, financial services, print, media, construction and not-for-profit sectors, local government, education and health services.

Unite represents approximately 100,000 health sector workers. This includes seven professional associations—the Community Practitioners and Health Visitors’ Association (CPHVA), Guild of Healthcare Pharmacists (GHP), Medical Practitioners Union (MPU), Society of Sexual Health Advisors (SSHA), Hospital Physicists Association (HPA), College of Health Care Chaplains (CHCC) and the Mental Health Nurses Association (MNHA)—and members in occupations such as allied health professions, healthcare science, applied psychology, counselling and psychotherapy, dental professions, audiology, optometry, building trades, estates, craft and maintenance, administration, ICT, support services and ambulance services.

This diverse membership includes a range of members who are involved in public health functions including the professional body of health visitors, and Unite members who work in the specialist public health workforce where the Unite/MPU has public health doctors in membership and Unite is the main union for non-medical public health consultants.

Executive Summary

Unite is extremely concerned about the impact of wider changes to the NHS on public health.

Fragmentation of public health infrastructure and services will damage public health outcomes.

There is insufficient information and detail on the Government’s proposals for Public Health England and the role of directors of public health. There needs to be clear systems of accountability and regulation fully integrated into this new system.

Given the critical role of Public Health England there is a strong argument for public health consultants and specialists to continue to be employed by the NHS as Public Health England employees.

Unite believes that several key workforce issues need to be considered in any changes. These include governance and reporting arrangements, training and professional development and terms and conditions.

1. Introduction

1.1 Unite welcomes the opportunity to submit evidence to the Health Select Committee inquiry on public health. Comments are organised under five key themes; accountability, governance and reporting; individual professional development; terms and conditions; workforce development; and future capacity. Before looking at the specific issues considered by the committee it is necessary to discuss the wider context of government health policies that will dramatically affect the public health of the population.

1.2 Firstly, the Government’s plans, as currently detailed in the Health and Social Care Bill, will cause huge upheaval for the NHS workforce. The bill will result in increased privatisation through the contracting out of health services to the private sector, which in turn will lead to further fragmentation of providers. Delivering health services is labour intensive and the drive to reduce costs to maximise profits will come at the expense of the number of staff employed and their morale. Unite has previously detailed why the Government’s plans will result in a decrease in the quality and range of health services available to people, contribute to increasing health inequality, increase healthcare costs, and reduce accountability. Unite also believes that this will lead to public health policy becoming more reactive, rather than long term and strategic. This will inevitably have a negative effect on public health.

1.3 Secondly, the agenda of deep spending cuts that the current government is implementing across public services, welfare and housing benefits run contrary to any aims to improve public health. Unite fully supports actions that improve and prioritise preventative healthcare measures, but to be effective such measures must recognise the impact of the wider social and economic determinants on health and wellbeing. These wider determinants include—but are not exclusive to—employment, the quality of that employment, employers’ duties to protect workers’ health at work, housing, local environment, the strength of civil society, facilities for active recreation and both income level and income inequality. Poverty plays a crucial role in health inequalities and a person’s health and wellbeing. In all of these areas current government actions and policies undermine progress to improving public health. This is the bleak context in which any newly created public health agency, directors of public health or public health consultants will be operating. There is a danger that the role very quickly becomes about minimising the detrimental impacts of government actions on public health, rather than positively driving forward improvements in public health and local environments.

1.4 Unite’s wider and more detailed views on the Government’s strategy and plans for public health were given in the response to the Government’s consultation, “Healthy Lives, Healthy People”.

2. Accountability, Governance and Reporting

2.1 At the moment there is insufficient information and detail on the Government’s proposals for Public Health England, the role of directors of public health and public health consultants. The roles, responsibilities and nature of Public Health England require substantial clarification. Unite has previously pointed out that at the moment the Government’s public health plans lacks specific actions and measurable targets so that the success, or otherwise, of the implementation of the Government’s public health agenda can be assessed.

2.2 Directors of public health are to provide governance and professional guidance for public health staff, and there is an urgent need for the Government to provide clarity around the reporting arrangements for these roles, how they will be regulated and how they are to be held accountable.

2.3 Unite believes that the role must not be marginalised and should be given sufficient status to enable the post holder to operate strategically in promoting the public health of the local population. The role holder should therefore report directly to the local authority chief executive, have the right to put their views on health matters into the public domain, and have a right of access to elected members. The multi-agency public health challenge process must be recognised as part of the director of public health role, along side relations with communities, voluntary organisations and business. Unite public health members, who are from a multidisciplinary background, further believe that directors of public health should be statutorily regulated.

2.4 Unite agrees with the BMA that non-medical public health consultants deserve the same status and NHS terms of conditions as medical public health consultants.

2.5 While regulation of the specialist public health workforce is currently under review Unite would welcome discussion regarding the development of a regulatory structure for non-consultant level posts within public health. In particular Unite would support more flexible arrangements for progression into the specialist workforce. It is important that there are appropriate systems of career progression between specialist and non-specialist grades to prevent a replication of the medical/non-medical divide of the 1990s.

3. Individual Professional Development

3.1 Unite members have strongly expressed the view that the current uncertainty around the future roles and employment arrangements will have a negative effect on the public health workforce and individual professional development within the field.

3.2 There is currently a lack of detail on future training and professional development of the public health workforce. Government proposals in the Health and Social Care Bill are also raising fears about career development and training. The fragmented commissioning arrangements in the bill are expected to create barriers between different organisations and prevent consultants and public health staff from gaining and maintaining competencies across all of the key domains in public health. In addition this will create difficulties in the identification of suitable and accredited specialist training placements. At the moment the public health workforce is relatively mobile across the public health domain which allows them to gain a wide range of experience. Unite is committed to ensuring that this system is maintained.

3.3 Local authorities currently do not have the knowledge or capacity to provide required training and development for the public health workforce. For example, local authorities will be unprepared or able to properly support staff in achieving revalidation and the continuing professional development requirements of the Faculty of Public Health. Unite would query whether authorities, given the financial vice they are in, will be able to develop this capacity.

3.4 One idea that should be explored is whether all public health staff should be employed by Public Health England, with staff then seconded to local authorities. If Public Health England is to be a special health authority, this arrangement would minimise the problems associated with public health consultants and specialists moving to local authority employment.

4. Terms and Conditions

4.1 Unite has previously outlined the benefits of national collective bargaining, and specifically the benefits of Agenda for Change to the NHS. As well as bringing about equal pay for work of equal value and providing a framework for career development and progression for staff, it has brought a myriad of other benefits. National negotiation prevents the duplication of resource intensive HR functions and negotiation at local and regional organisations across the country. A single pay spine across the country brings a great deal of stability to the healthcare labour market and means organisations do not get into a “bidding war” for health professionals that are in short supply. Unite believes that the non-medical and medical public health workforce should continue to be employed on NHS terms and conditions, with the retention of the public health knowledge and skills framework. This would easily fit with staff being employed directly by Public Health England.

5. Workforce Development

5.1 There is no suggestion yet that Public Health England will be well-equipped for workforce development roles and government has not engaged with this problem. For example, there appears to be a view that workforce development can be managed at local level but a national shortage of public health specialists and consultants will make that impossible.

5.2 Unite believes that public health teams, which will include registered consultants, specialist and practitioner staff able to work across all three domains of public health, should be retained whether at borough level or higher. These three domains are health improvement, health protection and health services. Given the uncertainty of structure in local government and health and well being boards in public health, there needs to continue to be team working with dedicated leadership at the appropriate level.

5.3 Some local authorities are proposing to disperse their public health staff across the organisation. Unite believes this would lead to the marginalisation of the public health agenda and leave public health staff without sufficient professional support. Unite believes this would also effect the wider general workforce, such as non-consultant level and registered public health staff who would be unlikely to be managed and supervised by a consultant. This would limit the level of public health coaching, management and mentoring received. Furthermore, the continued government emphasis on a “diversity of employers” will lead to public health specialists and consultants increasingly working in professional isolation and with variable support.

5.4 There are concerns that disparity will develop as a result of the multidisciplinary nature of public health. Location of these roles within local authority may disassociate public health as a speciality away from other clinical and medical specialities, making future recruitment of public health specialists and consultants difficult.

5.5 Unite wants to see clarification from the government about how to ensure that public health trainees will have access to the full range of public health experiences, once public health is dispersed across several organisations.

5.6 Unite also wishes to see clarification on the position of defined versus generalist specialists, including where defined specialists would be placed, and the future of these specialists in light of the changes proposed by the government.

6. Future Public Health Capacity

6.1 Increased demand for the public health workforce is already being seen in terms of local authority commissioning and should be part of future GP commissioning processes. If the public health workforce is eroded, and/or split amongst several agencies the variety or skills required and the capacity to deliver these may not be sufficient to meet increased need. A key focus for the public health agenda is prevention of ill health and disease and to date there has been insufficient evidence that the QIPP agenda has delivered on these prevention issues.

6.2 The future funding of public health is not clear. Given the wider spending cuts agenda being pursued by this government there are fears that sufficient funding for public health will not be forthcoming and there is doubt about any funding being ring-fenced. There are serious concerns that the competitive business model and fragmentation of NHS services will cause major problems when implemented. Unite members are predicting serious problems with budgetary responsibility, the impacts on other services and confusion about which organisation is providing infrastructure for public health work.

6.3 Finally, information analysis is another important area of shortfall in the Government’s plans. Unite is concerned that the Government is not taking the necessary steps to preserve the skills in the Public Health Observatories, whose existence is being prolonged by a short term extension with no clear strategy for the longer term.

June 2011