Written evidence from the Health Protection
Agency (PH 06)
SUMMARY
1. The Health Protection Agency (HPA) welcomes
the opportunity to contribute to this inquiry.
2. In preparing its response to the white paper,
"Healthy Lives, Healthy People", the Health Protection
Agency identified positive benefits for public health that will
flow from the proposals but also some issues and risks that need
to be considered and addressed in order that the benefits are
fully realised.
3. Since publication the HPA has been working
with partners, including in particular the Department of Health
(DH) and the Association of Directors of Public Health, to fully
understand the implications of the proposals and how they will
be implemented.
4. We welcome the Government's commitment to
public health and remain of the view that overall the white paper
proposals present a positive opportunity to develop and improve
the wider public health system in England, and indeed to create
a world-leading public health system that will begin to address
the important issues raised by the Marmot Review.
5. To realise this vision the proposals must
embrace a whole system approach to public health, not just the
creation of Public Health England and the transfer of Directors
of Public Health (DsPH) to local authorities. It needs to consider
the impact of wider NHS reforms and also how the system is accountable
to the public as well as to parliament.
6. We also, however, remain concerned about some
aspects of the implementation that we believe are still unresolved
and carry risks for the future success of Public Health England
(PHE), and so the wider system, which we would invite the Committee
to consider.
7. These key issues are:
(a) Independence: there is a risk of losing independence
(or perceived independence) in PHE as currently envisaged.
(b) Expertise: there is a risk of losing critical
scientific and public health expertise.
(c) Clear Roles and Responsibilities: the nature
of the local relationships between PHE (especially local units)
and Directors of Public Health in local authorities.
(d) Emergency Preparedness, Response and Resilience
Capability: maintaining, and strengthening, emergency preparedness,
response and resilience (with particular concern about the timing
in relation to preparedness for the London 2012 Olympic and Paralympic
Games).
(e) Operating Model: the need for PHE to be established
in a way that will encourage a culture and ethos that focuses
on the needs of the population, a sense of unity within the public
health community, and supports career paths to develop rounded
public health professionals.
DISCUSSION
8. The white paper "Healthy Lives, Healthy
People" set out a vision for a public health system for England
that aspires to be one of the best in the world - building on
the existing excellent public health expertise across the range
of public health bodies. The vision is a cohesive public health
system based on locally led delivery supported by a new national
expert public health service, PHE.
9. The realisation of this vision through the
devolution of responsibilities and budgets to local authorities
and the implementation of PHE will arise from three key founding
principles:
(a) empowering communities to address their own
particular needs and giving them the tools and support to do so
effectively;
(b) integration of public health services from
national to local level, with national expert centres supporting
the delivery of excellent public health services at the local
level to achieve improved outcomes, and
(c) integration of all the domains of public
health in one expert organisation, bringing together the wide
range of expertise that currently sits in separate organisations.
10. PHE will bring together expertise in high
quality epidemiology, intelligence and information analysis from
across public health, including the Public Health Observatories,
Cancer Registries, the HPA's national epidemiology centres as
well as local and regional public health departments across the
health service. The synergy between these groups will create the
opportunity to develop new ways of working, allow greater effectiveness
and efficiency, and substantially improve and develop the evidence
and knowledge base for effective public health interventions.
Working closely with local authorities and the NHS will lead to
greater impact in tackling the causes of ill-health and poor wellbeing,
as well as strengthening the national emergency response capability.
11. PHE will also inherit a proven model of national
expert HPA centres working to support local delivery in a seamless,
consistent, science-driven and quality-assured system.
12. Together, these will create an organisation
with the knowledge, capacity and authority to lead the public
health system and support local innovation to deliver real improvements
in the health of the public. Local communities, supported by this
national expert body, will be empowered to build a stronger healthier
country.
INDEPENDENCE
13. Independence (real and perceived) of scientific
and public health advice to government, at national and
local level, is essential if it is to be seen as credible within
the scientific community and by partners and stakeholders; if
it is not seen as credible it will not be effective. Equally when
giving advice to the public, independence is one of the
most significant factors determining how the public will receive
and respond to that advice.
14. The HPA has, over the 8 years of its existence,
developed a reputation with the public, the public health profession,
and with the scientific community, for the provision of effective,
high quality, and evidence-based public health advice. This confidence
of the public in the HPA and its advice has been tested and confirmed
in surveys. The independent status of the agency and its statutory
right to publish its advice have been an important element in
ensuring that confidence.
15. We believe it is essential that PHE builds
on that reputation and maintains the same level of public and
professional confidence across its wider range of public health
responsibilities if it is to be an effective leader and deliver
health improvement through supporting people to make better choices
about health risks. If PHE is viewed as part of a department of
state we believe that its independence, and therefore its credibility,
will be seen as seriously compromised. PHE needs to have a distinct
identity from the Department of Health and have its independence
guaranteed in its constitution. It is notable, for example, that
the significant loss of public confidence and trust in the advice
of "government scientists" following the BSE incident
was partly because they were seen to be part of the government
establishment and "not independent". This was one of
the original drivers behind the establishment of the independent
HPA and we are not aware that this requirement has changed.
EXPERTISE
16. The HPA has also built up an internationally
respected body of scientific expertise which should be transferred
to PHE as part of its core capacity. That expertise derives in
part from, and is funded to a significant extent by, the research
and commercial activity that is an integral part of the HPA. Critically
the staff involved provide a significant part of the agency's
response capacity in incidents. This has been amply demonstrated
in many incidents, most recently by the UK response to the Fukushima
nuclear reactor incident where the staff developing advice for
the UK were those supported by research and commercial activity.
Without this, in future PHE will either have substantially higher
costs to the taxpayer or substantially reduced expert capability.
17. The HPA has been able to recruit and retain
the highest quality of expert staff because of its reputation,
the integration of research and commercial activity into its core
business, and the ability of its staff to be influential with
the scientific community, with government and with the public.
18. As a part of a government department these
attributes will be at risk in PHE. PHE's ability to compete for
research funds will be severely reduced as the major funding bodies,
such as the Medical Research Council, do not fund Government departments.
The academic sector cannot fill the gap because, as noted above,
it is essential that the expert capability is embedded in PHE
to be available to directly support the frontline in real time.
19. In addition, it will be far more challenging
to engage successfully in commercial activity both in terms of
the willingness of prospective clients (including foreign governments)
to trade directly with the UK Government and in respect of maintaining
the necessary flexibility and responsiveness of structures and
support systems within the environment of a Government department.
20. If there is also a perception that expert
staff will be constrained in how they communicate and offer advice,
both to the public and within the scientific community, by being
within a government department of state, then PHE would cease
to be an employer of choice for this calibre of expert. This would
inevitably reduce the capacity of PHE to deliver its core public
health responsibilities and also damage "UK Plc" in
terms of its scientific capacity and its international reputation
for high quality science and translating research into successful
frontline practice.
CLEAR ROLES
AND RESPONSIBILITIES
21. It will be important to ensure clarity of
roles and responsibilities for the organisations involved in delivering
effective public health. A key element of the new public health
service will be the transfer of some responsibilities and resources
to the Local Authority to ensure delivery of agreed public health
outcomes. Local Authorities will depend on the PHE (mainly through
local PHE Units) to provide the right expertise and resources
to support them in their role.
22. We believe the new public health system will
be made stronger if each local authority is given statutory responsibility
for the health of its local population, discharged through a properly
qualified Director of Public Health (DPH). DsPH have this responsibility
now in their PCT role and it is a significant tool in advocating
for the health of the population.
23. Similarly, the current statutory responsibility
of the HPA to protect the health of the population should be transferred
to PHE along with the mutual duty of cooperation with other bodies
with health protection responsibilities. PHE, with its specialist
expertise, will therefore be responsible for identifying and leading
the response to health protection incidents, including setting
up Outbreak Control Teams. At a local level the local PHE Unit
Directors will be acting on behalf of the DsPH, but will be professionally
and managerially accountable via the national PHE structures to
deliver this response function (giving the line of sight to SoS).
PHE will be responsible for informing DsPH and keeping them updated,
and the DsPH on behalf of their local authorities will wish to
be assured that the response is being undertaken appropriately.
24. Our experience of outbreaks and public health
incidents confirms that many (indeed most of the more complex
incidents) cross local authority boundaries and require both coordination
and leadership beyond the local authority level, and the seamless
application of the specialist expertise currently available in
Health Protection Units and the HPA national centres.
25. We are also conscious of the need in a national
emergency for the Secretary of State to have a clear line to direct
the response through one organisation, from national to local.
26. There needs to be a clear partnership between
PHE (nationally and locally) and DsPH that ensures consistent,
evidence-based support is available from the national to the local
level to support local public health action.
27. This partnership would be facilitated if
DsPH were formally part of PHE (for example by having a joint
appointment with PHE and the local authority).
28. Ensuring clear responsibility for the population's
health nationally and locally will support the government's aim
of protecting the population with a clear line of sight from the
Secretary of State to the "frontline".
EMERGENCY PREPAREDNESS,
RESPONSE AND
RESILIENCE
29. Our response to the public health white paper
highlighted the critical need to ensure emergency preparedness
and response systems and resources are maintained both during
the transition and in the new health system.
30. Considerable work has been done by the Department
of Health, and key stakeholders, to mitigate this risk and there
is emerging consensus on many aspects of how this function should
be delivered across the health system and across government but
there is not yet clarity.
31. The HPA is currently a "Category 1 Responder"
under the Civil Contingencies Act. This is an important part of
national capability for emergency response because it confers
a duty on the agency to identify and prepare for health risks,
to cooperate with others involved in emergency response and to
warn and inform the public; but it also confers a duty on others
to cooperate with the HPA.
32. The mutual duty to cooperate is not currently
replicated under the proposed Health and Social Care Bill and
we believe that it is important that PHE is designated as a Category
1 Responder to ensure that this capability continues in the new
arrangements.
33. We remain concerned about the impact on Olympic
preparedness of the pause in the progress of the Bill and the
consequent delay in implementation of PHE.
34. Changing key elements of the Olympic response
weeks before the start of the Games, and after the Games-time
daily operational response has started, adds significant risk
to a key national priority. The inability to live test the new
system before implementation adds to the overall risk.
35. We are aware that a programme of work is
underway within DH to address this issue but we feel this remains
a risk until there is greater clarity about the proposed arrangements.
OPERATING MODEL
36. The framework within which PHE is established
will have a significant impact on its culture and be a major determinant
of both its success and its sustainability.
37. As noted above we believe establishing its
independence and close partnership working with local authorities
will be important to ensure it can be effective. This will enable
PHE to provide leadership to the whole public health system, using
its expertise and evidence to focus attention and action on those
issues which will deliver the maximum benefit to people and communities
across the country.
38. Showing how it is accountable to the public
(as well as to parliament) will also be critical. The Parliamentary
Committee on Public Administration looked at the government's
own tests for Arms length Bodies and set out recommendations on
when public bodies should be established outside departments of
state as Arms Length Bodies or Executive Agencies and described
the importance of public accountability. We believe these arguments
apply very directly to PHE.
39. PHE will also depend for its future on a
dynamic exchange of specialist staff across the public health
system including the NHS, and the training of the specialists
of the future will depend on free movement of staff and trainees
across organisations.
40. Variations in staff terms and conditions
of employment between different parts of the public health system
will be a barrier to this free movement and will therefore compromise
the future development of the workforce. They should therefore
be avoided unless there is a strong justification for introducing
them.
CONCLUSION
41. We invite the Committee to consider these
questions and encourage it to advise government to establish PHE
in a way that will safeguard both its independence and its expertise
and which will bring greater clarity to local roles and responsibilities
and minimise any impact on emergency preparedness.
42. Further, and more detailed, information on
these issues is included in our response to the white paper, "Healthy
Lives, Healthy People", and similar comments that have been
made in the responses of many other professional scientific bodies
such as the Wellcome Trust and the Faculty of Public Health. We
would be happy to elaborate on any of these comments if that would
be helpful.
June 2011
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