Public Health - Health Committee Contents


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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Prepared 2 November 2011