Examination of Witnesses (Question Numbers
Professor David Hunter, Professor Lindsey Davies,
Angela Mawle and Dr Fiona Sim
17 May 2011
Q1 Chair: Thank
you very much for coming along this morning. I would like to open
the evidence session by asking you to introduce yourselves very
briefly and to tell us a bit about the organisations you come
from and how they fit into the public health world.
Angela Mawle: I
am Angela Mawle, Chief Executive of the UK Public Health Association.
We are a multidisciplinary group and we represent public health
workers across the whole sector: local authorities, NHS, PCTs,
community activists and retired people, who pay only £5.
They all have a common mission of promoting sustainable development,
combating health inequalities and combating antihealth forces,
which we say is the tobacco industry and perhaps the food industrythose
sorts of things. We are broad based. We don't have a lot of money
and we do what we can with the resources we have, but we are very
I am Lindsey Davies, the President of the UK Faculty of Public
Health. We represent specialists in public health. All our members
are qualified specialists in public health. We are the body that
sets standards for public health practice training in the UK and
we also do a lot of public health advocacy work.
I am David Hunter, Professor of Health Policy and Management at
Durham University. I am the academic here. I head up a little
centre called the Centre for Public Policy and Health, which undertakes
research on public health, and we have completed two major studies
recently, one on partnership working in public health and the
other on public health governance in primary care. However, I
do get involved in the real world as well. I was a former chair
of the UKPHA until a couple of years ago and I am a nonexecutive
director of NICE, with particular responsibility for public health,
which is a growing area of its activity.
Dr Sim: I am Fiona
Sim, the Vice Chairman of the Royal Society for Public Health.
It is a very wellestablished, centuriesold organisation
that has merged over the years from several predecessor organisations.
It is a third sector body with a broad membership of people who
are interested in public health, from specialists in public health
and consultants, people working in local government, in environmental
health and nutrition, in leisure services and so on, through to
interested individuals and health professionals, including GPs,
pharmacists, dentists and so on. It has a number of qualifications,
mostly in food hygiene and environmental health, and a strong
Q2 Chair: Thank
you very much.
This is the first public evidence session of an inquiry
we are doing on the management of public health and the opportunities
for public health, which is obviously against the background of
the Health and Social Care Bill and the Government's proposed
changes to the way in which health care is managed. The first
question is probably best addressed, at least in the first instance,
to Professor Hunter. It would be very helpful to us to understand
both how public health accountability currently is supposed to
workwhere the strengths and weaknesses, in your view, of
that process areand then how you think those accountability
structures are changed by the Government's proposalshow
you reflect on those. That is quite a wide range of questions,
but it would be helpful to get all those issues on the table at
the beginning of the discussion rather than them coming up in
an unstructured way during the session. Perhaps we can start with
As you say, it is a tall order, but I will try to be succinct.
First of all, debates have raged over what we mean by (a) public
health and (b) the public health system. However, I think most
people would agree that it is a broad based and complex system.
On one level, it affects all that happens in public policy and
in the organised efforts of society, as Acheson put it, to improve
the public's health. It therefore embraces what happens in the
NHS, in local government, in organisations outside government,
including in the private third sectors. Therefore, the boundaries
are a problem.
Public health at one level is about everything that
affects our lives, and, arguably, that is a strength. Public health
challenges, including obesity, alcohol misuse, sexual health,
are what might be termed 'wicked' problems, that is, they are
complex, cut across multiple practitioners and organisations,
and defy easy or simple solutions. They do not belong to one sector
or agency but require cross-boundary working usually conducted
by partnerships of one sort or another. The difficulty, when it
comes to accountability and governance, is that the public health
function has a very broad, allencompassing, allinclusive
definition that doesn't take one very far in terms of effectively
holding those parties whose activities impact on the public's
health to account. Generally, there is agreement that the public
health community comprises: specialists in public health, who,
at the moment, primarily work in the NHS; people working in public
health practice, who, again, primarily work in the NHS but also
in local government; and then the wider public healthpeople
whose work does touch on public health issues but who would not
describe themselves as public health practitioners. At the moment,
the public health function is led by the NHS, both locally and
nationally. I say "at the moment" because I am not sure
what is left of the previous NHS because things are happening
to change that now but, in terms of primary care trusts and so
on, it does have the principal responsibility for public health.
It is also probably useful to say that public health comprises
what is generally acknowledged to be three domains: health improvement,
health protection and health service development. Whether one
agrees that those domains should all come under one specialty
or one individual director of public health is arguable, but the
public health community generally accepts those three domains
as a typology for describing the functions. The controversyand
one of the reasons for the changes being proposed by the governmentis
that the health improvement part of that agenda has more to do
with what happens outside the NHS than inside in terms of improving
the public's health, addressing the social determinants of health
and tackling health inequalities. Arguably, that is a nonNHS
core function, yet the lead for it has been invested in the NHS
since 1974, and that has been a source of tension. It is concededand
the move towards appointing joint director of public health posts
over the last few years is an acknowledgement of this that
local government has to be a central part of that arrangement.
Therefore, partnership working is very important and the whole
previous structure of local area agreements and local strategic
partnerships was an attempt to embrace all that.
Health protection is split between the NHS, local
government and nationally, although the NHS has a key though not
exclusive role. The wider public health, again, lies outside the
NHS for the most part and embraces pretty well everything that
local government and other agencies do. Accountability is mixed,
in terms of the lead role, at the moment. Prior to joint DsPH
posts being introduced a few years ago, it came through the DPH,
who was accountable, initially, to the NHS. Now the joint posts
held by DsPH are accountable to both local authorities and the
NHS. That arrangement has worked variably across the country in
terms of the degree of "jointness" and integration.
It is, therefore, a bit mixed, messy and uneven across the country
The Government's move to make local government the
lead agency for public health is a recognition, in some quarters,
that public health's natural home lies in local government. There
is a strong view that a mistake was made in 1974 in transferring
public health out of local government. The Health Committee report
in 200110 years agowhich I remember well as I was
involved in it, argued at length over whether local government
should assume the lead role for public health and take public
health back from the NHS or whether it made more sense to leave
public health where it was and avoid a major organisational upheaval.
It was accepted that major structural change should be avoided
why mess around with structures?and that far more
important was the function itself, ensuring the necessary governance
structures were in place and holding people to account for what
they achieved. Structural rejigging, the Committee conceded,
would be detrimental, unhelpful and a distraction.
This Government have decided to restore the lead
role for public health in local government. While the move was
initially widely welcomed, in the last few months we have seen
some retreat from that position and growing concerns that what
might have been seen to be important gains in the NHS for public
health might be lost if local government were to take a lead role
at a time when local government itself is under severe pressure
financially. I could go on.
Q3 Chair: In terms
of where accountability rests in the proposed structure, if the
Bill goes through in its current form, is it clear in your mind
that lead responsibility rests in local government?
I think it is confused, to be honest. Part of it - the health
improvement component of accountability - lies there and part
of it - the health protection componentlies with the new
entity within the Department of HealthPublic Health Englandand
the Secretary of State for Health. There is dual accountability.
For local government that is a problem, because to have somebody
in their chief officer ranks who is simultaneously accountable
locally and to a central Department Ministerin this case
the Secretary of State for Healthis a problem. Professional
accountability to the CMO would be acceptable. The problem would
be having a senior local government officer jointly accountable
to the Secretary of State for Health at the centre and locally
to the chief executive of the local authority. That is a red line
that local government would find it difficult to cross. It would
set a precedent that local government would find it hard to accept.
Q4 Chair: That
remains, in your mind, an unresolved difficulty about the proposals
at this moment.
Chair: That is helpful.
Q5 Valerie Vaz:
Some public health experts have been saying that Public Health
England is not the proper way to deal with public health and that
there needs to be a population view. What is your view about some
of the proposals that have come through about a special health
authority that has only public health?
I can see the appeal, but there are drawbacks. In terms of what
the Government wanted to achieve, turning the Department of Health
into a health departmentnot an illhealth department,
because the NHS would be responsible to the proposed commissioning
board which would be hived off. If you take public health out
of the Department of Health and put it into a special health authority
as some critics of the proposed changes favour, I am not quite
sure what is leftyou have got virtually nothing except
the Minister, or several Ministers, and no function. I am not
clear how that would work in practice, plus there is the fact
that hivedoff agencies do have problems engaging at the
top table and shaping and influencing policy since they tend to
be at one remove from these internal systems and processes. If
you look at what happened in New Zealand, for example, some years
ago when they had an independent Public Health Commission, it
began to flex its muscles and raise controversial issues and,
in the end, was abolished for being too critical of government.
It had no way of fighting back. If you want to influence and shape
policy, being at the top table and part of the system, however
messy and uncomfortable it may be, is preferable to being hived
off to a nextsteps agency where you may not have that degree
of traction on the system.
Q6 Valerie Vaz:
The way I understand it is that there would be accountability
to the Secretary of State, but they could be left to get on with
their work. What do the others think?
We have a rather different view in terms of Public Health England.
We think that it is fundamentally important for public confidence
that people who are practising public health are able to speak
in a professional way and in a way that the public and professionals
can have confidence that they are speaking from their own authoritative
judgment on the evidence and drawing on their own experience,
as well as that there isn't any overlay that relates to the organisation
that happens to employ them. Obviously, that is a challenge.
As public health people, we are all about wanting
to make change, to drive things and to be influential. Sometimes
you have to make a choice between being able to influence internally
in your organisation and being able to speak freely externally.
I made that choice, myself, when I moved from a health authority
years ago into the Department of Health as a civil servant. I
have been back out and forwards and I have spent a lot of time
in both ways of working over the years. I know perfectly well
how easy it isor isn'tto speak freely as a civil
servant on matters of public health. You can say some things but,
naturally, you have to be sensitive to where you are coming from.
On the other hand, as a director of public health at one remove
from the Government, you can and should speak from professional
expertise and understanding.
If Public Health England is set up as planned at
the momentas one more directorate of the Department of
Healthit will lose any opportunity to speak influentially
and authoritatively to the public about important health matters.
I think that that would be a huge loss. Also, if it is part of
the Department of Health, it will not be able to generate the
income that, for example, the HPAthe Health Protection
Agencycan do from research and other ways that subsidises
a lot of its other public health activity.
The model we would see for Public Health England
would be that it is set up, ideally, as an NHS body, but, failing
that, as an Executive agency of the Department of Health that
is able to employ specialists and consultants in public health
and to deploy them to work with other organisationswhether
local authorities, consortia or whoeverto use specialist
skills appropriately and effectively, and able to put surge capacity
in place to deal with emergencies and things if it needs to do
so. We think that that could work very well.
We acknowledge the issue that of course local authorities
will want to feel the people working for them are their people
working on their behalf and not on behalf of Government. However,
entirely reasonable models already exist. For example, all university
academics are employed by universities, but clinical academics,
employed by a university, also work in the NHS and there is no
doubt that they are working for their trust when they work in
the NHS. We see that model as working very well and we are very
positive about it. We do not see working as a directorate of the
Department of Health as the right way to go, for the reasons I
have explained. I take the point that the Department of Health
needs public health expertise. It does, absolutely. There is not
nearly enough of that inside the Department of Health at the moment,
in our view, but that isn't the same as the agency that we are
Finally, on accountabilities, that model, we feel,
will work only if the local authority is clearly in charge all
the time and not if sometimes it is Public Health England and
sometimes it is not. The local authority is in charge, with Public
Health England supporting local authorities to discharge their
very important responsibilities for health improvement and protection.
Q7 Valerie Vaz:
Before I hear the others' view on that, who, in your models, would
have control over the population view if you remove it down to
local authorities? They are only interested in their particular
area, so who would pull together all that evidence? Who is doing
it now and who will do that in the future under both your models?
The local authority would be concerned about its population and
its community. It would have a population perspective.
Q8 Valerie Vaz:
Would the GP have that?
GPs are variable in whether they see a population as opposed to
individual patients. I think it is very much the latter. There
are exceptions, but generally there is a problem in general practice
and given the reality of mixed boundarieslack of coterminositybetween
GP consortia or whatever takes their place and the local authority,
there would be a tension there.
Nationally, at the moment, the top health person
is the Chief Medical Officer, and they ostensibly have responsibility
for public health in the round in government, not just in the
Department of Health. I think we are wrong if we see public health
as only being the responsibility of the Department of Health.
That has been a weakness in the past. Arguably, in most Governments,
Departments of Health aren't seen to be necessarily the strongest
Department. If you think about what happened under the previous
Government, it was the Treasury that drove much of the impetus
on public health, not the Department of Health. It goes back to
Lindsey's point about the weakness in the public health group,
if you like, in terms of the capacity to make public health matter
in the Department of Health. The trouble is there are no rights
and wrongs or perfect institutional structures here. There are
weaknesses and strengths in all these models and there is no single
answer. It depends on what you are seeking to achieve.
There is a worry with nextstep agencies. For
example, NICE is a special health authority that has never seen
its role as being to antagonise or take on Government, much as
it would like to on occasion. Some of its guidance has begun to
challenge what the Government is doing, as occurred in its public
health guidance that came out last summer in respect of alcohol
misuse and cardiovascular disease preventionthe Government
resoundingly dismissed it. There were issues there affecting the
whole of Government and the Government said, "We're not interested
in all this. Your role is to influence what has happened locally."
NICE withdrew at that point and didn't confront the Government,
so I'm not sure being independent, in reality, makes a great deal
Q9 Valerie Vaz:
I want to come on to NICE, but could I hear from Dr Sim?
Dr Sim: Our view
about Public Health England is very much in accord with what you
have heard from Professor Davies. I don't want to take time, but
I would simply say that we have very similar views about the need
for Public Health England not to be part of the Department of
Healthfor very similar reasons.
If I may, I will say something more about local accountability
because Professor Hunter mentioned dual accountability to the
chief executive in local government and to Public Health England.
The reality we are picking up from colleagues is that accountability
at a local level within local government is not necessarily to
the chief executive. If you look backat what some people
are calling "the golden era" and what others are calling
"the era well left behind" the medical officer
of health was a very senior officer within local government and
had the sort of freedom of speech to which Professor Davies is
alluding. If you are a third-tier officer accountable to a director
of adult social care, that is somewhat less likely, I feel, and
there is significant concern about whether the public health voice
would be heard, let alone heeded, in local government if it is
that well hidden. That is a real concern among our public health
Q10 Chair: Factually,
is that where it is now envisaged the local government responsibility
will rest as part of adult social care?
Dr Sim: No. Factually,
it is an incredibly variable feast, so there are some directors
of public health who are negotiating and have already been offered
posts that are directly accountable to their chief executive in
local government and
Q11 Chair: But
it rather undermines the whole logic of taking public health out
of the health service on the grounds that it is a crossgovernment
responsibility. If you take it out of the health service and put
it into social services, it's a step backwards, isn't it?
Dr Sim: There are
certainly examples of that, which is why I am suggesting it is
possibly inappropriate. It would be very helpful to protect that
role in terms of its breadth within the organisation, which is
not the case at the moment.
I was going to respond about general practice very
briefly. I work part time as a salaried GPI should declare
an interest, perhapsas well as being a public health specialist.
My GP colleagues, as somebody said, are very variable. It is very
common for GPs to recognise and to be aware of the importance
of public health. The average GP, or most GPs, are not trained
in public health. Their experience, largely, is of delivery and
of secondary and tertiary prevention, and they recognise that,
particularly with the encouragement of the Quality and Outcomes
framework. Those are the main issues around the public health
agenda that I think GP colleagues are interested in and have experience
of. They recognise that they need public health specialist expertise
andI do not know if this is an upcoming question or whether
I should pick it up nowthere is a lot of concern about
what that might look like, how they would access it, whether consortia
can afford to buy in public health expertise, whether local authority
public health departments, if they exist in that form, will be
allowed, encouraged or released to provide support to consortia,
and whether, as is one of the concerns, there will be an isolated
very parttime presence in a consortium that would be its
public health presence. In an isolated, very parttime, no
team support presence, it is very difficult to be effective.
Many consortia we are welcoming are looking at having
a director of public health on the consortium board which, obviously,
is very helpful and could well provide a public health conscience
for that organisation. However, they will need to call upon the
proper resources of public health expertise if they are going
to be seriously influential, in the work of the consortium, for
the consortium to commission on an evidence base efficiently,
effectively and to meet the needs of its population. In our view,
they need proper public health expert advice and support to be
able to deliver on that agenda.
Angela Mawle: To
answer generally, while we were very excited when the public health
White Paper came out because it gave a vision, we thought that
the crossdepartmental SubCommittee of the Cabinet
headed by the Secretary of State gave a too general acrosstheboard
look. We feel in the meantime that, as to the kind of processesI
will not say factionalisationthere has been a degree of
divide and rule that means that people are running for cover and
are more worried about posts and positions than about this vision.
The actual time taken to achieve this has been far too short and
the vision has been lost in the process.
Michael Marmot came out at much the same time and
we thought, "Great, the local authorities can take over."
If that was implemented, we would have wonderful public health.
Throughout the life of the UKPHAand I am sure that David
will support thiswe have been trying to take apart the
medical model of public health. Because it is in the NHS, it is
very easy to see public health as an NHS function. The public
are brought into this, too, so they tend to see health as something
provided by doctors, nurses or the clinicsand I am sure
the GPs will agree with thatbut they don't see themselves
I and the UKPHA see GPs as prime champions in the
community alongside the director of public health. However, the
problem arises if there is a cultural difference between the two
organisationslocal authorities and PCTs. There is a huge
cultural difference in terms of training processes, and the kind
of member involvement that you get in local authorities you certainly
don't get in PCTs. Therefore, the whole opening up of people to
looking at new ways of doing things is very hard for them, particularly
when the pace of change is so fast.
When I first came into this post, Wanless was pronouncing
the £30 billion saved to the NHS. He said that most people
in public health do not have "health" in their title
and that public health is everybody's business. Donald Acheson
talked about the organised efforts of society. We don't want to
see lost this opportunity to have champions out there with communities
helping people to produce their own health and to understand their
rolenot to be asked or told how to do it. I am sure that
that is not what people want to do, but it is a culture that has
built up through the generations and is particularly reinforced
by the fact that, since 1974, the public health provision has
been in the NHS.
We see accountability as a real issue because, clearly,
if the current directors of public health are going to be reporting
to social services or somebody similar, that, to them, immediately
takes away their credibility, their independent voice, etc. Perhaps
if there was a bit more time, but we haven't got a pause in ours.
I know the pause of the Bill is happening and we have used that
very creatively, we hope, to encourage an involvement of everybody
in the thinking of how you can create these champions who will
implement and help to develop the Marmot work out there in communities,
which is where GPs are active and where all health professionals
In the northwest, where we are working on fuel
poverty actively at the front line and not just sounding off about
itwhen you get into these sorts of issues it is easy to
sound off about things and not be involved in the practicalitieswe
found that when you approach GPs, PCTs and local authorities in
a collaborative way you can get a very good linking and crosssectoral
approach to public health problems, notably fuel poverty. That
really helps to free up both energy within the work force and
data release in a way that does not impact on the Data Protection
Act. If you want to do this, you can. However, because we don't
have a "can do" culture and because of the speed of
these reforms, it stops this vision so that even people in our
organisationwho are very keen to see this work and want
to see local authorities take authority for public health and
well-beingare really worried about the division that is
being created by the speed of change and the inability to look
at the individual people currently involved in delivering that.
One more thing is that in the future we should use
a visionand I would love everybody to be able to help in
thisto see what public health would look like in 10 or
15 years' time when we are confronted with all the issues about
climate change, environmental degradation, population and food
production. What will it look like then and what do we need to
do now to prepare for that? With this constant navelgazing
in looking at this current issue, we are losing sight of what
should always be, for public health, a scanning of the future
and what is going to be fit for purpose. I would endorse what
has been said but I have to say, for our membership, that we welcome
the vision, the crossdepartmental approach and the fact
that Marmot has been put into that report. We want the opportunity
to help it all work.
Q12 Chair: What
is your answer to the question that Professor Hunter raised at
the beginning about accountability in the proposed structure of
the director of public health? Is it to the local authority or
is it to Public Health Englandor should it beand
how is that balance struck?
Angela Mawle: I
have controversial views on this and I haven't discussed it with
people here. My view, and the view of a large number of our members,
is that the local authority has alwaysor for a long time
nowhad statutory responsibility for health and well-being.
That should remain with them. Somebody in the local authority
has to be responsible for the health of the population and that
should be at the highest level. We argued a long time ago that
there should be a cabinet post for public health. We are saying
there should be a cabinet post for public health and it should
be at a very high levelwhether it is chief executive or
whatever, there should be somebody therewhether you then
buy in services from Public Health England for specialisms, or
whether you spend time bringing your own work force up to speed
so they begin to take the responsibility for health.
Michael Lyons, when he was doing his report on the
council tax, was astonishedhe reported to one of our seminars,
didn't he, David?and could not believe that when he talked
about public health, that local authorities said, "Gosh,
no. That's the PCT. That's not us," and he felt that was
because they didn't have the confidence to say that they were
health because health is the NHS, not them. That is why I think
this is a real opportunity. I am not saying, in the current position,
that I could say which would be the best position to be in but,
looking to the future, I would definitely see local governance,
local collaboration and community involvement and that the person
responsible for health is at the very senior level of all the
collaborations at local authority level which help create a healthy
Can I pick up a number of those points, particularly focusing,
first, on the director of public health and their accountabilities?
We are saying that the local authority should be clearly accountable
for improving and protecting the health of its population. They
need somebody who understands how to do that, and who can do the
business, put in a position to be able to do that for them and
to lead them and enable them to do it. That we see as the director
of public health. Of course they have to be senior in the organisation
and of course they have to be accountable directly to the chief
executive of that organisation and with direct access to councillors.
If they do not have that, they will find it enormously difficult
to influence across the whole breadth of the local authority and
really to realise the potential that that brings with it.
I mentioned that they need to be qualified, but the
Bill just says "Appoint an individual". I have heard
it mooted that, in these stringent times, a local authority may
decide to add these to the responsibilities of a director of social
services or even the director of education. I would love to think
that a director of education was qualified in public healththat
would be fantastic and I could see great potential in thatbut
we really do have to have in the Bill that this person needs to
be qualified and we can perhaps touch later on other aspects of
The directors of public health themselves, I think,
need to be able to influence and provide this leadership across
all three domains of public health. The health servicesmaking
sure you have the right health services when you want themhealth
protection and protection against harm, and health improvement
and healthy lifestyles, if you like, work together. The DPH and
their team are the people who can look across all that and advise
on balance generally. As individual members of the public, that
is what we need.
Very quickly, we should not forget that leadership in local authorities
comes from elected members, not from officers. Therefore, the
role of a DPH moving into local government will be very different
from the role they may have enjoyed in the NHS becauseand
local government will tell you thisusing the word "leadership"
to describe an officer function is incorrect . It is the officers
who support the leadership coming from the elected member. A quite
different culture and set of skills are needed for that relationship
to work. That might account for some of the protectionism and
tribalism we are seeing in relation to fears in some public health
quarters about going into local government because
Q13 Chair: I think
you mean that the shrewd officer of local government volunteers
that his councillors are the leaders.
Of course. It is the "servant leader", or whatever term
you might use, but it is not an up-front leadership role. It is
a very different kind of leadership role from that which exists
in the NHS. Don't forget that this agenda is all about localism.
Local authorities are different. That is the whole point about
local government. They will vary in how they want to hold their
DPH to account, but that is the price of localism. You are either
for it or against it, but if you buy it, you have to buy what
goes with it, which is variation and difference.
Q14 David Tredinnick:
Listening to you all, it seems there are a couple of big issues
here. You suggest first that local government doesn't have a lot
of confidence in becoming responsible for health because it has
not done it for so longsince 1974and, secondly,
that if they are to make anything of it, they are going to need
expert advice, although I am not sure you see where that is coming
from. Is that right?
Some local authorities have a very confident view about their
role. Birmingham, for example, appointed their own DPH alongside
the DPHs from the primary care trusts. There are different models
and some local authorities do see their role very much as being
about health and well-being. They use the term "well-being"
rather than "public health" to describe that, but they
would see themselves as being at the forefront of health improvement
and of having more employees in public health than the health
service, if you take environmental health officers into account,
Q15 David Tredinnick:
That is a huge authority you have cited.
It is, yes. I am using one extreme.
Q16 David Tredinnick:
Is that representative?
I don't think any local authority is terribly representativethat
is part of the problem. But I don't think it is fair to say local
Angela Mawle: It
shows what is possible.
It is what is possible but I think local authorities, generally,
are up for this. Their worrythe poisoned chalice bit of
thisis that they are doing it at a time when they are being
massively cut and having to retrench and make savings in all areas
that, arguably, contribute to public health. Their worry is that
they are taking on this exciting and demanding role at a time
when they are being decimated in some respects.
Q17 Chair: In
a nutshell, I don't think we are hearing from the panel of witnesses
a case against a strong local government leadership role of this
public health function. It is a question of how that relates to
the rest of the system.
Angela Mawle: Absolutely.
Chair: I think that is
a fair summary of the starting point.
Q18 Chris Skidmore:
Can I, very quickly, pick up on that? I don't know if you have
read an article that was published in The Lancet back in
February: "Public health in England: an option for the way
forward?" You all seem to be in broad agreement about local
authorities having a greater role and, as far as I am aware, this
article mentioned that the big issue with moving public health
into local authority control would be a lack of scrutiny and that
"Moving local public health functions outside the NHS risks
them being overlooked to a much greater extent than when they
were within the NHS, andcruciallylocal government
is not gaining any of the additional regulatory powers it would
need to address the determinants of population health." Is
that a valid risk?
I don't think so. As Angela said, local government has had this
power since 2000 for the health and well-being of their communities.
We overrate the extent to which public health has been successful
within the NHS, to be honest. I'm not sure the evidence base is
there to substantiate that. Many of us feel disappointed with
public health punching below its weight, in some respects, over
the last 30-odd years and the distraction by an NHS agenda has
been very powerful. We have seen examples in the past, and the
previous Chief Medical Officer, Liam Donaldson, used to complain
about public health budgets being raided by primary care trusts
to prop up hospital services. There are huge tensions. Going into
local government could be a relief and a release from all of that
distraction from the core business in public health, which is
why I think the three domains are problematic. The third domain,
health service development, is not one that should necessarily
sit with the DPH moving into local government. You could decouple
that function and put it back into the NHS. I accept there's a
public health role in the NHS, but as to whether you need those
three domains being overseen by one person is arguable. Apart
from being a massive job stretch, it has been a problem in the
Q19 Valerie Vaz:
When you say "put it back in the NHS," whereabouts do
you mean? Do you mean Public Health England or
It depends on what we end up with, but the commissioning bodies,
and/or health and well-being boards, if they continue to exist,
and foundation trusts. There are many foundation trusts which
are seeing their role in terms of easing demand on the NHS and
of therefore being about having to take an upstream public health
perspective both with staff and patients.
Q20 Valerie Vaz:
It is quite important, isn't it, health care public health?
Q21 Valerie Vaz:
People seem to be forgetting about that.
Because it gets lost in the White Paper. It is not really made
Q22 Chair: Is
it not a core function of commissioning?
Q23 Chair: I am
slightly surprised you put it into a foundation trust. I would
have thought health care public health.
It is both.
Q24 Chair: If
commissioners aren't using health care public health as one of
their signposts, I don't quite know what map they are using.
No, absolutely. The joint strategic needs assessment has to be
at the core of that.
At the core of the joint strategic needs assessment is the DPH's
annual report, which needs to be on not just the health of the
population, but the needs of the population and the extent to
which those are being met across health services and on health
and social care and everything else.
Q25 Chair: Do
you agree with what Professor Hunter was saying about the possibility
of splitting the health care public health function away from
the rest of public health?
It is a difficult issue. The director of public health needs to
have that responsibility to advise across all of it. How the public
health expertise in a communityand I am including in that
everything that is supporting that community, including what is
employed by Public Health England or whereveris, on a daytoday
basis, organised to best effect is difficult to get right. It
is absolutely right that consortia and any commissioning body
need to have public health expertise embedded in their fabric.
On the other hand, having one person doing it half a day a week,
completely isolated from anything else that is going on and not
understanding the other bits of public health in their community,
would be equally poor. We have to find a way of bringing that
together. That is why we are saying that having a director of
public health with those teams of people acting on their behalf
and outposted for part of their time makes a lot of sense.
Picking up odd bits of public health time does not. I think that
foundation trusts should have public health expertise in them
because they have huge responsibilities, and public health in
health services is about making sure that services are efficient,
effective, appropriate and accessible. If foundation trusts aren't
doing that, I don't know what they are doing. They need to have
Dr Sim: Can I come
in there? I, too, would feel very uncomfortable about fragmenting
the public health function even more than is likely to be the
case. I have the pure good fortune to work in an area where the
proposed consortium, the unitary authority and public health could
all cover the same ground. There is every reason, in that situation,
to have a director of public health holding the ring on behalf
of the health of the population, influencing local government
and commissioning and, at the same time, if resources allow, influencing
the thinking in the local foundation trusts, and local mental
health trusts for that matter.
There are two big issues. One is to have the leadership
and the resources available to deliver on improved health on behalf
of the population. The other is that coterminosity isn't particularly
common in terms of the proposals for consortia, and is further
complicated by the lack of any geographical boundaries. I am now
talking about coterminosity on the basis that it is a town with
reasonably circumscribed edges to it, but it is not purely coterminous.
If a consortium is responsible for only its registered patients,
that is an added complication and obviously has significant implications
for health inequalities, if we have an unregistered population
that is left out in the cold. But I don't think that is what we
are talking about now.
Q26 Dr Wollaston:
It would be interesting to hear your views about coterminosity
and how that could perhaps be changed in the Bill. However, I
want to focus on the point about good information for consortia
because concerns have been raised about the future of the work
of regional public health observatories due to the core cuts of
the Department of Health funding. Could you explain the role that
they play in the public health system, whether there are grounds
to be concerned and what the way forward is?
Dr Sim: Yes. The
public health observatories, at the moment, are regionally based
and there are 10 in England. They are providers of, to my mind,
an extremely robust quantity and quality of information about
health and health care, health services and the health status
of the population at regional level. For many health topics, the
observatories have also provided information and are able to do
so at a much more local level. Therefore, yes, they have immense
value at a local level. Some of the examples one might take are
in terms of their value to primary care commissioning around some
long-term conditions where they have done a lot of work, they
have a nationally organised association and each of the observatories
takes a lead role in certain areas. For instance, around the care
of people with diabetes, the observatories have produced information
for the whole country at a very local level, which is immensely
valuable for commissioning to make needsbased decisions
or to allow needsbased decisions to be made about, for instance,
the planning of services, planning for primary and secondary prevention
and the needs for health care. I am picking up that example as
a very common condition with a fair degree of potential for prevention
and a lot of potential for high-quality, needsbased commissioning.
What I would sayand my colleagues may not
agreeis that I have a very high regard for the information
provided by the observatories and I think it is wonderful. But
it helps a good deal if, at a local level, you have people who
can interpret that information and who know what they can do with
it. You still need the local public health expertiseI feel
as though I am making a claim for this, as I believe it to be
the caseto make really good use of that information, to
interpret, analyse and then to advise local commissioners, the
local authority and local health care trusts, how best to promote
the health of their population by using that information. It will
be a great loss if they go.
Q27 Dr Wollaston:
You feel they do play a valuable role in advising those local
public health specialists.
Dr Sim: Very much
I have a couple of facts. The funding for the Association of Public
Health Observatories, which is the co-ordinating function that
Fiona was describing, is not there any more, so there is no Association
of Public Health Observatories to any good effect at the moment.
One of their strengths was that they were well coordinatedthey
had this local ability to influence and give informationand
one would take a lead on one thing and another. That is much more
difficult now, in their current circumstances, although they are
trying their best to do it. They also have a 30% cut in their
core funding for 201112, which is a cut of £1.5 million
in terms of resources going to public health observatories, as
I understand it, in this coming year. That, of course, is causing
them huge uncertainty. Put that alongside the fact that a couple
of them are based in universities, and at one of them in London
the staff have already been told that they are at risk of redundancy,
if we are not careful, we will end up with a great fragmentation
and dissolution of the expertise that is currently really working
in a very wellcoordinated way.
Q28 Dr Wollaston:
To clarify, you are saying they have a 30% cut this year and then
no funding for subsequent years.
The Association of Public Health Observatories has lost all its
funding. It was funded for £300,000 over three years and
that has now ceased. The core funding for the observatories themselves
has gone down by 30% for 2011.
Q29 Chair: How
are they currently funded? Is it a direct grant from the Department?
Does it come out of the university budget?
Direct grant from the centre.
Q30 Chair: So
it is a direct grant.
From the Department of Health.
Dr Sim: It is a
direct grant but each of the observatories has also been entrepreneurial
in terms of its local or regionwide contractswith
both NHS and other bodies.
The North East Public Health Observatory, with which I'm most
familiar, set up the National Library for Health which is now
part of NHS Evidence, which NICE runs, but the contract is with
NEPHOthe North East Public Health Observatory. Also, the
Learning Disability Observatory is housed there, so NEPHO has
been entrepreneurial and there have been all sorts of spinoffs
into other areas.
Another thing to mention is that having NEPHO located
in an academic setting has been useful because it feeds into training
and research in a way that wouldn't otherwise be the case if you
didn't have that resource or relationship. There are huge databases
held by NEPHO that provide a rich resource for students and others
to access and use in their teaching and research. It is a valuable
spinoff which, again, we lose at our peril, I think.
Q31 Chair: Are
there any opportunities for those observatories to generate alternative
revenues by using some of those resources you have referred to,
either from within the health care system or beyond it?
They are looking at that and many of them are exploring the social
enterprise option, possibly turning themselves into a different
kind of body. The view is that you need some element of core funding
to enable you to do that. You need the seed corn fundingthe
pump primingto enable you then to go and get other funding.
Many of the PHOs have used their core funding, which is roughly
£250,000 per annum, to do that. You do need that continuation
of the core element to generate new income to do additional things.
But they need to be employed in the future or organised in a way
which allows them to do that, which, if they were part of a directorate
of the Department of Health, they couldn't.
Q32 David Tredinnick:
As things stand at the moment, how do you see the role that the
observatories currently play being carried out in the future?
We would love to see that there are still to be observatories
that retain some sort of subnationalmore close to
localcontext so that they really can understand the bones
of the communities they are providing the information for as well
as doing the hardnosed statistical analysis and data collection
they need to do, and they can set their information in context.
We think that that is very important. But we would like to see
a network of them. We want to see them sharing resources a lot
better. We see Public Health England as a good place for that.
I don't see any reason why an organisation that is funded and
managed by Public Health England couldn't be nested in a university
in much the way they are at the moment. As long as it is a coherent
set of functions with good relationships locally, that is how
we would see it. We do see Public Health England as having an
important co-ordinating role to ensure that that happens.
Q33 Grahame M. Morris:
In relation to that, the Bill is proposing huge changes to the
architecture of the NHS and a new role for the Secretary of State
in relation to public health. For me, it is a huge priority. Professor
Hunter mentioned the North East Public Health Observatory and
the key role it plays in relation to addressing issues associated
with barriers to people with mental health accessing health services.
That has national significance, hasn't it, even though the work
is carried out in the northeast?
Q34 Grahame M. Morris:
I went along to listen to Angela and Professor Sir Michael Marmot
last week talking about the impact of cold homes on public health.
It was an excellent report with national significance. I wonder
where it should sit in order to secure this very important service,
the evidence base of which is vital to proper public health policy.
Is there not an argument for making a special health authority?
Would you support that view?
It is easy to have a little
Q35 Grahame M. Morris:
I am not leading you. I was seeking an opinion in terms of the
Faculty of Public Health and the Department.
Personally, I would like to see much more of a tieup between
the public health observatories and what NICE does, in terms of
both generating and implementing the evidence. At the moment NICE
has an implementation team, but it is only seven people, one in
each region. We have one for the north, which is everything north
of Doncaster, I think, up to the borders. That is a problem because
they do valuable work but it is not enough capacity. It seems
to me you have all this resource in the public health observatories,
which, in a sense, has been wonderful, but you could argue that
there is a winwin to be got by linking some of these activities
together in a different way to maximise their potential. These
analytical skills are scarcethey are not plentifuland
we do risk losing them. Certainly, with our observatory in the
northeast, we have lost staff. Staff sensed uncertainty
and disappearedthey have gone. Some went to academic posts
and some went outside the university, so we are losing the capacity
built up over many years already. It seems to me that we do need
to think about the options. A special health authority would be
one option, but we should also perhaps be thinking about ways
in which we could more creatively make better use of the information
and analytical resources we have across NICE, PHOs and elsewhere.
My support for them being part of Public Health England is dependent
on Public Health England being constructed as a special health
authority or an Executive agency.
Yes, being an SHA.
Grahame M. Morris: Okay,
Chair: We can't spend
all morning on observatories. We will turn to questions about
Q36 Dr Wollaston:
Touching on nudge, the Government have effectively said that the
Public Health White Paper, "Healthy lives, healthy people"
constitutes its response to the review led by Professor Michael
Marmot. How adequate a response is it?
Underwhelming, I think. On the first page of the White Paper it
talks about this being a response to Marmot, but then the rest
of the White Paper is about individual lifestyle behaviour change
and that is not really what Marmot was saying in his six areas
of policy priorities, all of which seem to be about tackling the
upstream social determinants of health. There is a role for lifestyle
and behaviour change in the mix, but to see that as a centrepiece
of changing people's lifestyles flies in the face of the evidence.
The evidence doesn't exist to back that up. What evidence there
is, which is reasonably positive, says that it will take 10, 20
or 30 years to bring this about, and even then there is no guarantee
it will be sustainable. Given that we do not have that amount
of time, given the pressures on the NHS budget from lifestyle
diseasesobesity, alcohol and so on, which are complex and
immense and with which we struggle to cope nowto see this
as an issue for individual lifestyle and behaviour change is completely
missing the point. Therefore, I am disturbed at the shift from
being a nanny to being a nudger. There is a lot to be said for
Government shoving people occasionally. The public health tobacco
ban was a good example of that. It didn't go against public opinionit
largely went with the grain of public opinionand it has
worked. There is a role for upstream Government action. To see
it all as being about nudge and incentivising individuals is not
the right response.
Q37 Dr Wollaston:
Evidence for shove but no evidence base for nudge.
That would be the conclusion of the Cambridge research unit set
up to look at nudge, and the BMJ article earlier this year concluded
that, as of now, the evidence base does not exist.
Q38 Chair: There
were two elements of your reply. One was that you feelif
I am hearing you correctlythat there is too much emphasis
on the local and not enough on the national, while the second
is that there is too much emphasis on the nudge and not enough
on the shove.
Nudge can be at national and local level. It depends what you
mean by "nudge", to be honest. It is a very flaky, slippery
Q39 Chair: What
do you mean by it?
I think what is meant is incentivising people to behave differently
by, maybe, bribing them, as they have done in Dundee. They have
given teenage pregnant mothers vouchers to shop at M&S if
they stop smokingthat kind of thingwhich has worked.
But there is an ethical argument as to whether you should be bribing
people to behave sensibly and how long you keep the bribery going.
Presumably, it is for the extent of the pregnancywhether
that then encourages multiple births, I'm not sure. There is an
issue about that kind of behavioural responsewhether it
is both ethically and practically the right solution.
We were encouraged to see in the public health White Paper the
Nuffield interventions ladder, which does acknowledge that there
is a whole range of interventions needed. For any public health
programme to get populationbased change, you need to bring
all those things into play. Regulation has a place and so does,
from time to time, giving people a bit of help to move in the
right direction. To put a huge emphasis on nudging, for which,
as we have heard, there isn't evidence, and to say, "We will
do regulation only if nudge doesn't work," is not an evidencebased
way of going on. There is evidence that regulation, in the right
place, when the public are with it, can have an enormous effect
and bring about a real step change. We have seen that with seatbelts,
drink-driving and tobacco, as we have heard. That would be our
position. Everything has a place, but we think you shouldn't simply
wait for the lower levels of the ladder to fall off before you
put the top one there.
Angela Mawle: My
concern is that it can be manipulative. One of the examples I
heard from a learned seminar was when they put a bus stop outside
a dementia care home. The reason they put the bus stop there was
because people would wander and off and go and find a bus to catch,
and they thought that putting the bus stop there would encourage
them to wait outside the care home. Ethically, that is very iffy,
and if you subscribe to that kind of individual way of going on,
as our colleagues have said, you are ignoring the bigger picture.
You mentionedI am sorry, should I call you "honourable
Chair: None of us do.
Grahame M. Morris: That's
the nicest thing anyone has said to me.
Angela Mawle: I
am a bit nervous of this setting.
You were referring to last week's launch and that
showed that housing costs for the NHS are £2 billion and
they are £1.8 billion for the police servicebecause
of dangerous housing and also distractive, delinquent behaviour.
Why does the White Paper talk about Marmot and say, "Yes,
Marmot is great"and he was there supporting that argument?
The housing costs to health are huge. Of course, it takes me back
to my previous statement, about Wanless about preventionand
prevention has always been Cinderella. Public health is prevention
and we have never included "public" in public health,
as far as I am concerned. We have hardly mentioned at all this
morning the people out there who could make it all happen. Nudge
is something that you can useI don't like the term "armoury"in
a range of ways to help people improve their life, but you have
to address the causes of the causes, and you can't quote Marmot
if you are not then prepared to take on the implications of what
Dr Sim: I agree
that the evidence for nudge is very limited. What there is suggests
that the people who are going to be influenced by nudge are largely
those who are already on track for making a behaviour change,
rather than those people who are much harder to reach. If it is
effective at all, we are talking potentially of widening health
inequalities. Certainly we feelparticularly if the public
is beginning to realise that certain things are in their intereststhat
the Government should not shy away from regulation to influence
Chair: This huge subject
is probably not at the heart of our inquiry, but it is clearly
relevant. David, you were going to ask about the role of the Secretary
Q40 David Tredinnick:
How would the Secretary of State's role in respect
of public health change under the Government's proposals? That
is my opening question.
The honest answer is that I don't think we know. First of all,
it presupposes the Secretary of State will be able to divest himself
of the NHS in the manner that is proposed. I am not sure, in reality,
that that will prove quite so easy, despite having the Independent
Commissioning Board. So I remain to be convinced that a great
deal will change in practice. The jury is out on that. In terms
of his or her role in respect of the broader health agenda, that
is very welcome, potentially. In the past, those of us looking
in from the outside have been critical of the Department of Health
for not being a health department at all, but rather of being
an illhealth or a sickness department and not taking public
health seriously. If it changes its philosophy, ethos and culture
so that it is more health-focused in the broader sense that we
have been talking about, that is to be welcomed, but I am not
quite sure what the drivers would be for that. At the moment,
you have the Cabinet SubCommittee, I think, which the Secretary
of State chairs.
Q41 David Tredinnick:
Yes, it is the Cabinet SubCommittee on Public Health. What
potential is there for a crossdepartmental approach?
There is tremendous potential. But we have been here many times
before and previous incarnations of these crosscutting committees
don't seem to have had a great deal of traction or impact. Therefore,
one worries that it is simply reinventing the wheel and that the
same lethargy or systemic failure will result. Personally, I would
be inclined to give that committee chair to someone who is not
from the Health Department. If public health is a serious function
across Government, it shouldn't simply be in the silo of the Department
of Health or the Secretary of State for Health.
Angela Mawle: I
think the Secretary of State should be the champion of public
health. I was really impressed by the mental health strategy,
about which I spoke to the Secretary of State when it was launched.
Clearly, there is an understanding of the breadth of health and
well-being, so to have somebody at the head of health who understands
that and tries to champion it is really important. As to the actual
SubCommittee, I don't know whether I would agree with David
or not because, unfortunately, people still see, as we have talked
about earlier, health as being the NHS domain. We called a long
time ago to have somebody who is the head of health chairing that
committee and enforcing it. We also called for there to be a chief
civil servant and a Minister in each Department responsible for
health so that that person then reported to whoever was going
to be head of thatin this case it is the Secretary of Stateto
make things happen. My experienceand all of our experience,
I am surehas been that crossdepartmental working
is a nightmare because there is no common culture and understanding,
and things get reinvented in different Departments. We desperately
need to unify and show the public that it is all about being joined
up: their transport, their planning, their green space and their
housing. Exemplifying that is a brave step to take, and I just
hope it happens.
Q42 David Tredinnick:
Two different Departments; a department of sickness, too, rather
Angela Mawle: Definitely,
beyond a doubt, yes.
Q43 Chair: Can
I bring in Professor Davies? I have to say I am a bit of a sceptic
about this. It seems to me that what the Secretary of State is
envisaged as being in this world is an authoritative voice on
some quite sensitive issues of public health. For example, do
you think the Secretary of State would have been an effective
voice on the MMR vaccine to give people advice about that kind
of health prevention, or would it have been better for it to have
been from an authoritative voice one step removed from a practising
Angela Mawle: It
has to be a relationship. We talked about local authorities and
elected members, and the relationship there. There has to be a
more mature relationship whereby the political lead is seen as
leadership for the whole community and they are informed by expertise.
That needs to happen in a partnershipa collaborative approach
rather than with these demarcations that occur between civil servants
and elected Members. I understand why that happens, but the public
don't trust the system as it currently operates. I see what you
are sayingthat he or she shouldn't pontificate on issues
about which they are not expertbut if they draw from expertise
and then they are shown to have the community and the national
population's interests at heart, I believe it could work.
I have two points. First, picking that one up, it is fundamentally
important that Ministers have confidence in the civil servants
working for them and supporting them, and that they do have working
for them civil servants who can advise them from a professional
understanding on the various other bits of external and independent
advice they are getting. They need the Chief Medical Officer,
and the Chief Medical Officer needs to be supported by people
who know what is what. Ministers need to be confident about that
advice. The public need to be confident that there is independent
advice that is able to inform them, as I said earlier, from a
professional and scientific expert point of view. There are those
two different sorts of confidence we need in the system.
My earlier point was going to be about health protection.
We have talked an awful lot about lifestyles and a bit about health
services. We have not really talked about the emergency response
and protecting people. That is where there are some quite important
new powers for the Secretary of State in the Bill. For example,
he or she will, in an emergency, will be able to direct NHS organisations
to do things, to stop doing things and to cooperateto
work together. That is going to be terribly important. Unfortunately,
what the Bill does not do is say that they can direct providers
of NHS services to cooperate. It says he can stop and start
things, but they don't have to cooperate. In an emergency
situation, given the proposed plans for the NHS and for health
generally, where you will potentially have a much more fragmented
system than you do at the moment, it is very important that the
Secretary of State, or somebody, is able to tell people what to
do in terms of health service providers. That is going to be a
really important new power; I would almost like to see it extended
rather than reduced. On the other hand, if you build other controls
into the system so that it is not so fragmented, perhaps those
powers are not quite so important.
Q44 Chair: I quoted
the example of MMR in order to depersonalise this but to remind
you of my own experiencetrying to be a public health Ministerin
giving people assurance about CJD. The result of that, rightly
or wrongly, was that the successor Government concluded that this
advice was better given by an independent authority, and I don't
find anybody arguing for going back to the old system on food
I totally and absolutely agree with that. It is that sense of
history: the Health Protection Agency was set up for exactly the
same purpose. It seems to me that if you do what is proposed at
the momentput the Health Protection Agency, the National
Treatment Agency and others into the Department of Healthyou
will soon find yourself inventing a new organisation to give independent
advice, and that doesn't seem a frightfully sensible way to go
Q45 Chris Skidmore:
I have a couple of questions around local authorities. They have
mainly been answered, but looking at the nuts and bolts of how
they work, first, local authorities' performance has to be judged
against a public health outcomes framework, which is in the process
of being developed at the moment. What would you hope is put in
that framework and how would you see it operating? We have talked
about interventions and budgets and all that sort of stuff and
whether that is part of it. Would that be acceptable? This framework
can be effective only if it has teeth with which to hold local
authorities to account. Do you have any experience yourselves
or any research that might suggest how this might come about?
Personally, I think the outcomes framework has to be linked to
the quality standards work that NICE has been asked to do for
the NHS150 quality standards over the next five years.
It is not clear whether public health is going to be included,
but it ought to be. It then ought to underpin the outcomes framework
and that ought to be the basis against which local authorities
are held to account for delivery. I would like to see the Marmot
priorities reflected in those health outcomes. If the Government
were serious about responding to Marmot, they would build the
six Marmot priorities through the life course into those outcomes
from early years interventions right through to old age. To that
extent, there are bits there that could come together quite neatly
into an outcomes framework, which will cut ice only if it is implemented
effectively and people are held to account for delivery. The weakness
in the past has been that we have not closed the circle in terms
of holding people to account. People should be required to implement
Q46 Chris Skidmore:
How would you hold them to account? At the moment we have this
health premium idea that local authorities, by reaching their
outcome frameworks, might get extra cash at the end of it. For
me, that seems to be misjudged in that it should possibly be the
other way round. The money should be given to local authorities
that are in more desperate need, but surely you should have a
system of penalties rather than an incentivisation. If local authorities
don't reach the targets of their outcomes framework, they should
be held to account for that. At what level should that be? By
the Secretary of State?
Ultimately. The thing is we have done away with a lot of the instruments
and vehicles that were designed to bring that about. The Audit
Commission and the comprehensive area assessment initiative it
introduced last year have been scrapped, so a lot of the levers
for holding a local authority to account are going to have to
be reinvented or replaced in some way. At the moment, it is not
clear what the space between the local authority and the centre
is going to be in that regard. Obviously, there is a local accountability
dimension to this as well, but clearly there is a lot of uncertainty
about the national level at the moment.
Absolutely. If you look at experience in the NHS, why is it that
there hasn't been as much emphasis on public health in the NHS
as we would like to see? Frankly, until you make improving health
as important to a chief executive as balancing their books, you
are not going to get the kind of change that you want to see in
health. We have to find some levers that will enable that to happen,
and that is what we are grasping for at the moment. There needs
to be a really robust set of outcomes in the framework over the
whole lifestyle, but we have to be realistic about that. A lot
of public health outcomeschanges in healthtake years
to implement and need sustained action. Somehow the system has
to reward sustained action over years, but encourage people in
the short term. There need to be some process indicators in that
as well so that we can see what people are doing and how they
are doing it, as well as what the outcome is. Much as I love outcomesof
course I dothere have to be both.
Q47 Chris Skidmore:
The other nutsandbolts issue I wanted to address was
funding. Obviously, the White Paper talks about there being maybe
just over £4 billion of funding towards public health. There
are two issues. First, I wanted to ask you if you think that is
enough. By my calculations, if you are doing a wholearea
calculation with 60 million people, that is roughly £67 per
person per year. Is that going to be effective to deliver public
health interventions that will work? Secondly, there is the issue
of that funding being ringfenced. Professor Davies, I saw
in your White Paper response that the risk in a ringfenced
budget for public health will obviously be that that would be
expected to cover all public health interventions. That mirrors
what the local government group has said in its paper. It is worried
that ringfencing will mean that councils will tend to see
ringfenced sums as the total resource available for public
health. The two questions I wanted to ask were, first, whether
you think that is enough money at £4 billion. We have a situation,
with Wanless, where the local demographic need will always increase
over the next 30 years. Where can you see that sum rising to?
Secondly, is ringfencing a good ideayes or no?
Is £4 billion enough? I have no idea. It all depends what
you want that £4 billion to do and, at the moment, we have
no idea what the boundaries of the budget are going to be. The
Faculty of Public Health did a survey a little while ago asking
people what they thought was spent on prevention, anda
significant numberthought that at the moment we spend about
25% of the budget on public health. That is interesting; I wish
we did. Until we know what the boundaries of that budget are,
I do not know if it is enough or not. I am concerned about the
risk of it being seen that that is all that anybody has to do
for public health, given that the whole point of these changes,
I hope, is to get many more people engaged in doing what they
can from their own budget's point of view. The value of ringfencing,
on the other hand, will be that if its boundaries and uses are
defined and clear, there will hopefully be a bit of protection
for public health when things get tough and a lot of other priorities
come in. It is a way of maintaining focus on public health but,
equally, we have to make sure that it is marketed in the right
way and that everybody understands that they still have to do
I agree with that, but I take a slightly different stance on the
last issue about ringfencing. It is problematic in local
government to give a particular function a ringfenced budget
when that is not the norm in local government. When you are bringing
public health into local government, it is precisely the wrong
time, perhaps, to give it special treatment and special favours
in respect of a ringfenced budget. I would prefer it if
local government welcomed public health with its budget - akin,
perhaps, to bringing your own bottle to the party, where you put
it into the general collection"Here's my budget. I'm
going to put it alongside yours."
Under the previous Government, we had the Total Place
initiative, which was about pooling resources across all the agencies
in a local areaMichael Bichard of the Institute for Government
and others were the architects of that initiativeand the
pilots were quite encouraging. I don't think the experiment ran
long enough to demonstrate great successes, but in terms of process
factors and people beginning to break down silos and to think
about a placebased approach to improving health, having
those integrated budgets was quite important. The present Government
have held on to that through the notion of communitybased
budgets or placebased budgets, so it is not dead, but it
seems to me that the ringfencing notion flies in the face
of that other driver to integrate budgets and not see them as
little silos kept separate and protected.
Angela Mawle: I
endorse what David said, and what Lindsey said to some extent.
How can you have the public health responsibility across the whole
authority and £4 billion across the land? It is a nonsense.
If you look at the outcomes framework and all the things like
social capacity, cycling and housingand fuel poverty is
in therehow on earth can you deliver on the public health
framework with £4 billion? It is a contradiction, because
if you are genuinely saying that the local authority is responsible
for health right across, all the budgets should be used. Are you
saying, therefore, that £4 billion across the country is
only going to be for health programmes such as obesity and all
the usual stuff such as smoking etc.and I am not denigrating
the usual stuff by any means? If it is only going to get funnelled
down those particular programmes, that is a real lost opportunity,
unless it is seed corning other activities and the DPH, or whoever,
goes and says, "Here is what we want to do together. We can
feed this much into it. What are you going to do?" and looks
at those outcome indicators in a way which means you can deliver
them. What is the point of having them if you are not going to
deliver on them in a few years' time?
Going back to your first question about the indicators,
process is really important in terms of an indicator because you
need to involve communities in this. Over time, it has been shown
how much you can achieve by involving communities in their own
areas, in asset mapping rather than needs assessment, and you
can get a coproduction of health out there with communities
if you look at that new way of doing things. Traditionallyand
I have worked in both PCTs and local authoritiesI am afraid
you do things the way they have always been done, and if you don't,
you basically get knocked on the head. In some authorities it
is okay, but if you are working with communities in your own different
ways, you have to be given the responsibility and confidence that
you can do that, and work with GPseverybody in that community.
The process indicators, I think, are really important. The outcomes
framework and the indicator that is being developed shows that
£4 billion is almost a distraction.
Dr Sim: I was going
to add that I have no idea if the amount is adequate or not, but
our view is that, ringfenced or not, it is really important
that local authorities take responsibility across the boardacross
all directorates. One of the important concerns to us is that
it gives a message that it is only local authority responsibility
if the ringfenced public health budget goes into local government.
That, immediately, is quite easy to interpret as "Nobody
else has responsibility for public health, so the NHS is off the
hook" and so are other sectors, potentially. That would be
really unfortunate. Whether the amount going into local government
is adequate or not, I have no idea, but the message that says
the amount for public health is only going into local government
To pick up on outcomes, obviously the amount does
depend a little on what we are trying to achieve by way of outcomes.
Our view is thatand I think it has already been mentionedthey
have to be evidence based. A lot of the outcomes suggested in
the consultation document were beautiful, aspirational things,
but with no evidence base to them. The other thing that would
have ownership of outcomes is to have some sort of local discretion.
Some health outcomes are going to be much more relevant to certain
communities. If you get local ownership with inter-agency contribution
to achieving them, they are much more likely to be achieved. There
is something about not just having a blanket approach with the
"targetitis" that we have seen historically but having
outcomes that are meaningful to populations.
Q48 Grahame M. Morris:
I have a supplementary question because that is leading nicely
to the point I wanted to raise about the risk of fragmentation
in relation to the new commissioning arrangements with GPs, especially
where there is no coterminosity with the local authority boundary.
If public health is the preserve of local government, will GPs
commissioning services simply think, "That is not really
our concern any longer"? What are your views on that?
Dr Sim: That is
a major concern, certainly. I was saying earlier that most GPs
view public health as being very important. Increasingly, they
are viewing it as something that is relevant to consortia. Precisely
what that means is still being bottomed out. I am aware, for example,
that the Royal College of GPs is holding seminars around the country
to introduce the role of consortia, including their public health
role, which is extremely helpful. But we have a long way to go
and, unless there is resource to support those aspirations, that
is going to be a real problem.
Q49 Grahame M. Morris:
I have some real concerns about that. I don't know if you remember
the "Miserable Measures" report that you did for the
local authorities with PCT funding. I wonder whether the GPs would
recognise the value of such a report. I am sorry, it is just a
I absolutely agree with all of that and totally share your concern.
One way that you could begin to mitigate that risk is if the health
and well-being boards, which are proposed as being the places
where all the concerns come together, have real teeth and are
able to sign off the commissioning plans. If the health and well-being
boards make sure that those plans are aligned with the joint strategy
and the joint strategic needs assessment, you can then see that
you have some way of bringing coherence to the system. However,
if the health and well-being boards are simply fairly benevolent
talking shops, where are you going to go, really? There is nothing
there to encourage and inspire anybody.
Q50 David Tredinnick:
What impact will the abolition of the boundaries have on the collection
of information and statistics that are relevant to public health?
It will make it hugely more complex. The best we can hope for
is that the abolition of boundaries means that GPs do not have
their patients in particularly widespread areas. But there is
the potential, particularly with commuting and so on, for them
to have patients spread over a huge number of local authorities.
That will make things much more complicated, although not impossible,
because it means that the analysis and the collection of data
will take longer and will need to be much more carefully thought
through in terms of the way it is brought together.
Q51 Chair: Nobody
has commented specifically on Chris's question about health premiums
and the extent to which incentivising authorities to do things
is a sensible approach.
I agree with your scepticism. I don't think they are a good idea.
I think they will prove unworkable, particularly for the local
authorities that, for whatever reason, do not meet the criteria
for the premium through no fault of their ownthrough circumstances
beyond their control. Battering people over the head if they don't
perform, even though their ability to perform is limited by what
they are able to do directly, is a rather curious way of trying
to incentivise behaviour. I am not sure it is a mechanism that
is going to survive, to be honest, or have real impact.
I cannot see how you could make it work. All I can see is that
it will exacerbate health inequalities rather than tend to reduce
Yes. It will do the opposite.
It is a totally perverse incentive.
Q52 Valerie Vaz:
Kensington and Chelsea would get the most money.
Yes. That is especially the case in local authorities where you
have a lot of what they call churnas soon as the population
starts to be doing better and gets a bit healthier, they move
on. How do you measure whether that local authority is really
doing good stuff or not? If it does not seem to be making a difference,
you will not be giving it extra moneythat is not fair.
Q53 Dr Wollaston:
Can I go back to an issue that was touched on briefly before:
whether GPs tend to focus on the patients who are in front of
them in the consulting room rather than the population as a whole,
and whether they are even less concerned with those who aren't
registered with them as their GP? Several members of the panel
have expressed concerns about the abolition of practice boundaries,
particularly with the new funding formula coming in. How fair
is it to doubt that GPs will take a public health view when acting
Q54 Dr Wollaston:
Yes. Do you think people are right to be concerned?
It is fair to be sceptical. As I said earlier, I am sure there
are exceptions. The GP par excellence in this area was probably
Dr David ColinThomé who, before coming into the Department
of Health to head up primary care, ran a very successful health
centre in Runcorn in Cheshire - Castlefields - that put public
health at the centre of its activities. It was, in many ways,
a mini version of Kaiser Permanente in the United States, in terms
of encouraging people to stay well. It is not undo-able here,
but it is not part of the general ethos and culture of general
practice to behave or operate in those ways. There is either a
huge training issue herea huge development issueas
we have to accept that some GPs will do it and others will need
a lot more help and support. I It is high risk.
Q55 Chair: If
primary care is to fulfil its part in the refashioning of
health care, you cannot accept that they will not do it, can you?
No, because primary care is not general practice. We often confuse
the two, but if you go back to WHO and Alma-Ata in the 1970s,
it is not about general practice. Primary care is much broader.
Angela Mawle: There
are some hugely brilliant GPs around. There are the ones we work
with up in the north-west and in Bromley-by-Bow. Bromley-by-Bow
is unbelievably good. It is a total public health experience,
or health and well-being improvement experience, if you go there
as a patient, I am sure. Obviously I am not a patient there, but
it just shows. If it becomes the ethic or the way we go forward
and society points in that direction, more and more GPs will want
to join that. Before now, it has all been silo-dvery professionally
demarcated outas to who does what and where. Patients see
it like that too, so you don't get this freeing up of the energy
we spoke about earlier, about how you can engage in new and different
ways of working. I believe that GPs are very capable of it and,
because they have always been traditionally small businesses as
well as altruistic doctors, they have been able to forge their
own way, take chances and move on. I think that that is what they
need to do, and I am sure they will. They should do it and have
to do it.
Q56 Dr Wollaston:
Do you think there is a risk, though, that where it is happening
well already, it will continue to work well, but in the parts
of the country where general primary care is, if you like, failing,
we will see that inequality widen?
That is a huge risk. Fiona will know more of the detail. I would
say there is middle ground, though. There is a young GP principal
known to me up in the north-west who has become really inspired
and energised by this and can see all sorts of exciting things
to do. She has been in general practice a while and, yes, it is
great seeing the patients and everything, but this has given her
a new lease of life to get on and do different things and see
what they can do together. It has generated a lot of enthusiasm
and I am sure that will be great for their patientsand
they are going out and getting the advice to do it right. At the
other end of the spectrum, Fiona, you might come in here.
Q57 Chair: Before
you come in, can I take the discussion a stage further? We can
all acknowledge that there is wide variation of experience of
general practice and the full scope of primary care. From a policy
point of view, how should we go about trying to address those
variations of experience? What is the right way of addressing
that, rather than simply tolerating the variances you describe?
Angela Mawle: Personally,
if we are talking about a new era, with the health and well-being
boards, there has to be a raising of awareness. The trouble with
the speed at which we are doing everything is there is not the
opportunity to encourage people and to give them the hope and
vision that Lindsey has described. We need to use the health and
well-being boards. We should flag them up as being important.
They should be collaborative with communities as well. To become
part of them, there should have to be a degree of training or
induction, and these classic good examples from around the country
should be used. That is resource intensive, but it is a false
economy not to do it because, as you rightly said, health inequalities
will increase. The ones who genuinely want to do it and can do
it will get on with it, and the others will think, "Oh well,
they are doing it," and they won't be audited and they won't
be accredited, in terms of their achievement. I think that, for
policy purposes, if somebody could champion those health and well-being
boards and say that they must be collaborative across GPs, public
health, local authorities and the community, a whole new ethos
could be generated. I am not saying it would be, but it is something
we should strive towards to overcome that inverse care law, which
is what always happens. Whatever anybody does, we end up with
the inverse care law, and part of that is because people slavishly
follow policy, in that they deliver on their targets and they
say, "This is my job now" and they are not given the
preparation and development time to help them take on the new
agendas. I believe that that is critical.
The trouble is that at the moment health and well-being boards
have no driveshaft linking them to the consortia. You need to
put something in place there or else you do not have them at all
which in my view, may be preferable. I share the recommendation
in your last report on thatI really doand having
studied partnerships, I can see health and well-being boards being
a repetition of what we had in the past, where they are glorified
talking shops where people have no power to do anything, and then
go back to their host organisations and life goes on unchanged.
It is another layer in the system creating significant transaction
costs. There are huge risks around health and well-being boards
as presently conceived.
Angela Mawle: As
Dr Sim: There is
a big difference between what GPs do, what they might do, and
what the responsibilities of the consortium are going to be, and
I think we are possibly conflating those things. The enthusiastic
GPsthe people who are providing wonderful servicesare
usually providing wonderful clinical services as well as being
publichealth orientated. Good general practice, very often,
is holistic general practice with a public health
Q58 Chair: I was
asking the question in the way that I did so as not to lead the
witnesses. It seems to me that one of the big questions is how
we narrow variations in general practice and primary care.
Dr Sim: The role
as a consortium then becomes really important. The leadership
of the consortium, if it is minded to hold the practitioners to
accountwe don't know yet what the clinical governance arrangements
are going to be, either within the consortia, for general practice
or for the other contractor professionsis potentially important.
At the moment the view on the street, if you likecertainly
on my streetis that there will be enthusiasts for the commissioning
function in the same way as there will be enthusiasts for improving
the health of the registered population, as there already is.
Some of those enthusiasts will become part of the consortium management
and leadership. I don't know to what extent they will be able
to pull with them that rump of perhaps the variation in quality,
as you have described it, and pull it up by its bootstraps and
to what extent, therefore, that rump could be made accountable
to ensure improved practice. It is not only about public health,
clearly. It is very much about where the accountability is going
to lie, I think, and how that improvement is going to be achieved.
Policywise, there is certainly scope to look again at the
GP contract in all its parts. Whether that has been considered,
I have no idea. I haven't heard that it is being considered.
Q59 Chair: That
is a big subject. Perhaps we will not go too far down there. Did
you want to comment?
Very briefly. I agree that we do need to look at the contract.
There is potential there within the contract, but even if that
is done, there is still going to be the need for robust, believable,
timely information at a practice level because being able to see
where your practice compares with others and other people being
able to take that oversight is a very powerful lever for change.
We have demonstrated, over time, that if we do not have the good
information, we are not going to be able to begin to do that.
Chair: It is also one
of the things we covered in our second report on commissioning:
is it wise to have the commissioning process for primary care
separate from the commissioning process for secondary care? We
made our view clear.
Q60 Rosie Cooper:
I was really taken by what Angela said because in our last report
we said that health and well-being boards should disappearfrankly,
I am 300% behind thatas they are so constructed. This last
weekend I talked to a councillor who is a retired pharmacist,
and he was enthused beyond words. He wanted to get on a health
and well-being board and change everything, so he was asking me
what powers it would have. In my usual style, I said, "A
power to spout. You can talk and talk and talk and no one will
listen." There is a huge danger here if people start to see
the health and well-being boards as something that will draw togetherwhich
they canall that expertise. But if they cannot and do not
have the power to do anything to join up those things, they are
the lever that will destroy all this.
Angela Mawle: I
agree with you, but if we are looking at a new era, which is how
I always try to look at it, it is an opportunity to join people
up with a common purpose and with powers to go with it. You talk
about commissioning. Commissioning has not been done that brilliantly
in the past. It is a foreign subject to most people, even in the
health service. If you talk to the public about commissioning,
they don't know about it and just turn off. What I am trying to
say to you is that if we can re-fashion the structures that are
there now to make them more usable for the public, and for those
people who have the expertise and can feed in the information
and then give it the power, we could make it work. I quite agree
with you that it could be seen as a talking shop, but the concept
is great. The partnership working, the collaboration and people
being able to do this is very risky because they are not generally
very good at it and, as David said, they just become talking shop
after talking shop. If you could genuinely create now, in this
new generation of practitioners and community, something that
is fit for purpose out of the mixture of what you have suggested,
with a local commissioning board, and make that somehow answerable
or interrelated to the health and well-being board, that would
be so effective. It would bring people in to understand the process.
Talking about local data, we heard about the PHOs
and how important local data is, but the public do not ever access
that. I sometimes had trouble accessing it as a health worker
foraging through the system. What the good public health person
or GP in their community would be doing is to say, "Here
is the information, here is the board, here is the public. What
are we going to do about our community?" To create that commonality
and joint sense of purpose, you have to give them the opportunity
to be not just a talking shop. That is what I am saying.
Q61 Rosie Cooper:
It is just very dangerous as it is currently because it will destabilise
everything if it remains and does nothing.
Angela Mawle: I
I absolutely agree.
Q62 David Tredinnick:
I would like to ask a few questions about emergencies. The Government's
plans include significant provisions for major disease outbreaks.
I would like to ask Professor Davies about what the Faculty of
Public Health has said. It is argued that Public Health England
must be a category 1 responder under the Civil Contingencies Act
2004 as the Health Protection Agency currently is. Can you explain
this thinking, please?
Yes. Category 1 responders are those who are at the front line
of the response when disaster strikes. There are all sorts of
duties for them, but one of them is that they need to cooperate
and work with other category 1 responders. That makes a very powerful
response. We think that if Public Health England is going to be
the organisation that has within it all the public health expertise,
or a lot of it, and it is charged with the duty of supporting
local authorities to discharge their health protection responsibilities,
Public Health England really does need to be designated as a category
1 respondersomebody acknowledged as having responsibilities
to respond and to cooperate with others when disaster strikes.
Q63 David Tredinnick:
The Faculty of Public Health says that there is lack of clarity
on the accountability of Public Health England and local authorities
and that this "puts the health of the public at serious risk,
particularly in emergency or epidemic situations." Can you
explain why that is, please?
One of the fundamental principles of effective emergency planning
and response is that people have to know what they are expected
to do and they have to know who is in charge. All parties need
to work cooperatively and they need to accept the direction
and leadership of the person or the organisation that is in charge.
That needs to be something, ideally, that reflects the way in
which things work on a daytoday basis, because another
principle of emergency planning is that you don't suddenly do
something totally different in an emergency. It is much better
to base your emergency response on things that you are used to,
working with people whom you are used to, with plans that, between
you, you have developed over time. As the current proposals are
cast and the responsibilities are described, it is very difficult
to see who, in any one situation, would be in charge because local
authorities are described as being responsible for the health
protection of their population and so is Public Health England,
in some circumstances.
There will, of course, be times of national or very
significant local disaster or emergency when it is important that
the Secretary of State is able to say, "Okay, I am going
to take charge. This is so important that I have to be able to
see top to bottom in the system and I will direct Public Health
England to direct the local authority," or whatever. That
is entirely reasonable. But, for the general run of things, it
needs to be understood that the local authority is in charge and
Public Health England will support itwhether there is an
outbreak, an epidemic, a flood or whatever it is locallyso
that it can then take a lead in the planning and preparation and
so that, when the emergency arrives, everybody knows who is doing
Q64 David Tredinnick:
The Secretary of State is proposing that he has extensive powers
under the Bill to direct emergencies if necessary. Do you think
that is a good thing?
It is important that somebody does, given that the system is going
to be very fragmented. There is a risk that unless there are those
powers vested somewhere, we will end up with a lot of time and
resource wasted by not being able, for example, to persuade providers
of care that they should let some of their staff come and work
with other providers to fill gaps or whatever. It is important
that someone is able to do it if you have a system where there
are all sorts of different providers
Q65 David Tredinnick:
There will be civil contingency exercises and surely, soon after
the new arrangements are brought into place, you will see where
the problems are. Is it really going to be that difficult? Under
a new system, won't it naturally shake down?
I would love to believe that that is how it would happen. I hope
very much that that it is how it would happen and that everybody
would act in the best interests of the communities in the situation,
but there might be times when priorities are really very different
for different organisations in different situations. At that sort
of time, it is important that somebody external is able to say,
"This has to happen. Now everybody get together and do it."
My experience most recently was as director of pandemic influenza
in the Department of Health. We had many exercises for that across
the country and there was lots of learning, both in the exercises
and when we had the pandemicfortunately, not a severe one.
It was very clear that when thinking through initially how NHS
hospitals and private sector hospitals would work together in
an emergency, for example, some private sector organisations were
really keen to offer their staff and their resources to support
the NHS and others were absolutely not inclined to do so.
Q66 David Tredinnick:
On that specific point, do you think you ordered too much flu
I couldn't possibly comment.
Q67 Grahame M. Morris:
Before we move on, I have a really quick question because you
raised exactly the point I was interested in. I am thinking about
the practicalities of how it worked in our region in the northeast
and the role that the SHAthe strategic health authorityplayed
when there was some doubt about where the distribution centres
would be. What are the implications now that the SHAs are going,
in terms of saying, "No, there will be a distribution centre
in Tyneside, Wearside, Teesside, Weardale"? Who is going
to take charge of that? It needs an organisation or an individual
if it is a national outbreak like a flu pandemic.
I am very worried about that. I know that, sitting as I did and
colleagues did at the Department of Health, both during the preparation
and the response, how the people working in the strategic health
authorities and in the local resilience forums took this forward
and really made things happen locally. They have the relationships,
they can make things work and they know where their things should
be. Similarly, the Health Protection Agency's local units and
their regional directors did a fantastic job in setting up the
initial response centres. Whatever system we put in place, we
have to make sure that there is the ability not just to have the
right line of sight and the relationships and trust locally, but
also, somewhere in the system, a locus that is not too distant.
Chair: Thank you for that.
We have a concluding set of questions on professional regulation.
Q68 Valerie Vaz:
I am sorry that we are making you work very hard. I will be breaking
all the rules on questions by asking a threeheaded one,
but it might help in terms of your answer. First, what is happening
with the public health work force at the moment? What is morale
like? Secondly, how do you see their role in future under the
new system? Thirdly, could you comment on Dr Scally's review on
training? Everybody else can comment afterwards if they want to.
I have quick answers on both and I can expand them if you like.
In terms of morale at the moment, it is very low indeed. People
are exhausted. A year ago they were really enthusiastic, encouraged
by the fact they were told Christmas was coming early for public
health. This new emphasis by the Government on public health is
really welcome. There is no doubt about that and it is very, very
good, encouraging and heartening for everybody in the work force
to see that. However, when you have such a major change in every
system going on at the same time and you have the cuts that need
to be made in terms of funding, directors of public health, consultants
and specialists are telling me that they are hardly able to spend
time on the day job of improving the health of the population
at the moment. They are spending all their time on HR, on thinking
where they are going to go and on managing staff in very difficult
circumstances. We know that the cuts are having an impact. For
example, they have lost a lot of the support that they were getting
from the regional teams, which have gone, and the national support
teams have gone. That is causing them, across the country, to
have to do more on their own than they did, and a lot of them
do not have the resource or the energy anymore to do it. I have
enormous respect for how they are carrying onjust keeping
their heads up and doing their bestbut I really feel for
them and I hear from them every day.
The worry at the moment, though, is that that is
beginning to turn into not just frustration and exhaustion, but
anger at the continuing uncertainty. Although the pause in some
ways is good for people to reflectagain, they are encouraged
that considered thought is being given to what is being donefor
them it is putting further delay and uncertainty into what they
are going to do.
Trainees in public health are in a particularly difficult
situation at the moment. There are those who will come to the
end of their training because they have timelimited training
posts, and they can see the abyss of unemployment, frankly. We
have invested huge amounts of money and effort into getting the
brightest and best to come and go for it in public health, but
of course jobs are not being advertised at the moment. The faculty
has to approve all the job descriptions to make sure that things
like the right standards are being required, but we are seeing
hardly any. Who would recruit at the moment? There is nowhere
for the trainees to go into. We are trying to get some help for
them. It would be good if there could be funding supplied to extend
their training for that little bit longer and to give them the
confidence to stay on, but we haven't been able to negotiate that
yet. It remains a real problem. Yes, there are real worries and
a fragility in terms of what we will have to supportwhat
comes nextin this exciting new world that we are trying
to put in place.
Of course, the people working in health care public
health are particularly anxious about where they might be and
how they are going to have a future because they don't see themselves
acknowledged in any of the reports or the Bill. But, we are hoping.
As you say, we have models and we can see a way forward on that.
Morale, however, is not great.
On the role of the work force going forward, we have
spoken about that a little already, and I can elaborate on particular
issues if you like. We are particularly concerned that, going
forward, there will still be in this country, as there is at the
moment, an internationally recognised specialist and practitioner
work force in public health. We are really well respected for
having that, and others can talk about it. Focusing on the specialist
work force, we need to understand that many specialists in public
health work in all three domains at the moment. It is quite unusual
for somebody to do only the health improvement bit or only the
health service bit, and that is where a lot of the strength comes
because you understand all of it. Assuming that you can artificially
divide people and put them in different places will mean that
you end up with a number of the links being very wobbly, at least
in the short term. That said, once things are settled down and
there is a vision that people can all work around, they will be
up for making that happen and putting their backs into it to support
this new drive to improve the public's health.
Who forms part of the specialist work force and how
can the public be confident in the advice that they are getting
and the advice that local authorities, Ministers and others are
getting? We think that it is very important, as Gabriel Scally
recommends, that there is statutory regulation for all specialists
in public health. You shouldn't be able to be a specialist in
public health unless you are on a statutory register, and that
should be legal. At the moment, if you are a doctor and you want
to work in public health, you have to do your medical training,
get on to the medical register, do postgraduate training
and then be put on the specialist register for the GMC, or as
a dentist for the GDC. That is the law. It is statute. If you
are not a doctor, you can do exactly the same trainingFiona
is the expert on thisand there are a number of other routes
by which you can get on to a voluntary register. That is fantastic.
It is there and putting that voluntary register in place over
the last few years has been a huge achievement, but it does not
have the ring of statute around it. It is possible at the moment,
as I mentioned earlier, in the Bill, for example, for a director
of public health to be appointed who was not on a statutory medical
or dental register and not on the voluntary registernot
on any register. Given that, to all intents and purposes, although
they may come from a range of professional backgrounds, they are
essentially the physician to the population who is taking decisions
and giving advice that can impact hundreds of thousands of people,
it seems to us to be a dangerous thing to say that they do not
need to be qualified to do the job. It is a matter of public protection
in just the same way as you would not want your heart surgery
done by somebody who was not on the statutory register. We do
think there needs to be a statutory requirement for registration
for public health specialists.
Q69 Chair: Would
anyone else like to comment on those issues?
There has been some concern that the Scally report has upset the
wider public health workforcethose specialists and practitioners
who come from a multidisciplinary background and who have been
keen to promote that. The report has been perceived as destabilising
and undermining what the voluntary register has achieved. As Lindsey
said, it has been a great success in many ways. People are unclear
why the Scally report came out in favour of a statutory model
based on the Health Professions Council, which has no history
of doing public health regulation. The fear is it would adopt
a narrow medical onesizefitsall model that would
not reflect the wider interests in public health. Far from going
forward, we are in danger of going back in terms of public health
being seen to be a predominantly medically qualified clinical
specialty. So there is fear about that. Rightly or wrongly, that
is the concern out in the field and this uncertainty, at the moment,
is again a further factor making for destabilisation and low morale
among those in training or in the profession. So it is a concern,
Dr Sim: As far
as the work force are concerned, the changesthe reformsare
already happening so part of the low morale is the reality that
budgets are being cut. Where clusters of PCTs are forming, it
is not uncommoncertainly in London it has already happenedthat
the number of directors of public health has been reduced to reflect
the clusters rather than the PCTs, so people's jobs are already
threatened and that is not helping morale, clearly. At the moment,
they have been slotted in as consultants, but obviously the future
is very vague.
There has also been a loss of the front-line troops
who are not protected in terms of their job titles, although they
work full time in public healthfor example, people who
are providing smoking cessation services. Some of those have disappeared
completely as part of the budgetary reductions, and that is another
thing affecting the morale of the specialists because they have
no front-line colleagues to deliver health-improving interventions.
It is also clearly going to have an impact on the health of the
population because those interventions are no longer being delivered
by those people who have been doing so. Therefore, there are real
issues about ongoing reforms that have little to do with what
we are talking about in terms of the future. They have already
cut quite deep in many places, and that is in addition to the
As far as regulation is concerned, when I was at
the Department of Health, I was responsible for establishing the
voluntary register for public health specialists. It was set up
with a view to becoming statutory in due course, so, at a personal
level, I do have an understanding that there should beas
there always wasa view that all public health specialists
doing equivalent jobs to people on the medical specialist register
should be registered in a way that is entirely equivalent. The
voluntary register has made great strides in going in that direction.
It is effective as a voluntary register and could continue to
perform that function for years to come. It does need the support,
however, of employers being required to appoint people who are
on the register, which is the case. There has been guidance to
the NHS for many yearsand I cannot remember the year that
the letter came out, but I think it was about 2005 or maybe 2004that
requires NHS employers to appoint people to consultant posts or
director of public health posts who are on the GMC, the GDC or
voluntary registers at specialist level.
Thus, moving to local government, even without changing
the regulatory framework, there is great uncertainty as to what
would be permitted by way of appointments. The Royal Society for
Public Health has, in its response to the White Paper, put in
a proposal to create a charter status to strengthen voluntary
regulation as a possible middle way rather than going all the
way to setting up either a new statutory register or coming under
the wing, as I think David has mentioned, of the HPC or another
existing register that may or may not be fit for purpose.
Angela Mawle: Very
briefly, we totally support a multidisciplinary approach. We tend
to feel that we are tinkering with 20th century structures that
are not fit for purpose for the 21st century. We produced a report
on health visiting. Health visitors are broad public health practitioners,
to some extent, although they are currently employed in the NHS.
It looked at widening the entry gates and at a new professional
entry and professional development for that work force. It led
us to think that the same could be done for all people entering
public health and that now is the time, if we are going to look
at these systems. Clearly what works now is good and efficient,
and the voluntary register is doing a very good job, but it still
seems to me that you are creating another sanctum within a sanctum,
or an external sanctum, of a largely medical model because it
is very specialisedeven the voluntary register. That is
not to say that you need that particular specialism in the tool
box, but in terms of Marmot's report and the coming difficulties
of this century, we are struggling with looking at it in the mechanistic
way and seeing that there should be a rootandbranch
review of what the public health work force should look like in
10 to 15 years' time and what it will have to deal with and, therefore,
how we create career structures for bright young things now to
come forward and pick up on these huge challenges.
I have one very quick point, if I may. On the general view of
the work force in public health on statutory regulation, we are
a multidisciplinary specialty and we surveyed our members earlier
in the year on what they thought about that. The overwhelming
response was that they wanted statutory regulation; they all want
to be the same. One can understand that, and the risk is almost
like saying that as doctors are registered already, they want
to be sure that local authorities or whoever don't say, "I
will have the doctor because I know what that is." We need
to be sure there is a clear ring of confidence around the specialist
work force in total.
As to the advisory appointments committee, as Fiona
has said, that really is an important point: in the NHS you can
be appointed only to a consultant specialist, DPH post through
a statutory committee set up in the right way with the right content
and with advisers and so on around it to ensure that standards
are there. The statutory instrument does not apply anywhere other
than in the NHS. It does not apply in the civil service and it
does not apply in local authorities, and we would like to see
that extended to make sure that standards are maintained and the
public can be confident.
Chair: On that note, thank
you very much. We have covered a huge amount of ground this morning
at a fairly brisk pace, but it has been a very useful session.
Thank you very much for coming.