Examination of Witnesses (Question Numbers
Professor Alan Maryon and Dr Gabriel Scally
12 July 2011
Q356 Chair: Thank
you very much for joining us this morning and for sitting patiently
through that last evidence session. Could I ask you both to begin
by introducing yourselves and your background of interest to these
Dr Scally: Certainly,
and thank you, Chairman. My name is Gabriel Scally. I am Regional
Director of Public Health for the South West Region. I have been
a regional director of public health in England since 1993. In
that role, I am employed by the Department of Health, so I am
a civil servant, but I am also a director of the Strategic Health
Authority for the South West. In the context of what we may be
talking about in terms of regulation, I should mention that I
have also been a member of the GMC for 10 years.
Good afternoon. My name is Alan MaryonDavis. I am a public
health doctor. I have a background in hospital medicine and general
practice, but I have been a public health doctor for over 37 years
now, including being a director of public health for an inner
city borough in south London. I am also the immediate past president
of the Faculty of Public Health, which is the professional body
for public health specialists. My role today is to provide a broad
Q357 Chair: Thank
you very much. We shall no doubt need that. I would like to begin
by asking Dr Scally to talk about the background to the work you
did on recommendations on professional regulation. What was the
remit you were given and the background to the report that you
produced? To what extent were you pointed in a direction, or did
you feel there was a sense of preference of what the outcome was
likely to be?
Dr Scally: I was
asked by Sir Liam Donaldsonthe former Chief Medical Officerwho
was acting in consort with his three CMO colleagues from the other
countries of the UK, to undertake this review because there was
a general feeling in the public health profession that the current
system of statutory regulation was not adequate. My task was to
look at the systems and come up with some recommendations, whether
they were a continuation of the existing system or proposals for
change. I duly reported back to the CMOby that time, it
was Dame Sally Daviesand then my report was published alongside
the White Paper for consultation in the autumn.
Q358 Chair: In
summary, what were the inadequacies of the current system that
led to the establishment of your process?
Dr Scally: It had
been a view from the early days of multidisciplinary public health
that there should be a statutory regulatory framework. However,
as part of the move towards multidisciplinary public health, a
voluntary register was established. Indeed, that is one of the
steps that the Government prefers to see in terms of a move towards
regulation of a professionor, in this case, a branch of
a professionbut it was always envisaged that it would move
to a statutory footing. That had not happened. The existing system
was continuing and was operating, but not in complete consort
with the rest of the regulatory system consisting of the GMC and
the GDC. There were a number of routes of entry to the voluntary
register of the GDC and the GMC and this was causing unnecessary
Q359 Chair: Was
there any evidence that it was leading to prejudices to public
Dr Scally: I am
unaware of that, but there have been concerns that the routes
were unequal. Some younger professionals seeking to come into
public health were choosing to aim for the voluntary register
route rather than going through training and qualification because
they had a feeling that it was somehow easier and less demanding
than going through proper training.
Q360 Chair: Is
that a coded way of saying it was easier to get into public health
through the nonmedical route?
Dr Scally: No.
The examination and the structured training route is open to medics
and nonmedics. Indeed, increasingly, the balance of people
going through that route is evening up, if not tipping in favour
of nonmedics going through the formal training route. It
was certainly a view that we needed to look at the whole system
and get it much more unified so that there was one route everyone
could rely upon to produce highly skilled, highly qualified and
regulated public health professionals throughout the country.
Q361 Chair: To
be clear, it was your recommendation that there should be a clear
pathway to a full, single compulsory regulatory framework?
Dr Scally: I had
several recommendations, but to summarise them, the three key
ones were, first, that there should be a system of statutory regulation
that covered all senior public health professionalsof course,
about 80% are doctors or dentists and already covered by statutory
regulationand it should be a universal system of statutory
regulation; secondly, that there should be protection of title,
that the term "director of public health" or "consultant
of public health" should be protected and only able to be
occupied by someone who was on a statutory register and the third
thing was that I recommended there should be a single predominant
pathway to registration, which would be through qualification,
structured training and doing the examinations of the Faculty
of Public Health. I very much saw the Faculty of Public Health
coming to occupy a very central place in the validation of training
and training programmes.
Q362 Chair: How
do you think those recommendations would change the balance between
the medical and nonmedical routes? Would that lead to a
process of change in what it meant to be a public health doctor,
or indeed a director of public health?
Dr Scally: No,
I don't think so. I do not think there would be any detriment
to that. Indeed, my view was that it would provide reassurance
that all senior public health professions were trained, qualified
and regulated to a satisfactory degree. Indeed, having looked
at various schemes of regulation for health care professionals,
I found that the closest analogy was with the pathologists, where
approximately 20% of pathologists occupying consultant posts are
nonmedical; the medical component of pathology is regulated
by the GMC and the nonmedical regulated by the Health Professions
Council. That was my specific recommendation. That would put us
very much on a par with pathologists and provide a very good basis
for going forward, particularly, should I say, into an era when
senior public health peopleof course, the White Paper on
public health appeared subsequent to my reportwill be employed
by local government, perhaps by the NHS Commissioning Board, by
the Department of Health via Public Health England and, indeed,
in academia. Therefore, one standard statutory regulatory framework,
I thought, would fit very well with that.
Q363 Chair: I
understand the point about reassurance. I was asking a slightly
different question, which is whether you thought the adoption
of that framework, as you recommend it, would, as a matter of
practical predictive effect, lead to a change in the nature of
the public health profession.
Dr Scally: No,
I do not think so. All the evidence from our recruitment to the
structured training programmes is that we have a good balance
between medical and nonmedical entrants and a good balance
of completion of that programme, and people are coming on to both
the statutory registers at the moment and, indeed, the current
voluntary register perfectly satisfactorily through that structure.
There is usually a five-year training programme involving the
examinations of the Faculty of Public Health.
Q364 Chair: You
do not see any particular reason to change that balance, nor do
you think that your recommendations would lead to a change in
Dr Scally: No,
Q365 Chair: Neither
an intended or unintended effect.
Dr Scally: No.
I cannot envisage that it would. It operates perfectly satisfactorily
in terms of recruitment into the profession at the moment.
Q366 Chair: Professor
MaryonDavis, you were going to offer us independent or balanced
What is more likely to change the balance of the public health
profession in terms of medical or nonmedical, which I think
is what you were getting at, are the new structures that are being
put in place under the current system in England; we are not talking
about other parts of the UK. That is going to have a much more
profound effect on the rebalancing because a large chunk of public
health specialists will be working in local authorities, as we
know, and that is a kind of alien setup for public health
specialists up till now. That may have the effect of deterring
some doctors who would have gone into public health from joining
because they may feel that they are moving away from the National
Health Service and into this slightly alien territory they are
not used to. I think the nonmedics will find it much more
comfortable working in that sort of setup. The medical members
will tend to move towards the health protection function of Public
Health England and, also, the health care public health function
you mentioned earlier onadvising on the needs assessments
and evaluating services or service reconfiguration. Therefore,
we will start to see a bit of a split in terms of the professional
background of public health specialists.
Is that a good or a bad thing? It is hard to say.
It should be a good thing as long as there is crosstalk
between the different groups. As long as there are good communications
across the commissioners, Public Health England and the local
authorities, in particular, and hopefully with academia as well,
and the information side of things, and there is a continuing
critical mass, as it were, and people support each other, that
could work okay. Otherwise, there are dangers in fragmentation.
Q367 Chair: I
was quite struck, in Dr Scally's response, that there was neither
an intended nor a predicted unintended consequence in terms of
changing the balance. This is a pretty profound change that is
being proposed. I am surprised that it is neither motivated by,
nor anticipated to produce, a change in the balance.
Dr Scally: Chairman,
I may have misunderstood your question. I understood your question
in terms of my recommendations around regulation. If you are asking
me a different question, which is about the overall effect of
the public health changes, I agree with Professor MaryonDavis
that there is that possibility. However, as I think perhaps you
mentioned earlier, these changes, in so far as they affect public
health practice locally, are very much public health coming home.
Neither Alan or myself are probably venerable enough
to have worked in the local authority settingI was a medical
student at the timebut you have to remember that there
is a long tradition, going back to 1848, of medical officers of
health working very successfully within local government. Of course,
they operated against a background of protection, in terms of
their independence, the inability to sack a medical officer of
health without the agreement of the Ministry of Health, a requirement
that they should be properly qualified and possess a diploma in
public health and that every local authority above a certain population
size had to have a medical officer of health. There was a very
rigorous system. The good name of medical officers of health ensured
that there was a steady flow of medical graduates into public
health at that time and that is very much what I hope we will
manage to establish in terms of the position and operation of
directors of public health at a local level.
May I add to that? Because of these changes and because directors
of public health, but also consultants in health protection and
other members of the team, are going to be, in the future, in
such crucially important roles for the health of their populationthey
will have responsibility for delivering on various health programmesit
is absolutely vital that they have statutory regulation as described.
It is very much an issue of public safety. That is at the very
root of it all. You only have to look at what has happened in
Germany just recently with E.coli. There have been over 50 deaths
there. That could so easily happen in this country.
The directors of public health have a crucial role
and responsibility for coordinating the response to that
sort of outbreak, working with Public Health England. Pandemic
flu could hit us again at any moment. God forbid that it happens
in the next couple of years while we are in disarray, but it could
happen. Again, there is a crucial responsibility. There is cancer
screening. I was always very worried when I was a director of
public health about cervical cancer screening, about the wrong
letters going to women telling them they are okay when they are
not okay and that sort of thing. It could easily happen and there
would be massive consequences.
Q368 Chair: It
Indeed. Emergency responses and immunisation are crucially important
things which have a direct effect on the health, life and limb
of the general public. There is also the role in communicating
with the general public, which can go horribly wrong. To my mind,
it is absolutely crucial that not only directors of public health
but also public health specialists in general enjoy the same statutory
regulation as the medics and the dental people. It should be an
equivalence. The trends in recruitment are now that there is a
preponderance of nonmedics coming into the specialty. In
fact, the latest figures are 2:1. Therefore, if you look to see
that cohort coming through, it is going to play out in terms of
the people on the ground.
We must not have a "postcode" public health
system. We have to have equivalence across, parity across and
we have to have employers, who will be largely local authorities
but others as well, confident that they are employing people who
are quality assured and are fit and properto use the current
phraseto act in those positions of responsibility.
Q369 Chair: David
wants to come in, but I want to come back to this question of
balance. The figure you gave of a preponderance of nonmedics
coming into public health is a striking piece of evidence against
the background of this having been originally a medical qualification.
Do you still say that we should be virtually blind to the proportion
of medics and nonmedics?
I am blind to that, but, in terms of the current debate about
regulation, it is important to point out that difference.
Q370 Chair: It
is important to point it out but then to be blind to its consequences.
Providing that people who are in those positions are quality assured
through a robust system of statutory regulation with the full
force of the law behind it, which is the big difference about
the statutory regulation, the employers can take comfort from
that and so can the public.
Q371 Chair: One
more go and then I will shut up. It surely goes to the culture
of what it means to be engaged as a public health professional
if we are moving into a world where less than half, and potentially
significantly less than half of them, are medically qualified.
Dr Scally: How
this will play out remains to be seen. I know, in my own region
in the south-west, that we have recently recruited five trainees
and none of them are medical. This is the first time in my very
long experience that that has been the situation. Public health
has moved to incorporate people from a wide range of professional
backgrounds, and that has been greatly to its advantage, but in
my view, public health would be weakened unless there was a substantial
proportion of people from a medical background working within
it because of the nature of much of the work that we do. Many
of the things that will stop that happening lie around the way
in which the new public health system is set up in terms of some
of the issues that you have addressed, in terms of the status
of the director of public health and of consultants within local
authorities and young people in medicine seeing public health
as an attractive career option for them.
Q372 Chair: One
of the issues that the Committee is interested inway outside
this current public health inquiryis the role of professional
regulators through the GMC, the NMC and those bodies. I would
have thought it merits further thoughtI put it no more
provocatively than thatthat a new statutory regulatory
structure should be established that would be blind to the balance
between medical and nonmedical input into a new regulatory
body or recruits into the work force.
Dr Scally: I certainly
think, as a system, we should not be blind to it. It lies within
the realm of developing a work force plan for public health for
the future rather than in relation to regulation, if I may say
Q373 Chair: Surely
the regulator has to own the concept of qualitywhat it
means to be a professionalin that particular profession.
If the regulator does not own that concept, who does?
Dr Scally: If I
can go back to my analogy with the pathologists, the organisation
that holds that role is the Royal College of Pathologists, and
I very much see the Faculty of Public Health holding that role
with regard to quality and advising the regulators as to who should
be admitted to the particular register that they operate.
A lot will depend on what jobs are out there. Where there are
jobs for public health people to advise on commissioning and to
advise on the commissioning of clinical services, there is clearly
a role for somebody who comes from a clinical backgroundmedical,
nursing or an allied health professional. If there are jobs out
there to advise on outbreaks of flu or other things, there is
a strong clinical or medical element, so that is another one.
Employers will play a big part in this in specifying the sort
of public health person they may want for a particular job.
Q374 Rosie Cooper: I
am flying a kite here really, but listening to you, would a local
authority be more likely to appoint a doctor to a public health
role or a nonmedic, in that they would more likely fit in
with local authority practices or ways of working?
Chair: Habits of thought.
It is an interesting thought, if one speculates. A key point in
this is pay. Most of us in public health are fighting to make
sure that the nonmedics and the medics are at the same pay
level so that the issue of the cost of employing that person does
not come into that kind of judgment.
Dr Scally: From
my own experience in the south-west, we have 14 directors of public
health, 13 of whom are joint appointees between the local authority
and the local primary care trust. Having sat through a very large
number of appointment panels, the choice, as you have put it,
has never been a key deciding factor. It has been who has been
the best person for the job, though there is a view among some
local authority people that they would prefer a medically qualified
person to undertake that role.
Q375 Rosie Cooper: I
share that thinking, but I am looking forward. Times are going
to be very, very difficult and there may be a view that an independentthinking
medic may be more difficult than a public health professional
who was more used to the ways of business or local authority working.
The choices may just be different.
Dr Scally: Most
of the people who are nonmedical but within the public health
fraternity tend to come from some form of healthrelated
background. It is very interesting because it is not, by any manner
of means, the medically qualified public health people who are
less involved in issues such as the effects of transport on health
or housing on healthnot at all. There is, of course, that
very long tradition of public health people caring passionately
about the social determinants of health, and that does not divide,
in my long experience, necessarily along medical and nonmedical
Q376 Rosie Cooper: But
in the future they will be making those choices inside a local
Dr Scally: Chairman,
if I may say so, in terms of how I choose to spend my time and
energy as a regional director of public health, it is orientated
very little on the clinical side of the business, except when
it goes wrong, in which case I am called upon to sort things out.
It is very much about the determinants of health around smoking,
diet, physical activity, transport policies in the south-west,
for example, or housing policies and what kind of urban extensions
we want to build to house the increasing population. All those
areas are absolutely core to my personal practice.
Q377 Mr Sharma: My
question is about registration. If registration of nonmedical
public health specialists is to continue to be voluntary, as the
Government proposes, what are the options regarding who should
maintain the register and which do you favour?
Dr Scally: Chairman,
I have made my recommendation to the Department and the Department
is currently contemplating these issues. The current Government
position is that regulation should be commensurate to risk, that
there is a presumption in favour of voluntary regulation and that
more discussion is needed on these questions. I have made my recommendations
and I think there is a role in future in terms of the public health
work force, for example, for the Royal Society for Public Health
and the use of its charter in terms of potential regulation of
public health practitioners. Beyond that, I am unable to go.
I would agree. I have argued very strongly for statutory regulation
of public health specialists, who are the senior ones. There is
a role, potentially, for voluntary registration or regulatory
registration of people at public health practitioner level, which
is the intermediate level. There are some good reasons for that
and it would seem to fit quite well. In that respect, I could
see either the current voluntary register taking on that role
or the Health Professions Council. There are various models, but
that is for practitioners, which is the intermediate level of
public health. For the senior people, the public health specialists,
as I have argued very strongly, we should have statutory regulation.
My concern is that dogma is ruling common sense here at the expense
of public safety, which is really the issue.
Q378 Mr Sharma: The
Council for Healthcare Regulatory Excellence has argued that it
should have the statutory power to recommend a professional group
for statutory regulation in the interests of public protection.
How much merit would that approach have?
Dr Scally: That
is a perfectly valid approach. There is a difference in respect
of public health in that about 75% or 80% of current senior public
health professionals are currently already subject to statutory
regulation, so we are not a professional group coming de novo
to the issue of regulation. My report was making the suggestion
that that should become 100% of the public health profession,
subject to statutory regulation.
To extend the regulation to the nonmedics is simply an extension
of the statutory regulation, of the current setup. It would
not require huge amounts of legislation to put through. It is
a step which I think is important to take.
Q379 Chair: You
said, in your previous answer, that you favoured doing it because
you felt the public were at risk if it was not done. That harks
back to an earlier question I asked Dr Scally, whether there is
evidence of risk to the public arising as a result of the nonregistered
status of nonmedics.
Yes. The public needs assurance, and needs to take comfort from
the fact that the people who are in charge of the health of the
population are fit and proper. Employers need that assurance too.
Indeed, if you are employed by Public Health in England, the Secretary
of State could do with a bit of assurance.
Q380 Chair: The
desirability of assurance is a different thing from evidence of
risk of the current position, is it not?
Gabriel will probably be able to answer this better than I can.
The risks in the current system are that if, for some reason,
the checks, balances and assurances are not there and if there
are people who are employed who do not fit the system, that could
put the public and the employers at risk, specifically around
the issues I mentioned, which were outbreaks of disease, cancer
screening and immunisation, where there are decisions that are
made by people in positions of responsibility that can affect
the lives of literally thousands of people. There could be a communications
breakdown, which, again, could affect the lives of these people.
The potential risks are huge. It could be tabloid stuff. It could
happen tomorrow and it does happen, as you said earlier on. That
is a worry. There needs to be a strong system which provides the
sort of assurance that we are talking about. There are risks in
there which could be alleviated by having a statutory system where
the force of law comes into play in dealing with any issues that
arise in terms of falling down on the job, basically.
Dr Scally: I think
there is considerable risk. I look back at my own professional
career and some of the decisions I have been involved in and taken
around, for example, intervening to stop paediatric cardiac surgery
in Bristol or on several screening issues, or even things like
the siting of pyres and burial pits for animal carcases during
the footandmouth outbreak. Always at the back of that
was that if I made the wrong call on those I would be held to
account professionally. That was because a requirement of my post
was that I was a registered medical practitioner.
One of my fears about the use of voluntary registers
is that they are just that, and someone can leave them. This is
indeed a problem, I remember, that we confronted in the GMC. When
someone got into trouble in the medical profession they merely
resigned from the GMC and could go off and practise perhaps somewhere
else in the world or in another jurisdiction. The Government's
position on voluntary registration is quite clear. The White Paper
in February this year, a Command Paper, stated that: "No
staff will be compelled to join these registers and employers
will not be required to employ staff from these registers, though
they could choose to do so."
It is not just an issue of the assurance of
standards, to make sure the right decisions are made in some crucial
circumstances; it is also a matter of maintaining those standards
so that if people transgress, for whatever reason, we have an
ability to ensure that their future practice is moderated or modified
in some way.
Q381 Chair: Going
back to this question of the twin routes into public health, you
still propose that two lists are maintained in one register.
Dr Scally: My preference
would have been to be able to convince the General Medical Council
to take on all of public health, but they were reluctant to do
so. They felt they had enough on their plate with revalidation
and various other changes in the GMC. That would have been my
preference. Having looked at all the options, however, as I think
I said earlier, the closest analogy I could find was with the
pathologists where the medically qualified pathologists were registered
and regulated with the GMC and the nonmedical pathologists
by the Health Professions Council. That seemed to me the best
way forward and is indeed what I recommended.
Q382 Chair: Professor
MaryonDavis referred to the grades of specialist practitioner,
and there is a third one.
It is the wider public health work forcehealth visitors,
GPs and a whole bunch of people who do public health. They would
not see themselves as necessarily public health people per se.
Q383 Chair: No.
One of the surprises I had when I was reading some of the material
for this session was that a health visitor is regarded as part
of public health. That is another debate. Could you characterise
for the Committee the nature of the work that the specialist and
practitioner grades do and the implications of those classifications?
The specialists, who have either been through a five-year training
programme on top of their basic professional background or who
have presented a portfolio, are experienced people and they have
presented their experience and been accepted on the basis of that;
they tend to be senior people in positions of considerable responsibility.
They are either in strategic positions, like directors of public
health, or responsible for specific areas such as health protection,
for instance, or it might be around health improvementthe
three main domainsbut they will be in positions where they
are dealing with senior people in the hospital sector, in a local
authority or in other areas depending on who their employer is.
Basically, they are working at a senior level, making big decisions.
They might be in command of quite large budgets and so on and
so forth. The practitioners tend to be people who are at an intermediate
level, such as health promotion officers or specialists, people
working in informatics, people working in health protection but
at a lower level, and specialists. What other sorts are there,
Q384 Chair: It
is very unlikely somebody would be a qualified doctor and a practitioner.
It is pretty unlikely.
Dr Scally: It is
unlikely but not unknown. We should not try too much to demarcate
the boundaries here. It is quite clear at the high level of the
professionconsultant level, directors of public health
levelthat those people are highly specialised and work
solely within the public health realm. When you get beyond that,
the boundaries are more blurred, and I think correctly so. I would
like there to be public health peoplepeople who think of
themselves as contributing to the public healthwithin the
transport or housing departments. Indeed, in my region, we put
a lot of money recently into making it possible for people from
local government to undertake a certificate, diploma or masters
in public health to increase their skills. I firmly believe that
we need a spread of public health knowledge and interest across
the whole of the public sector.
Q385 Chair: I
understand that thought process, but it is, to some degree, in
conflict, is it not, with a desire to create a status for public
health as an identified regulated profession with all the obligations
that go with professional status?
Dr Scally: There
is territory to be worked on, particularly around people such
as health visitors who have their own regulatory body and framework.
As I say, it is no easy demarcation. The demarcation that my report
was particularly concerned about was the people who are occupying
the specialist professional roles, and it is much clearer there.
Q386 Chair: Your
advocacy of compulsory regulation is focused on the specialists,
not on the practitioners.
Dr Scally: Indeed,
that was the nature of my review and its recommendations.
Q387 David Tredinnick: I
want to move on to public health work force strategy. The White
Paper of November 2010 sets out the Government's vision for the
public health work force: "it will be known for its expertise,
professionalism, commitment to the population's health and wellbeing
and flexibility." Dr Scally, in your report you concluded
that "there should be, as far as possible and allowing for
dental public health, a single training pathway for specialist
training in public health". I know we have touched on some
of this before. How is this aspiration affected by the proposed
new structure of the public health services?
Dr Scally: I do
not think the aspiration is affected at all. What we will have
to do in public health is look at the competencies that are required
of people who go through that training programme. Quite clearly,
particularly with the move to local government, there is a requirement
for an expanded or a different skill set. I only have to think
of the challenges of dealing with local government councillors
and the move from directors of public health being an executive
board member of a primary care trust to being an adviser to elected
members and to a cabinet to see that that is quite a considerable
difference and quite a considerable skill set required of people.
There will have to be a look at the content of the training, but
our training framework is a good, sound one, which indeed is one
of the requirements for statutory regulation.
Q388 David Tredinnick: Thank
you. What dangers do you see in the cohesion of the public health
service work force in the proposed new system?
Dr Scally: I am
Q389 David Tredinnick: You
have a public health work force and we are coming up with a new
system. How far could dangers of a lack of cohesion be mitigated
by Public Health England taking on the entire work force, for
example, and then seconding it out to local authorities and NHS
Do you mean dangerous to the cohesion of the profession?
Q390 David Tredinnick: I
mean that the cohesion of the public health work force is important.
I want to know how, in the new improved system, this is going
to work and whether there will be the cohesion that is desirable
or whether it will be fragmented. There have been some issues
raised, some of which
Dr Scally: I can
see the issue. The biggest threat to cohesion is through the loss
of senior people as we go through a restructuring or liberation.
I am in my seventh incarnation as a regional director of public
health, so I have been through more than my fair share of these.
In every serious restructuring affecting public health at a local
level, we have lost anything up to 30% of the senior people. I
think that is our biggest single threat. There is no sign of that
happening at the moment. People are responding.
I would disagree with that.
Dr Scally: Maybe
it is just in my region. The Government's position is that directors
of public health and their senior colleagues will be employed
by local authorities and that Public Health England will be involved
in the appointment process. I know that some public health organisations
are advocating that they should all be employed by Public Health
England and then seconded in.
Personally, and I must give my personal view here,
it would be not good for public health if all directors of public
health were employed by the Department of Health and were all
part of the one organisation. It strikes me that that would not
be a healthy situation in terms of their independence, freedom
of thought and practice. Therefore, I would strongly support that
the employment should be with local government. When you look
at the coherence of the medical officers of health and the power
that they held as a group within the country when they acted collectively,
they were very coherent indeed.
Q391 David Tredinnick: Do
you mean before 1974?
Dr Scally: Pre-1974,
I am certainly in favour of directors of public health being employed
by local authorities. That is the legitimate locus for them, but
I think the links with Public Health England have to be pretty
strong and, as I mentioned before, the links with the commissioners
have to be pretty strong.
Q392 David Tredinnick: The
Royal Society for Public Health has told us: "Local government
has little experience of the expectations and responsibilities
associated with medical/public health training, or of working
with postgraduate Deaneries." Do you think that is a legitimate
concern and if so, what shall we do about it?
That is a concern. If you are talking about the training, there
are risks in what I would regard almost as the atomisation of
public health, going in different directions: local authorities,
Public Health England, commissioning, private sector or wherever.
There are issues there. Local government currently does not have
the mindset and is not set up, as it were, to understand the training
programmes. That can be learnt and that can be acquired and I
am sure it is a barrier that can be got around, but at the moment
it is a bit of a risk and will need to be addressed. What is important
is that trainees coming through the system must be given the opportunity
to have experience in a variety of settings so that they build
up a broad view of the range of public health.
Q393 David Tredinnick: Thank
you. Is there a danger then that in the absence of statutory regulation,
the public health work force within local government could become
professionally "diluted"? Should councils be obliged
only to take on appropriately qualified and experienced staff?
Yes. On that basis, they certainly should. That is something which
I would hope this Committee could make a strong recommendation
about because that is a considerable risk in terms of the effectiveness
of public health.
Dr Scally: We have
to remember that what is envisaged in the transition, and the
reason for directors of public health managing the transition,
is that public health teams will simply move from their current
bases in PCTs to local authorities. Indeed, many of them are already
in local authorities. As I said, 13 of the 14 appointments of
DPHs in my region are joint appointments. They are already well
integrated and have trainees in public health operating successfully
within the local authority area. While I can see the theoretical
risk to training, I believe that smooth transference will be achieved
without too much difficulty.
Q394 David Tredinnick: The
Unite union, when they came before us, told us that they feared
councils could disperse public health staff across their organisations,
leaving those staff without sufficient professional support, coaching,
management and mentoring. Is that a risk to the future work force
development or is that something you disagree with?
Dr Scally: Were
it to happen, it would be, but I do not believe for a moment that
it will. Directors of public health have a clear leadership role
and I would hope that they would have public health staff working
across the different aspects of a local authority but under clear
leadership. In fact, I go back to the Health Select Committee
report on public health some 10 years ago which pointed out the
importance of the leadership role of directors of public health.
A key part of their leadership role is to lead that team within
the local authority, irrespective of where public health people
are working within that local authority.
I agree with Dr Scally, but to help that process along it is important
that the directors of public health have control of their own
bit of the budget that they are given, however small it might
be. That will help to make sure that there is cohesion within
the local authority.
Q395 David Tredinnick: Fine.
Thank you for that. I am going to ask lots of supplementaries,
but I will have to keep an eye on the clock. How should public
health fit into the new systems for clinical work force planning,
education and training that the Government is currently developing?
Public health should be an important component of clinical training
as well, and certainly there is a lot of interest from some of
the clinicians to embed public health within their training. For
instance, GPs are very interested in having a public health module
within their training programme. The paediatricians are very interested
in them having public health, because it is so important for children's
health, as are psychiatrists and others. There is a move, and
there is work going on with the Faculty of Public Health in particular,
to try to work through training programmes that incorporate an
element of public health within clinical training.
Q396 David Tredinnick: How
big a danger is it that in the future public health could be less
attractive as a career choice for doctors and dentists? I think
one of you already said that it is down to the money. Are there
any other factors in there? How could you mitigate those concerns?
Dr Scally: I do
not think it was down to the money.
It is not down to the money, but it is a factor.
Q397 David Tredinnick: Proper
Dr Scally: It is
a potential factor, yes, and of course people will be concerned.
It is very important that we have a public health specialism within
medicine that doctors want to go into that can provide them with
a fulfilling career. That has a lot to do with how the system
is structured and operates locally.
Q398 David Tredinnick: Thank
you. The academic public health work force has an important role
to playI am sure you will agreenot least in the
work of the Public Health Observatories, about which we have had
discussion this morning. How satisfied are you that sufficient
attention has been paid to the future of this particular strand
of the public health work force?
We heard from Professor Newton this morning about the plans for
the observatories to be absorbed into Public Health England. My
worry is in the transition to that position, because we are seeing
what I would call the dissolution of the observatories. We are
seeing senior people in the observatories leavingrushing
to academia or taking early retirementbasically because
of all the uncertainty and unrest. My main concern is with what
is happening during the transition period. Ultimately, the vision
painted by the civil servants earlier on, at the end of that process,
is a reasonably rosy one, aside from the fact that an Executive
agency is still a branch of Government and that the people who
work for it are still civil servants. What restrictions will that
imply in terms of their independent voice? I do have continuing
concerns about that.
Q399 David Tredinnick: I
must say that when the representatives of the observatories came
before us earlier in the year they presented incredibly well and
one got the impression that this was a first-class integrated
It certainly is.
Q400 David Tredinnick: Now
there is a degree of haemorrhaging and there will have to be some
major repairs, effectively. Is that right?
That is my view.
Dr Scally: Sir
Liam Donaldson caught it quite well when he described the observatories
on more than one occasion as the Crown jewels of public health.
It would be unfortunate if there were any diminishing in the lustre
of those Crown jewels, particularly in terms of their ability
to support local directors of public health, local authorities
and all of the work that needs to be done to contribute to the
joint strategic needs assessments.
Q401 David Tredinnick: I
have one final question. You have both, gentlemen, had very long
careers by the sound of it. Dr Scally, you said you had been through
seven transmogrificationswhatever the word is.
Dr Scally: It is
six, I think. I am in my seventh.
Q402 David Tredinnick: That
is going right the way back to when you were training. When you
look at the landscape now, with particular reference to what we
are discussing this morning, is there anything that really worries
each of you? Is there something there that you personally would
like to get on the record today so that we could perhaps look
at it later?
Dr Scally: Not
from my point of view.
He is a civil servant.
This is by far the biggest shakeup that I have been through.
I have been through as many as Gabrielprobably morebut
this is by far the biggest and the most disturbing. We will not
rehearse all the stuff about "Why?", "Why bother?",
"Why now?" and all those other things. Given that it
is happening, from the public health professional point of view,
the most worrying aspect is the potential fragmentation of public
health not just as a profession but as a service to the public
as well. The Government missed a trick in not having a public
health person on the commissioning boards. That was a great mistake,
and I think work will have to be done to make sure that that input
gets in there. The crosstalk at the local level is important,
that the Health and Wellbeing Boards and the commissioning boardsconsortia
groupsdo crosstalk. Public health can play an important
part in that, but that has not been worked through yet. We might
hear about that coming soon. The biggest worry is the fragmentation.
There are concerns that training might also be fragmented and
that might cause problems. We do have to get the regulation right
and, as I have tried to say this morning, the time is absolutely
right and we have a real opportunity now, especially in the way
that the balance is changing in terms of the professional background
of public health, to put in place, not at great expense, proper
statutory regulation that would address quite a lot of the concerns
that have been raised this morning.
Q403 Chair: Could
we explore this concept of fragmentation? It is relevant to the
debate about regulation too, is it not? You can have a coherent
profession that works for a series of different employers and
subscribes to a common professional ethic.
Dr Scally: Indeed.
Q404 Chair: Would
it be fair to say that one of the arguments you would advance
in favour of stronger regulation is that with a variety of employers
the regulatory structure would address some of the fragmentation
The fact that we have a whole multiplicity of different employers
adds real urgency to the need for statutory regulation. It is
yet another reason why we should go for statutory regulation.
Dr Scally: Indeed.
It also places the Faculty of Public Health in a key and vital
position as the main professional organisation that is setting
the standards for public health against which regulation will
operate. The tasks falling to the Faculty and the distributive
system of public health increase commensurate to the distribution.
I agree. I think the Faculty of Public Health will have to have
a hugely expanded role in helping to mitigate some of the fragmentation
we have talked about in working with the regulators to make sure
that that regulation itself is fit for purpose. Yes, I agree.
The Faculty's role is going to be much greater.
Q405 Chair: Pushing
you a bit further on the concept of fragmentation, currently,
or traditionally, directors of public health have been employed
by PCTs and, before that, local statutory health authorities of
one sort or another, and they have been employed within the Department
of Health. In the future they will be employed through Public
Health England and through local authorities rather than through
the health service. Why does that add up to fragmentation?
They will be working in a whole variety of different milieux.
Some will be working for the private sector, which is going to
expand as well, and some will be in academia, as we have heard.
Q406 Chair: Yes.
What I am trying to test is your proposition that the world in
five years' time is more fragmented, from a public health perspective,
than it was five years ago. It is not immediately obvious to me
that that is true.
Dr Scally: I do
not think, Chairman, it has to be true, but it could be true if
directors of public health moved to local authorities and we did
not have the right structures in place to ensure that they remained
within a coherent system. What we are trying to create for the
country is a public health system that will serve us well for
the coming years. It is the systemisation of public health that
will ensure we retain coherence. If we do not have a system and
we do not have coherence, then the fragmentation could very easily
Q407 Chair: As
to the fragmentation, I think I am hearing you say that the danger
Dr Scally: Indeed.
Q408 Chair: And
that that leads to fragmentation, but actually the institutional
structure is no more fragmented in the Government's intended world
than it has been. The danger is that the culture in the local
authorities is more isolated than the culture in the health service.
Dr Scally: That
is right. In terms of professional accountability, the lines are
redrawn. For example, I am very clear about the professional accountability
of the directors of public health in my region. I sit within the
strategic health authority and I have an organisational role then
with the PCTs accountable to the strategic health authority, so
it is very easy to maintain coherence and to encourage collective
activity. If that collective activity falls away, it will be greatly
to the detriment of public health because some of the really good
things we do are done collectively, like the regional offices
of tobacco control and the fantastic work they are doing with
smoking, or our office in sexual health about integrating sexual
health service approaches across the region. Unless we have a
systematic approach to creating a system, then I do fear fragmentation.
Chair: Are there any other
Q409 Rosie Cooper:
What would you put into the system today to stop that happening?
If directors of public health are not directorlevel employees
at local authorities, that fragmentation will start, will it not?
Chair: I think we were
given the broadest possible hint today that that is an issue the
Government is going to address in a few days' time.
The Faculty of Public Health can have an important unifying role
across this potentially fragmented service by making sure that
the standards are set equivalently across the system, so there
are not differences in quality across the system, that the training
programmes again use the whole system and not just bits of it
and that communications between members of the Faculty working
in different settings are there to help to encourage networks
at local level, in particular, or the subnational level
and so on. Therefore, the professional bodythe UK Faculty
of Public Healthdoes have an important role in helping
to mitigate the potential fragmentation that might occur.
Chair: We try to draw
these sessions to a close by 1 o'clock. We are three minutes adrift,
so thank you very much indeed for your evidence this morning.