Public Health - Health Committee Contents


Examination of Witnesses (Question Numbers 356-409)

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 issues?

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.

Professor Maryon-Davis: 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 overview.

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 Donaldson—the former Chief Medical Officer—who 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 CMO—by that time, it was Dame Sally Davies—and 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 profession—or, in this case, a branch of a profession—but 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 confusion.

Q359 Chair: Was there any evidence that it was leading to prejudices to public safety?

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 professionals—of course, about 80% are doctors or dentists and already covered by statutory regulation—and 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 people—of course, the White Paper on public health appeared subsequent to my report—will 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 that balance.

Dr Scally: No, indeed.

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 advice.

Professor Maryon-Davis: 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 on—advising 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 setting—I was a medical student at the time—but 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.

Professor Maryon-Davis: 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 population—they will have responsibility for delivering on various health programmes—it 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 has happened.

Professor Maryon-Davis: 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 proper—to use the current phrase—to 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?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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 in—way outside this current public health inquiry—is the role of professional regulators through the GMC, the NMC and those bodies. I would have thought it merits further thought—I put it no more provocatively than that—that 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 so.

Q373 Chair: Surely the regulator has to own the concept of quality—what it means to be a professional—in 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.

Professor Maryon-Davis: 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 background—medical, 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.

Professor Maryon-Davis: 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 health—not 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 grounds.

Q376 Rosie Cooper: But in the future they will be making those choices inside a local authority.

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.

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: It is the wider public health work force—health 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?

Professor Maryon-Davis: 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 improvement—the three main domains—but 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, Gabriel?

Q384 Chair: It is very unlikely somebody would be a qualified doctor and a practitioner.

Professor Maryon-Davis: 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 profession—consultant level, directors of public health level—that 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 people—people who think of themselves as contributing to the public health—within 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 not sure—

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 commissioners?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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, yes, indeed.

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: It is not down to the money, but it is a factor.

Q397 David Tredinnick: Proper remuneration?

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 play—I am sure you will agree—not 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?

Professor Maryon-Davis: 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 leaving—rushing to academia or taking early retirement—basically 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 data­gathering system.

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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 transmogrifications—whatever 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.

Professor Maryon-Davis: He is a civil servant.

Chair: Professor?

Professor Maryon-Davis: This is by far the biggest shake­up that I have been through. I have been through as many as Gabriel—probably more—but 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 boards—consortia groups—do 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 concerns?

Professor Maryon-Davis: 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.

Professor Maryon-Davis: 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?

Professor Maryon-Davis: 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 happen.

Q407 Chair: As to the fragmentation, I think I am hearing you say that the danger is isolation.

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 questions?

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.

Professor Maryon-Davis: 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 body—the UK Faculty of Public Health—does 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. Thank you.


 
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