Communities and Local Government CommitteeWritten submission from the British Medical Association (BMA)

About the BMA

The BMA is an independent trade union and voluntary professional association which represents doctors and medical students from all branches of medicine throughout the UK. With a membership of over 150,000 worldwide, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.

Executive Summary

The BMA welcomes steps taken to move responsibility for public health into local authorities but is concerned that if reforms are not implemented properly it will lead to the fragmentation of the public health system.

Clear guidance is required on what public health activities a local authority is expected to undertake and how ring-fenced funds for public health can be used by local authorities.

For public health to remain an attractive specialty for the medical workforce there needs to be a unified set of terms and conditions, including pension rights, for those working in the new health service—whether they are based in local government, the civil service or the NHS.

Directors of Public Health (DPH) need to be directly accountable to the Chief Executive (or their equivalent) of the local authority. All public health consultants should be employed on terms and conditions that, like their current NHS contracts, enable them to give, and be known to give, independent advice.

Background

1. The BMA supports an increased role for local authorities in the delivery of public health, but there are serious concerns about some aspects of the reforms and how they will be implemented. Local government is ideally positioned to take on responsibility for aspects of public health, using the powers it has over housing, social services and schools as vital tools in improving the health of the population.

2. However, the scope of the public health system goes beyond this and the BMA is concerned that aspects of specialist public health work will not be adequately recognised in the fragmented public health system after 2013. The BMA has concerns that some local authorities do have not an understanding of public health as a distinct health specialty. Instead, they define public health as being any activity that improves the health of the population. This has led some authorities to view the public health reforms as a package of measures that gives them more money, and requires them to take on some staff to simply do more of the public health work which they already do. Some local authorities may fail to adequately address the new responsibilities that the Health and Social Care Act 2012 gives them.

3. Public health is a broad term which encompasses many activities and aspects of health policy. Public health activity can be described as any activity that in some way improves the health of a population. In order for local authorities to adequately lead on public health issues, the BMA believes that there needs to be clear guidance on what public health activities a local authority is expected to undertake and crucially limits the use to which ring-fenced funds for public health can be put by local authorities. The BMA also thinks it is vital that it is Directors of Public Health (DPH) that make decisions on what the budget is spent on at a local level.

4. The Faculty of Public Health’s definition of public health is the ‘science and art of promoting and protecting health and wellbeing, preventing ill health and prolonging life through the organised efforts of society.1 The Faculty sets out three domains of public health: health improvement (including people’s lifestyles as well as inequalities in health and the wider social influences of health), health protection (including infectious diseases, environmental hazards and emergency preparedness) and healthcare public health (including service planning, efficiency, audit and evaluation).2 All three domains need to be addressed actively if the public’s health and wellbeing are to be protected and improved. It is important to recognise the diversity of the public health workforce. The BMA represents many public health consultants who specialise in various aspects of public health. This highly specialised workforce have undertaken at least seven years of medical training in addition to five years specialist training required by the Faculty of Public Health. Many of these consultants will also have additional qualifications, such as a Masters or a PhD in public health.

5. The public health medicine consultant workforce provides expertise on all aspects of public health. They are not only committed to, for example, reducing childhood obesity, but are also able to use their years of training and experience to design a whole range of interventions based on local circumstances.

6. The BMA is concerned that local authorities will not be able to offer terms and conditions of employment that will be attractive to someone considering entering the public health consultant workforce, and thus there is a real risk that the expertise of this group will be lost in the future.

7. In recent years public health has developed as a medical and multi-disciplinary specialty that has become embedded within the NHS. It is important that moving public health responsibilities into local authorities does not mean that the NHS stops undertaking any public health work or that public health specialists stop having a role in the health service. Healthcare public health (HCPH)3 specialists have a vital role in ensuring that Clinical Commissioning Groups (CCGs) offer a service that is cost effective, population based and patient oriented. A local authority that fails to appreciate the vital role given to their HCPH specialists by the Health and Social Care Act will be failing in its duty to improve the health of the population they serve.

The Introduction of a Public Health Role for Councils

8. Local government has always played a central role in the delivery of activity that impacts on the public’s health and a strong case can be made both for very close working links between public health specialists and local government and for basing director level staff within local government. Prior to the implementation of the Health and Social Care Act 2012, this was achieved by making directors of public health (DPHs) joint appointments between primary care trusts (PCTs) and local authorities. The BMA, and a number of other organisations, expressed an initial conditional welcome to the idea that local public health teams would be located within local authorities.4

9. The BMA has concerns about moving the public health specialist workforce into local authorities without it being given the proper status and independence that is required for success. Whilst the BMA is aware of many examples of local authorities which embody integrated public health approaches5 we also have concerns about some local authorities which appear to place little value in public health as an independent health specialty.6 The importance of recognising that public health specialists operate within essentially a professional model and not an administrative or managerial model must be better understood.

10. If public health, as a distinct health specialty, is to be a success in local government, then it will be because its move will be seen as a widening of the “health system” so that this system incorporates work done by local authorities to improve the health of the population they serve.

11. The BMA is concerned that these reforms, rather than leading to a widening of the health service, could lead to its fragmentation—with public health experts leaving the NHS largely due to unattractive terms and conditions. This would deny the NHS expertise in the designing and commissioning of healthcare systems.

12. One way to counter this potential fragmentation is for there to be a unified set of terms and conditions, including pension rights, for those working in the new health service –whether they are based in local government, the civil service or the NHS. A failure to offer such equitable terms and conditions will undoubtedly lead to local authorities not being able to recruit the best public health doctors, who will instead seek jobs in Public Health England (PHE), CCGs the NHS Commissioning Board, or outside the publicly funded health service.

13. The reforms to the health service will also give local authorities a vital role in the training of the future public health workforce. Although public health registrars (those on the Faculty training programme) will be employed on NHS contracts, they will be training and working across the whole of the new public health system, including some local authorities. The BMA is hopeful that many authorities will recognise the added value that the trainee workforce can bring to their organisations, and will aim to offer a working environment that is attractive to both trainees and their trainers.

The Adequacy of Preparations for the new Arrangements

14. The current reforms to the public health service are the largest in over a generation and are being undertaken as the rest of NHS is undergoing reform and restructure. At the same time, the entire health service is trying to achieve unprecedented levels of savings7 and local government funding has also been significantly reduced.8

15. The recent health service reforms have involved the disbanding of the main NHS organisations that employed public health staff—Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs). These organisations have also been tasked with supporting the transfer of public health staff to multiple new employers (eg local authorities, PHE, the NHS Commissioning Board) whist disbanding.

16. The result of this is that these reforms have left the public health workforce in limbo for over two years, with many uncertain as to where they will be employed in April 2013—or even whether they will be employed at all. The BMA is aware that some public health doctors have recently received letters informing them that they will either be transferring to PHE or local authorities. However, other public health doctors have not yet been given the job description of roles in PHE into which they are hoping to be transferred. This means that they are unclear whether these are posts that they will fill automatically or whether they will be expected to compete with other doctors for these new posts. If these posts are subject to competition, the unsuccessful candidates are not guaranteed other posts in PHE.

17. Historically, reorganisations have always meant that consultants have left the specialty in large numbers. It should not be surprising therefore, that this uncertainty is having a significant negative impact on staff morale or that so many staff, and particularly senior staff, are leaving the English public health system. 9

The Objectives of the new Arrangements and how their Impact can be Measured

18. The Government’s public health whitepaper Healthy Lives, Healthy People10 provides a response to Professor Sir Michael Marmot’s report Fair Society, Healthy Lives.11 In particular it argues for a need to tackle the wider social determinants of health. It recognises that public health expertise must not be limited to within the health sphere, but should impact upon the decision making process in both local and national government. As such, it reflects the maxim that Parliament is the pharmacy of public health—most clearly shown by the significant gains to the nation’s health brought about the 2007 decision to ban smoking in the workplace.

19. The BMA welcomes this increased opportunity of public health teams to impact upon local and national government policies. However, as mentioned above, this opportunity must not be to the detriment of specialist public health’s ability to influence and shape the health service as a whole. In particular, DPHs and their teams must be able to act as the bridge between the NHS and local authorities if the health system is not to become fragmented.

20. The ability for public health teams to have an influence on local and national policy making is also dependent on the status and independence of those giving the advice. For this reason, the BMA has been arguing for DPHs to be directly accountable to the Chief Executive (or their equivalent) of the local authority and for all public health consultants to be employed on terms and conditions that, like their current NHS contracts, enable them to give, and be known to give, independent advice.

The Intended Role of Health and Wellbeing Boards in Coordinating the NHS, Social Care and Public Health at the Local Level

21. Health and Wellbeing Boards (HWBs) will be vital to the coordination of the new healthcare system. They will need to take a broad and holistic view of the health and social care system and must deliver strong and credible leadership across local organisational boundaries. As such, the input and advice of a fully-trained and properly regulated DPH will be vital in ensuring that HWBs are seen by CCGs as credible organisations with an understanding of healthcare commissioning.

22. It is also vital that they should not become just “talking shops”, but are instead given powers to hold to account robustly all of the various stakeholders across the fragmented health and social care system.

How the Transfer to Local Authorities of the Front-line Health Protection Role and the Creation of Public Health England will Affect Resilience Arrangements at the Local Level

23. The BMA recognises the merits of having a single central agency, like PHE, as the hub for national level health protection and fully support this approach. However, the BMA has concerns that the current proposals do not address the need to establish and maintain an effective health protection workforce at the front line (that is, at the local authority level).

24. The BMA believes that the reforms have failed to appreciate that the primary role of the Health Protection Agency is not to deal directly with individual health protection cases,but is instead to provide advice and support to health protection staff working in PCTs. There is a real danger that this failure to recognise how health protection incidents are currently managed will result in local authorities not being provided with the resources—both in terms of finances and staff—to deal with the new responsibilities they are being given to protect the public.

25. The fragmented nature of the new health system will require that each organisation (including the NHS Commissioning Board, PHE, local authorities and CCGs) are aware of the plans in place to deal with potential outbreaks of ill health, such as pandemic flu or legionnaires disease. Such an outbreak would also require a clear delineation of responsibilities across these organisations at local, national and regional levels. However, the Health and Social Care Act 2012 is not clear on these lines of responsibility. As such, it is possible that different areas of the country will develop different ways of dealing with outbreaks. This will be problematic for those organisations that have a national role and who will therefore have to tailor their responses to local plans. This could lead to inefficiency, duplication of effort and ultimately put lives at risk.

The Accountability of Directors of Public Health

26. The BMA welcomes the recent clarity given over the roles and responsibilities of Directors of Public Health.12 The role of a DPH will be to shape the culture and practice of local government to deliver services in ways that support the health and well being of the local population. Their importance is derived not from the size of their budget or the staffing of their department but from the nature of their task—improving and protecting the health of their patients—the population they serve. The BMA believes that in order to be able to effectively advocate for their patients the DPH must report directly to the Chief Executive Officer (or equivalent) and have the right of access to elected members.

27. We are concerned to hear reports that some local authorities wish to have their public health teams report to, for example, their Director of Adult Social Services. One such example is the planned structure in Berkshire, where the county’s six unitary authorities would share a strategic director of public health. Each authority would also have an assistant director of public health, who would be managed by their respective director of adult services. It is our view that these arrangements effectively make these public health teams a subcategory of adult services in each of these local authorities, stopping them from being effective across the full remit of their responsibilities.

28. The BMA believes that all public health specialist post holders, including DPHs and consultants, should, as a minimum, be registered either with the GMC or with the UK Public Health Register (UKPHR) and be competitively appointed through an advisory appointment committee (AAC). This is to ensure that those responsible for providing vital advice of a technical nature are appropriately qualified to do so and that the public can be assured of their competence. Ideally, the BMA would like there to be statutory regulation of all specialists in public health, as recommended by the Scally Review.13

The Financial Arrangements Underpinning Local Authorities’ Responsibilities, Including the Ring-Fencing of Budgets and how the new Regime can Link with the Operation of Community Budgets

29. The BMA is concerned that there still remains a lack of clarity over what services are to be funded from the public health budget and, most fundamentally, how much money will be allocated to local authorities. This lack of clarity is causing understandable and significant concerns within many local authorities. It is also leading some local authorities to state that they cannot afford to employ the public health teams due to transfer to them in just over five months time.14 This is, in turn, causing further concern among those staff due to transfer.

30. The idea of a ring-fenced budget is attractive to the public health workforce. However, due to the nature of public health practice (in which, for example, a good case can be made for spending “public health” money on housing) it is also vital that it is the DPH who decides what the budget can be spent on. This will ensure that public health money can be added to other departments spending when the DPH thinks that doing so will have a significant impact on the health of the population. Such examples of integrated spending are vital if public health is to be a success in local government. Public health advice cannot be sought at the end of a project, when it can make only cosmetic and peripheral differences. Instead, public health advice must be involved from the very beginning and must be embedded within the work.

31. It is also important that there exists robust and external monitoring of the ring-fenced budget. As such, the BMA believes that PHE and the relevant CCG should have a role in monitoring the integrity of the ring-fence.

October 2012