Transition to Public Health England
Public Health England's (PHE) written evidence stated that the creation of PHE and the transition of staff and functions to the new body had been undertaken successfully. The Department of Health shared this view and said that PHE achieved its objective of "being fully operational, with all functions transferred safely, to ensure no 'dip' in delivery."
During the process of transition PHE operated a number of national public health awareness campaigns, managed the response to local measles outbreaks, and led the national measles vaccination catch-up programme.
The Committee has received evidence that, in its first seven months of operation, PHE has established itself as a new entity whilst ensuring continuity of public information campaigns. This evidence suggests that PHE met its objective of ensuring that the transition to the new arrangements did not result in a 'dip in delivery' of existing programmes.
PHE's priorities for 2013-14 identified the importance of implementing a national surveillance strategy to "ensure the public health system responds rapidly to new and unexpected threats." The incorporation of the Health Protection Agency (HPA) into PHE means that PHE "will be responsible for front line health protection via its local centres which will support their local authorities." The Committee recognises that throughout the transition PHE maintained continuity of the vital work undertaken by the HPA.
Prior to being established, concerns were expressed by a number of parties regarding PHE's future ability to manage local public health emergencies. PHE provided evidence that it has worked to clarify responsibilities for emergency preparedness. The Committee is concerned, however, that the Faculty of Public Health reports that these responsibilities remain unclear and recommends that the Government takes urgent steps to put these important issues beyond doubt.
Duncan Selbie, PHE's Chief Executive, told the Committee that in its first six months of operation it had not attached a high priority to contributing to public health policy debates. Mr Selbie noted, however, that PHE exists to be an important voice in improving the nation's health.
In oral evidence PHE's management responded to questions about the potential impact that key public health measures such as minimum unit pricing of alcohol and the introduction of standardised packaging of tobacco products could have. PHE also discussed their report which examined the public health impact of shale gas extraction. During the evidence session the Committee questioned the PHE witnesses about the relative priorities of the work on shale gas extraction and other public health issues, and expressed surprise at the priority given to the shale gas report.
The Committee is concerned that that from the evidence it heard the PHE Board has not yet established prioritised programmes of work which reflect the objectives of the organisation and have been endorsed by the Board. The Committee believes it was unwise for PHE to follow through the work on shale gas extraction which had been initiated by the HPA without first taking care to satisfy itself that this work reflected both the public health priorities of PHE and the research quality criteria embraced by the new organisation.
Relationship with Government
In their written evidence PHE acknowledged that feedback from their survey of stakeholders has told them that "more needs to be done to demonstrate that the advice and guidance PHE provides is truly independent of Government". The Department of Health also said that:
it is important that PHE is and is seen as a trusted and impartial champion for the protection of the health of the nation and free to provide advice based firmly on the science and the evidence.
In oral evidence, the Committee asked PHE to outline Government policies which may be damaging to the nation's public health by increasing health inequalities. In response Duncan Selbie said that at this stage of PHE's development it would be too controversial to directly address this question. The Committee is concerned that that the Chief Executive of PHE should regard any public health issue as 'too controversial' to allow him to comment directly and believes that PHE should be able to address such matters without constraint.
Concerns were also expressed by external organisations in written evidence that PHE staff do not have freedom to contradict Government policy. The Committee is concerned that there is insufficient separation between PHE and the Department of Health. PHE can only succeed if it is clear beyond doubt that its public statements and policy positions are not influenced by Government policy or political considerations. The Committee believes that Public Heath England was created by Parliament to provide a fearless and independent national voice for public health in England. It does not believe that this voice has yet been sufficiently clearly heard.
NHS Health Check
PHE is responsible for supporting the delivery by local authorities of the NHS Health Check programme to 15 million eligible people by 2018-19. In written evidence concerns were expressed regarding the value of the programme relative to other public health interventions and this was discussed in oral evidence. PHE explained that the programme is targeted around cardiovascular risk and that its components have been accredited by NICE.
PHE has said that it will undertake research to assess the effectiveness of Health Checks and the Committee believes that an analysis of the clinical and economic benefits of health checks should be fundamental to this. As part of this process, PHE should consider the opportunity cost of investing in Health Checks instead of in other proven public health initiatives.
Public Health staff
Every unitary and upper tier local authority must appoint a Director of Public Health. The appointment is made jointly with the Secretary of State but in practice it is PHE that fulfils this duty. It is also PHE's responsibility to oversee the development of the professional public health workforce and ensure there is sufficient capacity across England.
The Association of Directors of Public Health reported in written evidence that a capacity problem is beginning to emerge within local authorities. They said there is a reduced capacity within the overall public health workforce because of unfilled posts. The Committee also received evidence expressing concern that despite their statutory position, some Directors of Public Health are expected to report to another local authority Director.
The Committee does not believe that it is possible for Directors of Public Health to drive public health reform if they are subordinate to other officials within local bureaucracies. The Committee recommends that PHE should announce on its own authority that it intends to make a formal report to Parliament if it believes that the public health function in a particular local authority area is unable adequately to discharge its responsibilities.