5 The landscape of public health |
NHS Health Check programme
46. PHE is responsible for supporting
the delivery by local authorities of the NHS Health Check programme
to 15 million eligible people by 2018-19. The PHE Health Checks
action plan notes that from April 2013 local authorities have
been mandated to provide the NHS Health Check programme. Funding
has been included in the ring fenced public health allocation
to local authorities of £5.45 billion over two years. The
action plan added:
PHE will support those LAs (local
authorities) taking on challenging programmes. It will work with
local authorities to achieve offers to 20% of the target population
annually with a vision to realise at least 75% uptake per year.
This will support local authorities to achieve offers to 100%
of their eligible population over five years.
47. In August 2013 it was reported that
Professor Clare Gerada, then Chair of the RCGP Council, had criticised
the Health Check programme. Commenting on a study by the Cochrane
Collaboration, Professor Gerada said:
the team's evidence showed population
screening would not reduce deaths, and said the programme risked
overtreatment and wasting NHS resources that would be better put
into other public health projects such as cutting smoking rates.
We run the risk of putting people
on unnecessary medication or worrying them unduly. At a time when
the NHS is having to slash its budgets and GPs and practice nurses
are already at breaking point as a result of rising workloads
and dwindling resources, this is not the best use of time or money
that should be spent on caring for people who are sick or at high
risk of illness.
48. In their evidence the BMA indicated
that PHE employees had been restricted in what they could say
regarding the Health Check programme. They said that:
The health check programme is a
deeply contentious issue among public health professionals. Many
are of the opinion that the programme lacks a robust evidence
base and will divert money from proven schemes and may even be
harmful; other public health professionals have expressed the
opinion that despite the lack of conclusive evidence in support,
health checks are a worthwhile experiment, the results of which
will need to be carefully evaluated. A number of our members have
reported that they were actively discouraged from expressing their
professional opinions publicly.
49. Answering these concerns, Professor
Fenton told the Committee that the relevance of the Cochrane Collaboration
work to the current Health Check programme is limited. Professor
The health check programme has come
under some controversy, in part because of a systematic review
that was done by the Cochrane Collaboration and published last
year. It looked at about nine randomised control trials of general
health checks that were offered between the late 1960s and the
early 1990sso the most recent study was nearly 20 years
The Cochrane study was unable to
demonstrate any impact on mortality. The systematic review also
tried to look at the impact on morbiditywhat happened with
disease outcomes; did it make any difference? Unfortunately, the
quality of the studies, because they were so old, did not allow
it to look at those intermediate determinants.
He added that the views of those within
PHE who were sceptical about Health Checks had been heard,
feel that the health check programme
as it is currently designed is very different from the health
checks that are in the systematic review. We are not doing a general
health checkwe are doing a health check that is really
focused on cardiovascular risk. We are doing a health check whose
individual components have been reviewed and approved by NICE.
50. Professor Fenton explained that
because the programme is targeted around cardiovascular risk,
patients are "screened for high blood pressure, cholesterol,
weight, alcohol intake, physical exercise",
and as part of this they are made aware of the signs and symptoms
of dementia. Professor
Fenton confirmed that the programme does not, however, screen
patients for dementia.
51. The PHE Health Checks action plan
stated that Health Checks could:
· prevent 1,600 heart attacks
and save 650 lives;
· prevent 4,000 people
from developing diabetes; and
· detect at least 20,000
cases of diabetes or kidney disease earlier.
In addition it noted that
The estimated savings to the NHS
budget nationally are around £57 million over four years,
rising to £176 million over a fifteen-year period. It is
estimated that the programme will pay for itself after 20 years
as well as having delivered substantial health benefits.
has said in relation to the Health Check programme that it will
undertake research to "generate the evidence we need to look
at the impact and effectiveness of the programme."
The Committee believes that this process is essential and that
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 other proven public health initiatives.
Public Health staff
53. One of the key achievements PHE
identified in their written evidence was the recruitment of Directors
of Public Health (DsPH) as part of transfer of responsibilities
to local authorities. They said in their evidence:
By 1 April 2013, 104 Directors of
Public Health had been appointed covering 114 of the 152 authorities.
Interim arrangements are in place in all local authorities without
permanent arrangements. [...] That not all authorities had DsPH
in place on 1 April in part reflected the inherited position and
that some established DsPH made a decision to not transfer to
local authority and take on the new leadership role of a local
authority Director of Public Health. Currently 116 out of 152
local authorities have substantive arrangements and interim arrangements
for the remainder. Local authorities with interim arrangements
are actively discussing with PHE the recruitment plans for appointing
54. Every unitary and upper tier local
authority must appoint a DPH and the appointment is made jointly
with the Secretary of State. In practice, however, it is PHE that
fulfils this duty on behalf of the Secretary of State. The Secretary
of State must also be consulted in cases where a DPH is to be
dismissed and, whilst the Secretary of State cannot veto the dismissal,
PHE should be consulted on the matter and will provide the Secretary
of State's response.
The Department of Health outlined the responsibilities of the
Director of Public Health as follows:
The DPH is a statutory chief officer
of their authority and the principal adviser on all health matters
to elected members and officers, with a leadership role spanning
all three domains of public healthhealth improvement, health
protection and healthcare public health.
55. The BMA, however, questioned the
authority of some DsPH and reported in their written evidence
Conversations with DPHs from across
the country reveal that a significant minority of them are expected
to report to another local authority Director. This is likely
to have a negative impact on future public health professional
Commenting on these concerns, Richard
Gleave told the committee that PHE did not:
have the data about precisely who
reports to whom within the structure, but we are absolutely clear,
in terms of the statutory guidance that we put out recently, about
them having a direct relationship with the chief executive and
access to councillors. We are seeking an assurance from everyone
56. PHE identified as one its objectives
the need to:
Implement the public health workforce
strategy and develop the PHE workforce to ensure: the continued
development of directors of public health and public health professionals
across the system.
This ambition represents the objectives
established for PHE within the Government's workforce strategy.
The strategy stated:
PHE will have the lead role in supporting
and developing the specialist public health workforce, including
DsPH, and building public health capacity in the wider workforce.
Professional workforce development is one of PHE's core functions;
across the organisation and at national, regional and centre levels
there will be people with responsibility for supporting professional
public health workforce development across the health and social
57. The Department's evidence highlighted
the role that PHE will play in developing the public health workforce
so that there is an adequate supply of DsPH in the future. They
DH and PHE are working together
to design and deliver leadership development programmes for aspirant
Directors of Public Health to ensure a future supply of highly
skilled professionals equipped for working in local government.
PHE added in oral evidence that the
latest figures showed that there were seven people for every position
within the public health workforce training programme.
58. The UK Faculty of Public Health
argued in written evidence that there was a disparity in the types
of people applying to public health roles in different organisations.
Data, though incomplete, around
applications for posts has begun to show a clear trend towards
greater numbers of non-medically qualified specialists applying
for LA posts, and greater numbers of medically qualified applying
for posts in PHE. Indeed, some LA posts receive no applications
from medically qualified specialists at all.
They attributed this to the failure
by local authorities to match NHS terms and conditions in the
posts they advertise.
59. The Association of Directors of
Public Health reported in their evidence that a capacity problem
was beginning to emerge within local authorities. They said there
is a reduced capacity within the public health workforce overall
because of unfilled posts
significant movement within the
public health workforce across England-with each element of the
local public health system effectively competing for staff within
a limited pool. [...]
Succession planning for DsPH and
other senior PH professionals; and ensuring seamless career pathways
for Public Health professionals to move between organisations
(e.g. local government/PHE/NHS), will be vital to support the
long term success of the public health system, and to ensure current
and future PH expertise and capacity for PHE, public health in
local authorities, and the NHS.
The workforce development role of
PHE is therefore critical to ensuring a strong and resilient public
health system now and into the future.
Committee is concerned by the reports in written evidence of a
capacity problem in the public health workforce. It is also concerned
that some Directors of Public Health do not enjoy a direct relationship
with the Chief Executive and Cabinet members of their local authority.
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.
health is now an important function of local government, but PHE
has an explicit duty of oversight over the public health function
at both national and local level. The Committee therefore 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.
51 Public Health England, NHS Health Check implementation
review and action plan, July 2013, p 4 Back
"Gerada: Scrap health checks programme", Pulse, 20 August
2013, http://www.pulsetoday.co.uk/clinical/therapy-areas/cardiovascular/gerada-scrap-health-checks-programme/20004025.article Back
British Medical Association (PHE 011), para 5 Back
NHS Health Check implementation review and action plan,
p 7 Back
Ibid, p9 Back
Public Health England (PHE 02), para 14 Back
Department of Health, Directors of public health: roles and
responsibilities guidance, October 2013, p 12 Back
Ibid, p 5 Back
British Medical Association (PHE 011), para 13 Back
Public Health England, Our priorities for 2013-14, p 11 Back
Department of Health, Healthy Lives, Healthy People, A public
health workforce strategy, April 2013, p 18 Back
Department of Health (PHE 21), para 7 Back
UK Faculty of Public Health (PHE 20), para 17 Back
Ibid, paras 16-19 Back
Association of Directors of Public Health (PHE 013) para, 12 Back
Association of Directors of Public Health (PHE 013) para, 15 Back