Public Health England - Health Committee Contents

5  The landscape of public health

The 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.[51]

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.[52]

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.[53]

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 Fenton said:

    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 1990s—so the most recent study was nearly 20 years ago. [...]

    The Cochrane study was unable to demonstrate any impact on mortality. The systematic review also tried to look at the impact on morbidity—what 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.[54]

He added that the views of those within PHE who were sceptical about Health Checks had been heard[55], but PHE:

    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 check—we 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.[56]

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"[57], and as part of this they are made aware of the signs and symptoms of dementia.[58] Professor Fenton confirmed that the programme does not, however, screen patients for dementia.[59]

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.[60]

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.[61]

52. PHE 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."[62] 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 substantive DsPH.[63]

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.[64] 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 health—health improvement, health protection and healthcare public health.[65]

55. The BMA, however, questioned the authority of some DsPH and reported in their written evidence that:

    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 recruitment.[66]

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 about that.[67]

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.[68]

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 care system.[69]

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 said:

    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.[70]

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.[71]

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. They said:

    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.[72]

They attributed this to the failure by local authorities to match NHS terms and conditions in the posts they advertise.[73]

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[74] and noted:

    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.[75]

60. The 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.

61. Public 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

52   "Gerada: Scrap health checks programme", Pulse, 20 August 2013, Back

53   British Medical Association (PHE 011), para 5 Back

54   Q44 Back

55   Q49 Back

56   Ibid Back

57   Q58 Back

58   Q55 Back

59   Q50 Back

60   NHS Health Check implementation review and action plan, p 7 Back

61   Ibid, p9 Back

62   Q67 Back

63   Public Health England (PHE 02), para 14 Back

64   Department of Health, Directors of public health: roles and responsibilities guidance, October 2013, p 12 Back

65   Ibid, p 5 Back

66   British Medical Association (PHE 011), para 13 Back

67   Q136 Back

68   Public Health England, Our priorities for 2013-14, p 11 Back

69   Department of Health, Healthy Lives, Healthy People, A public health workforce strategy, April 2013, p 18 Back

70   Department of Health (PHE 21), para 7 Back

71   Q138 Back

72   UK Faculty of Public Health (PHE 20), para 17 Back

73   Ibid, paras 16-19 Back

74   Association of Directors of Public Health (PHE 013) para, 12 Back

75   Association of Directors of Public Health (PHE 013) para, 15 Back

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Prepared 26 February 2014